On a basic level, healthy fertility requires that a person be healthy themselves. The body prioritizes all other systems before it puts extra energy into reproduction. It follows that a holistic approach would be the best way to enhance reproductive health by appropriately balancing our other biological needs. By focusing on diet, stress management, exercise, sleep, and mental health, we ensure the best possible outcomes.
One in eight American couples will have trouble conceiving children. Two percent of births in the United States are a result of some kind of artificial reproductive technology (ART) such as intra-uterine insemination (IUI) or in-vitro fertilization (IVF). Infertility is defined as the inability to become pregnant after a year of trying AND the inability to carry a baby to full term. There are a plethora of reasons for infertility but there are three primary categories: dysregulated menstrual cycle, poor sperm quality and quantity, and mate incompatibility. In this article we will delve into each one of these factors, and then look at what perspectives Traditional Chinese Medicine has to offer.
The Menstrual Cycle
Healthy women in reproductive years will have a regular menstrual cycle lasting anywhere from 21-38 days, with most being around 28 days. Day 1 of the cycle is marked with the onset of bleeding known as the period. Ideally, the bleeding will last 3-7 days with a minor amount of clotting, cramping, and pain. This bleeding occurs due to the rapid decrease of progesterone once the unfertilized egg passes through the uterus. Day one through the point of ovulation is known as the follicular phase, in which follicle stimulation hormone (FSH) is released causing estrogen to also increase. These two hormones coordinate to prepare the uterine lining and egg for ovulation.
At around day 10-14, depending on the woman, luteinizing hormone (LH) is released, causing a drop in estrogen and a rise in progesterone. LH also causes the mature ovum to be released into the fallopian tube (ovulation). The follicular phase ends at the time of ovulation and the luteal phase begins. The corpus luteum in the ovary maintains high levels of progesterone while the ovum passes through the fallopian tube where it is most likely to become fertilized. After 14 days the corpus luteum is reabsorbed, and if the egg hasn't been fertilized and successfully implanted in the uterus, then progesterone levels will drop, resulting in the period. Then the whole cycle begins anew.
Menstrual Dysregulation
The menstrual cycle is a well-tuned orchestra, requiring appropriate timing of all of the parts involved to work ideally. While there are numerous buffers built into the system, there are also many things that can cause it to go awry. A major source of menstrual dysregulation is caused by disruption in the hormonal milieu: elevated prolactin and cortisol, thyroid disease, and polycystic ovarian syndrome (PCOS). A second source of dysregulation is physical issues in the uterus, fallopian tubes, or follicles: fibroids, endometriosis, salpingitis, uterine scarring, pelvic floor dysfunction, and also PCOS. Less common causes of dysregulation are certain clotting disorders and Celiac disease.
Symptoms of a dysfunctional menstrual cycle include infertility, irregular periods, prolonged periods, short periods, no periods, unplanned bleeding, pain during/before/after bleeding, strange odors, chronic urinary tract infections or vaginal infections, pain during intercourse, and the aggravation of any normal premenstrual symptoms (irritability, breast distention, bloating, etc.)
Reproductive Technologies
For women who aren't trying to become pregnant, the most commonly prescribed Western medical intervention for menstrual dysregulation is birth control (oral, implants, or shots). These medications essentially halt the natural cycling of the hormones involved in menstruation by keeping progesterone artificially elevated, thus suppressing estrogen and ovulation. If symptoms do not abate, then typically the next step is some kind of exploratory pelvic surgery to remove fibroids, cysts, blockages, or signs of endometriosis. If symptoms continue still, a partial or complete hysterectomy is generally considered next. This obviously eliminates the possibility of conceiving a child.
For women who are trying to conceive, the most common intervention for a dysregulated cycle is the use of the drugs Clomid or Letrozole to trick the brain into releasing more FSH during the follicular phase. This causes increased ovarian activity and may result in a better ovulatory response, and possibly more than one egg being released. However, both of these medications stop working after about five cycles as the body acclimates to the response, so they can't be used long term. Furthermore, ovulation does not guarantee fertilization and implantation. If there is a problem further downstream, then a pregnancy will not occur, and often women who get pregnant via these methods must take exogenous progesterone to supplement what the corpus luteum is (or isn't, rather) producing.
The next level of intervention is intra-uterine insemination (IUI). In this process, sperm is washed and concentrated and mixed with a substrate that will increase their survival. The sperm is then directly introduced into the uterus as close to the openings of the fallopian tubes as possible around the time of ovulation. While IUI is most commonly used for male-factor infertility, it is a common second step for women who don't respond well to Clomid or Letrozole. Often times the two interventions are combined.
The final step in ART is in-vitro fertilization (IVF) in which eggs are extracted from the ovaries and combined in the laboratory with sperm. Viable embryos are then screened for maximum vitality and grown for several days before they are cryogenically frozen until they are needed. Simultaneously, the mother-to-be is placed on hormones to enhance her chances of a successful implantation. In some cases, a surrogate mother is used. An embryo is selected and thawed and then introduced into the uterus with a catheter. A positive pregnancy test after two weeks means that the transfer was a success.
Male-Factor Infertility
Up to fifty percent of all infertility results from a problem with the male's contribution. Anything that reduces sperm quantity, motility, or morphology will by extension affect fertility. The most common cause of male-factor infertility is varicocele (abnormal veins) in the scrotum, which reduces circulation to the testicles and can lead to inadequate blood supply and overheating of the sperm. Fortunately, varicocele is easily treated through surgery.
Other common causes of male-factor infertility are hypogonadism, exposure to environmental toxins, and lifestyle influences such as stress, tobacco, alcohol, or marijuana usage. These causes can be more difficult to diagnose and understand and may require a workup by a reproductive endocrinologist. Typically, by reducing toxins and other stressors will restore hormonal balance and normal sperm production. However, if normal sperm health cannot be restored through intervention, IUI is the most common recommended procedure and if unsuccessful, it is usually followed by IVF.
Mate Selection
The impact of mate selection is perhaps one of the least understood factors affecting fertility. The major histocompatibility complex (MHC) is a genetic marker that is present on the membrane of every cell in our bodies and it plays a major role in the regulation of the immune system. As a rule, people who are more closely related will have MHCs that are also more similar. The preference of animals, including humans, to select mates with more distant MHCs has been corroborated in numerous scientific studies. In conjunction with social pressure to mate outside of family circles, the MHC plays a role in shaping the attractiveness of potential mates. The MHC can be detected in body odor and sweat and explains why we are attracted to the smells of people we are attracted to, and often disgusted by the odors of our own family members.
If the attraction cues of the MHC are overridden (which occurs in the case of incest) or suppressed (which occurs when hormonal contraceptives are used) then infertility may result. The logic being that the sexual union of two closely related parents is more likely to result in unfavorable mutations and gene expression in offspring (case in point...hereditary hip dysplasia in pure bred dogs). Thus, naturally such unions become more difficult. The suppression of normal hormonal signaling, which is the case when a female chooses a mate while taking contraceptive medication, poses a risk of infertility once she stops taking those hormones in an attempt to become pregnant. Often times the MHCs are closer than desirable, which will lead to issues further down the road. Additionally, there are numerous psycho-emotional factors involved in mate selection that will affect fertility which will be discussed in the next sections.
Fertility and Chinese Medicine
In Chinese Medicine there are two organ systems that affect fertility: the Kidney and the Heart. When the two are coordinated, then conception happens seamlessly and new life is created. Women are primarily yin with with some yang, and men are primarily yang with some yin. When there is imbalance, issues occur.
Kidney System
The Kidney is the water element in the Five Element System and is the main source of yin in the body. The Kidney system encompasses the reproductive organs as well as the genetics of a person. The Kidneys are the seat of the pre-natal qi, or Yuan Qi, that is given to us by our parents, and if we have children we gift part of ours to them. As we age, our pre-natal qi decreases, which explains why older parents generally have a more difficult time conceiving.
Other elements of the Kidney system affecting reproduction include the health of the reproductive organs themselves, as well as the hormonal environment that supports fertility. The Kidney plays a part in controlling the levels of stress hormone, growth hormone, and sexual hormones in the body. The menstrual blood is said to originate from the Kidney itself as well as the sperm and ova.
The Kidney is negatively affected by environmental toxins, poor diet, lack of exercise, excessive work, poor sleep, prolonged emotional stress, and pathogenic cold exposure. In these instances the Kidney's energy is taxed and the pre-natal qi decreases.
Heart System
The Heart is the fire to the Kidney's water. It is the seat of passion and intimate connection. If the Heart and the Kidney are not in a state of balance, then fertility is diminished. The spark of life, is just that, a spark. There must be fire involved in conception. This pertains directly to the issue of mate selection discussed earlier in the article. Compatibility and attraction between partners is vitally important when discussing fertility.
The Heart also governs the vessels and blood flow. Circulation is an essential component to fertility. In men, poor circulation leads to poor sperm quality and difficulty maintaining an erection. In women, poor circulation leads to dysfunction during menstruation as well as difficulty during implantation and pregnancy.
We tend to associate infertility with biological factors (which are indeed important) yet completely forget about the emotions and their influence on the whole process. Chinese Medicine blends both of these realms together in a unified theory. When the body (Kidney) and mind/emotions (Heart) are both prepared, then conception can occur.
Conclusion
Promoting the overall health of a patient with a holistic approach will, by definition, lead to better fertility. The opposite is also true. By focusing on fertility we are also promoting overall health. The two are inseparable. The same things that disrupt global health, also disrupt sexual health. A skilled practitioner will be able to comprehend a patient's full picture, not just over a single menstrual cycle, but over several months and years into the future. Each cycle presents a unique challenge to both the practitioner and the patient.
Holistic medicine is one of the strongest modalities for combating the growing infertility epidemic in the developed world. It is both a stand-alone treatment to infertility, as well as an complementary treatment modality to be used alongside artificial reproductive technology (ART). The results speak for themselves.
Further Reading
Taking Charge of Your Fertility. Toni Weschler, MPH.
Treatment of Infertility with Chinese Medicine. Jane Lyttleton.
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