One in six Australian couples find it difficult to have a baby.[1]
The problem can lie with the female (40% of all cases), male (40%), or both partners (10%).
In 10% of cases, the cause is unknown.[2]
The average fertile couple is usually able to conceive within 12 months of regular (every 2-3 days), unprotected intercourse. If conception has not occurred within this time period, fertility assessment may be required. For women who are over the age of 35 years, and those who have irregular menstrual cycles or a known underlying pathology such as endometriosis, earlier assessment is recommended, typically after 6 months of trying.[1,3]
Normal menstrual cycle
Having a regular menstrual cycle helps women predict when they’re most fertile. A healthy cycle falls between 25-35 days in length [4] and can be divided into three phases.
1. Follicular phase
From the first day of menstruation through to ovulation. During this phase, follicle stimulating hormone (FSH) and luteinising hormone (LH) stimulate the ovaries to produce follicles. One follicle will become dominant and is the primary source of circulating oestrogen which stimulates the thickening of the endometrium (uterine lining) in preparation for pregnancy. As oestrogen levels peak, a mid-cycle surge of LH induces ovulation and ends the follicular phase.
2. Ovulatory phase
The follicle ruptures and an egg is released. This usually occurs 13-15 days before the next period begins.
3. Luteal phase
Having released its egg, the follicle “luteinises” and becomes the corpus luteum. The corpus luteum continues to produce oestrogen and also large amounts of progesterone. These steroid hormones are necessary for the maturation of the endometrium which becomes receptive to implantation by a fertilised egg. If implantation does not occur, the corpus luteum dies causing a sharp drop in oestrogen and progesterone levels. With the uterus no longer receiving hormonal messages to prepare for pregnancy, it sheds its lining and menses ensues.
Fertilisation
For conception to occur, sperm must swim through the cervical mucus in the uterus and into the fallopian tube where a newly released egg is ready to be fertilised. Once fertilised, the egg becomes an embryo. The embryo travels down the fallopian tube to the uterus and implants into the endometrium. Here, it releases human chorionic gonadotropin (hCG), a hormone that stimulates the corpus luteum’s secretion of steroid hormones to support pregnancy, until the developing placenta takes over at 7 weeks..Pregnancy is confirmed by a positive hCG blood test.
Female Infertility: When things go wrong
Ovulation disorders and endometriosis are common causes of female infertility (see Table 1). Advancing age and being overweight can also affect a woman’s fertility.
Ovulation disorders
A delicate balance of sex hormones is required for the timely growth and release of an egg from the ovary. Menstrual irregularities, amenorrhoea, and anovulation signify some sort of hormonal imbalance that needs to be corrected.
Polycystic ovarian syndrome (PCOS)
PCOS is characterised by excess androgens and poor glucose regulation. Hyperinsulinaemia and elevated sex hormones result in increased LH secretion. The consequent increase in LH:FSH ratio may contribute to inadequate follicular development and corpus luteum function. This in turn compromises progesterone release and may contribute to anovulation. The primary aim of treatment in PCOS is to reduce hyperinsulinaemia and androgen levels, and balance the LH:FSH ratio. Secondary aims include increasing progesterone levels and reducing elevated prolactin levels if necessary.
Endometriosis and uterine fibroids
Endometriosis is a condition where the endometrium grows in abnormal anatomical locations, such as the fallopian tubes, where it may cause adhesions and scar tissue formation. Uterine fibroids are benign growths of the uterus that appear during the fertile years. They may cause heavy bleeding (menorrhagia) and infertility. Both conditions are characterised by oestrogen dominance and low progesterone levels.
Advanced Age
As a woman ages, the quantity and quality of her eggs will significantly decline. In one large European study, women who had been trying to conceive for two years were 63% successful if aged 26 years or younger, but only 51% successful if aged 35-40 years.[5]
Being overweight
Overweight women are 2-5 times more likely to experience fertility problems.[6] They are also 2-3 times more likely to have miscarriages and reduced success with fertility treatment.
Clinical support:
Hormone regulation
Vitex (Vitex agnus-castus)
Vitex (chaste tree fruit extract) is commonly prescribed for menstrual irregularities and is particularly effective when hyperprolactinaemia, corpus luteum insufficiency, oligomenorrhoea, or secondary amenorrhoea are implicated.[7]
In a double-blind, randomised, controlled trial, women with luteal phase defects due to hyperprolactinemia were treated with either a vitex extract or placebo. After 3 months of vitex treatment, prolactin release was reduced, luteal phase normalised and deficits in luteal progesterone synthesis were corrected.[8]
Additionally, herbal/nutritional preparations containing vitex have been reported to more than double the rate of conception in “infertile” women compared to placebo after 3 months of treatment.[9,10]
Peony (Paeonia lactiflora), liquorice (Glycyrrhiza glabra), and cinnamon (Cassia cinnamomum)
Indications for peony include dysmenorrhoea (painful periods), menstrual dysfunction, and PCOS. Peony is often used in combination with liquorice, dong quai and cinnamon. Peony combined with liquorice has been shown to regulate LH:FSH ratio, normalise ovarian testosterone production, and induce regular ovulation in patients with PCOS.[11] A combination of peony and cinnamon is widely used in traditional Japanese herbal medicine for its ovulation-inducing effect.[12]
Dong quai (Angelica sinensis)
Dong quai regulates uterine function and is well respected in traditional Chinese medicine for its role as a female tonic. Indications include irregular menstruation, amenorrhoea, and infertility.[11]
Oestrogen excess
The main risk factor for endometriosis is heredity. Modifiable risk factors include prenatal exposure to high oestrogen levels, exposure to environmental oestrogens or endocrine disruptors, long-term dioxin exposure, and insufficient liver metabolism and excretion of oestrogens.[13]
Management of endometriosis should include liver function support to optimise the conjugation and metabolism of oestrogen, and the detoxification of endogenous and exogenous toxins that add to the oestrogen load. Additionally, probiotics will promote oestrogen excretion in the bowel,[14] and fibre will speed up bowel transit time to reduce the likelihood of oestrogen reabsorption.
Blood sugar regulation
Herbs such as Gymnema sylvestre (gymnema) and Trigonella foenum-graecum (fenugreek), together with nutrients that assist glucose metabolism (chromium and alpha-lipoic acid) are indicated in PCOS. Cinnamon also has been found to reduce insulin resistance and improve insulin sensitivity in women with PCOS.[15]
Pre-conception/pregnancy multi-nutrient support
A good broad-spectrum pregnancy formula which includes choline and CoQ10 is highly recommended for all women trying to conceive. Recent data has shown that having low levels of choline during mid-pregnancy is associated with a 2.4-fold higher risk of neural tube defects.[16] Meanwhile, low maternal levels of CoQ10 are correlated with spontaneous and threatened abortions.[17] CoQ10 supplementation will help to ensure adequate CoQ10 levels during pregnancy, and also reduces the likelihood of developing pre-eclampsia in women at risk.[18]
Detoxify before attempting pregnancy!
Low-level exposure to environmental contaminants such as phthalates, polychlorinated biphenyls (PCBs), dioxins, pesticides, and other endocrine-disrupting chemicals may be affecting your patient’s ability to reproduce.[19]
Phthalates, for example, are ubiquitous in our environment and can suppress oestradiol production in the ovaries, leading to anovulation.[20] Meanwhile, bisphenol A (BPA) has been reported to exert oestrogenic effects and alter plasma LH levels. It is related to ovarian disease in women. In males, BPA is linked to reduced sperm production and fertility.[21]
Conclusion
The prospect of infertility is a devastating one feared by many couples struggling to conceive. Appropriate clinical support that addresses hormonal, blood sugar and nutritional factors can greatly improve the chances of achieving a healthy pregnancy before more costly and invasive medical treatment options are explored.
References
- Access – Australia’s National Fertility Network. Viewed 24 Nov 2011
- McArthur S. Fact file: Infertility. ABC Health & Wellbeing, 30 May 2007. Viewed 24 Nov 2011
- Cedars MI (Ed). Infertility: practical pathways in obstetrics and gynecology. US: McGraw-Hill, 2005.
- Fritz MA. Evaluation of the female: ovulation. In: Cedars MI (Ed), Infertility: practical pathways in obstetrics and gynecology (pp.1-34). US: McGraw-Hill, 2005.
- Dunson DB, Baird DD, Colombo B. Increased infertility with age in men and women. Obstet Gynecol 2004 Jan;103(1):51-6. [Abstract]
- Clark A. National Fertility Study 2006: Australians’ experience and knowledge of fertility issues. The Fertility Society of Australia. Viewed 24 Nov 2011
- Vitex agnus-castus. Monograph. Altern Med Rev 2009;14(1):67-71. [Full Text]
- Milewicz A, Gejdel E, Sworen H, et al. Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolactinemia. Results of a randomized placebo-controlled double-blind study. Arzneimittelforschung 1993;43(7):752-6. [Abstract]
- Braun L, Cohen M. Herbs and natural supplements: an evidence-based guide, 3rd ed. Sydney: Churchill Livingstone Elsevier, 2010.
- Westphal LM, Polan ML, Trant AS. Double-blind, placebo-controlled study of FertilityBlend: a nutritional supplement for improving fertility in women. Clin Exp Obstet Gynecol 2006;33(4):205-8. [Abstract]
- Bone K. A clinical guide to blending liquid herbs. St Louis: Churchill Livingstone Elsevier, 2003.
- Sun WS, Imai A, Tagami K, et al. In vitro stimulation of granulosa cells by a combination of different active ingredients of unkei-to. Am J Chin Med 2004;32(4):569-78. [Abstract]
- Hudson T. Endometriosis. In: Pizzorno JE Jr, Murray MT (Eds), Textbook of natural medicine, 3rd ed. (pp. 1643-8). St Louis: Churchill Livingstone Elsevier, 2006.
- Gupta V, Garg R. Probiotics. Indian J Med Microbiol 2009;27(3):202-9. [Abstract]
- Wang JG, Anderson RA, Graham GM, et al. The effect of cinnamon extract on insulin resistance parameters in polycystic ovary syndrome: a pilot study. Fertil Steril 2007 Jul;88(1):240-3. [Full Text]
- Shaw GM, Finnell RH, Blom HJ, et al. Choline and risk of neural tube defects in a folate-fortified population. Epidemiology 2009;20(5):714-9. [Abstract]
- Noia G, Littarru GP, De Santis M, et al. Coenzyme Q10 in pregnancy. Fetal Diagn Ther 1996;11(4):264-70. [Abstract]
- Teran E, Hernandez I, Nieto B, et al. Coenzyme Q10 supplementation during pregnancy reduces the risk of pre-eclampsia. Int J Gynaecol Obstet 2009 Apr;105(1):43-5. [Abstract]
- Barrett JR. Fertile grounds of Inquiry: Environmental Effects on Human Reproduction. Environ Health Perspect 2006;114:A644-A649. [Full Text]
- Lovekamp-Swan T, Davis BJ. Mechanisms of phthalate ester toxicity in the female reproductive system. Environ Health Perspect 2003;111(2):139-45. [Full Text]
- vom Saal FS, Hughes C. An extensive new literature concerning low-dose effects of bisphenol A shows the need for a new risk assessment. Environ Health Perspect 2005;113(8):926-33. [Full Text]
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