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Pregnancy achieved following manual pelvic physical therapy for Mechanical Infertility

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Sumer Samhoury, MSPT

Manual Physical Therapy can help some women with Mechanical Infertility achieve  pregnancy.   To understand what Mechanical Infertility is and how manual pelvic physical therapy helps, let’s first review the steps to becoming pregnant.

Mechanics of pregnancy

To achieve pregnancy, the process of ovulation and fertilization within healthy, mobile, and supported reproductive organs (ovaries, fallopian tube and uterus) without presence of adhesions & scar tissue has to occur. The steps to pregnancy are

 

  • The woman’s body releases an egg from one of her ovaries (ovulation)
  • The egg is grasped by the “fingers” of the fimbria, located at the ends of the fallopian tubes.
  • The egg travels through the open, non blocked fallopian tube toward the uterus (womb)
  • The man’s sperm joins with the egg (fertilization)
  • The fertilized egg attaches to the inside of the uterus (implantation)

Mechanical Infertility

Mechanical Infertility (MI) is defined as the inability to become pregnant due to intra pelvic and abdominal adhesions on/around or within the reproductive organs. MI affects approximately 2.5 million ( 40%) of the 6 million infertile women in the United States who have not conceived after 1 year of unprotected sexual intercourse.

Adhesions around the ovary can prevent the release of the egg (ovum) from the ovary. Adhesions can squeeze the fallopian tube (s)like a used tube of toothpaste, so the egg cannot travel to the uterus to hook up with the sperm.    Adhesions can pull the uterus out of a centered, midline position which makes implantation of the fertilized egg difficult. Adhesions within the uterus could increase uterine spasms which can result in miscarriage.

What are Adhesions?

An adhesion is a sheet or band of scar tissue that binds two parts of tissue or organs together.   Normally, with no scar tissue present, organs are slippery and they glide against each other. Adhesions can look like thin sheets similar to  plastic food wrap or they can be thick fibrous bands,  like ropes.  These bands of scar tissue can wrap around your internal reproductive organs squeezing them too tight or pull the organs out of their normal centered alignment which prevents their  optimal  function during pregnancy.

Cause of Adhesions

Adhesions naturally develop when the body’s healing/repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation.  Our body naturally cleans a damaged area, which is followed up by the laying down of collagen fibers to replace the damaged tissue.  The replaced new collagen is haphazard, fibers get bunched up  and cross-links form. As healing time continues, cross links may grow into microadhesions, then adhesions and may eventually thicken into scars  When a woman has pelvic or abdominal surgery,  such as a C-section or other gynecological surgeries,  the only visible scar is on the outside where the incisions may have been made, but  tissue also heals on the inside,  resulting in internal scarring.

The formation of internal pelvic adhesions is known to accompany any inflammatory process, whether it be internal trauma and bleeding (ruptured ovarian cysts or ruptured appendix), Endometriosis, or sexually transmitted infections such as Chlamydia, Gonorrhea, pelvic inflammatory disease (PID).  Pelvic spasms, bowel obstructions and chronic abdominal/pelvic pain can also lead to adhesions.

The most common cause of adhesions within the uterus is due to previous uterine surgeries such as D&Cs either for abortions, miscarriages, or excessive bleeding. In addition, adhesions may be related to child birth when there are uterine infections or bleeding associated from childbirth, or if a Cesarean Section is performed.

What is Manual Pelvic Physical Therapy?

Manual pelvic physical therapy is a gentle hands on approach, no surgery, no drugs, to improve motion, decrease restriction and improve organ function. Manual therapy techniques for Mechanical Infertility can include:

  1. Myofascial Release to decrease restricted muscles and fascia (the web-like covering that surrounds all organs, muscles and nerves of the body)
  2. Visceral Mobilization to improve organ mobility and function
  3. Pelvic lymphatic drainage to reduce pelvic congestion

Myofascial Release is a safe and effective hands-on technique that applies gentle sustaining pressure to the restricted connective tissue to eliminate pain and restore motion. The slow sustained, gentle pressure allows fascia to elongate.

Visceral mobilization technique is a gentle hands on technique to release tight ligaments and connective tissue which surrounds and supports the internal organs. Just as a therapist would mobilize the shoulder for someone who has lost motion  tight  ligaments that support the organs also need to be treated.

The lymphatic system helps our body detoxify, drain stagnant fluids, regenerate tissues, filter out toxins and maintains a healthy immune system. Pelvic lymph drainage helps to re-circulate body fluids, stimulates the immune system and promotes relaxation and balance in the autonomic nervous system.

Pregnancy Achieved

In 2012, Doctor Mary Ellen Kramp, DPT published her infertility case study in the Journal of American Osteopathic Association demonstrating that 6 out of 10 women diagnosed with mechanical infertility conceived and delivered their healthy babies at full term following  manual pelvic physical therapy. These women were found to have mechanical infertility due to lymphatic congestion, sacral dysfunction and restrictions in uterine mobility and were treated with a group of manual therapies Dr Kramp described as above and  termed  “The Infertility Protocol”.

At EMH Physical Therapy, we received training to treat Mechanical Infertility and can offer this service to women to  help them achieve pregnancy.

 

Diastasis Recti Abdominis (DRA) or “Split Seams” can be treated by Pelvic Physical Therapy

Diastasis Recti Abdominis (DRA) can occur in up to 66% of pregnant women due to hormones that allow ligaments and joints to relax, the increasing baby size in utero, improper weight lifting (ie heavy food bags, other children, furniture etc), a history of prior C-section or  abdominal surgery and repetitive poor mechanics during daily activities and lack of regular exercise.

Men can also develop DRA due to faulty weight lifting mechanics, obesity and chronic medical conditions that result in frequent coughing such as bronchitis.

What is a DRA?

DRA is defined as the separation and thinning of the rectus abdominus muscles (see diagram in green) and stretching of the linea alba (see diagram in blue).  The linea alba runs from the xiphoid process (base of sternum)  to the symphysis pubis (center of pelvic bone).  Both the rectus abdominus muscle and linea alba are the main support for the front of the abdomen, keeping the visceral organs in place and functioning well.  They are also maintain pelvis stability during walking, lifting, bending and squatting.

What are the symptoms of DRA?

Symptoms may include:

Noticeable small or large bulge in the center abdomen

Sharp or burning abdominal pain during bending, lifting, standing and walking

Lower back pain

Feeling like the intestines or stomach may fall out

Poor posture

Longer term problems of prolonged DRA may include Stress Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse.

 

How To Measure for a DRA?

The best way to measure is a finger width measurement.  Lie on your back, knees bent,head resting on floor/pillow. Place tips of 4 fingers across the body at naval or just above/below the naval per your comfort.  Now raise your head and shoulders slightly upward. If your fingers descend inbetween the  parallel rectus abdominus muscles on either side of your naval, measure how many fingers move downward.  If there is a true split of the linea alba, your finger will fall into a space that feels squishy (your intestines live here!).  A positive DRA is one where there more than 2 fingertips (1 inch or 2.5cm width)  that lower.  We have measured women with 3 to 4 inches ( 8cm) wide and have helped them narrow back to 2.5cm width

 

What to Do if you have a DRA?

Best to first consult a pelvic physical therapist for a tailored postural, stabilization and home exercise program targeting the Tranversus Abdominus (deepest and lowest muscle of our abdomen), the pelvic floor muscles and the multifidi muscles (lower back stabilizers).

Here are some tips that you can do immediately:

Avoid positions that may further separate the recti muscles, like doing sit ups, crunches and quick trunk rotation movements.  Avoid being on “all fours”  or on hands and knees for too long during exercise classes.  Assuming the yoga, “cow position” where your belly drops down as your head and hips arch upwards,  puts too much pressure on the already stretched linea alba.  Plus, the yoga position of  “Up dog” and extensive backward bends are not recommended.

Stand and sit symmetrically in good posture  (don’t stand on one leg or sit with crossed legs leaning on one hip for too long)

When you are standing, gently unlock your knees and pull  your stomach inward while breathing normally to give abdominal  support and prevent “hanging out” on your ligaments

When you sneeze, cough or laugh you you can self bracing of your stomach with your hands pushing each side of the rectus abdominal muscles towards the midline, or hold a pillow against your stomach for bracing

Wear a pelvic and/or  abdominal support product to help support the growing baby in uteruo , maintain erect trunk posture and decrease pain until your muscles are stronger by doing core exercises.

By keeping your core toned during pregnancy and taking the steps to prevent further widening of your recti muscles, you can prevent extensive DRA.

 

 

Tips for regaining firm abs and pelvic floor for all Moms

As a licensed physical therapist specializing in pelvic floor and core dysfunction, I treat women who experience pelvic pain, sexual pain, leaking, constipation, urinary urgency, have restricted C-section/episiotomy scars and  weak pelvic and core muscles, months or years after delivering their children (Vaginal or C-Section).

If all moms consulted a physical therapist soon after giving birth, this is what I would teach:

1)   To prevent leaking urine or feces, or future prolapses of the bladder or rectum, do pelvic floor strengthening exercises (if there is no pelvic pain). Many women do not know how to recruit these small muscles surrounding the vaginal and anal region.  Some either hold their breath, or tighten their inner thighs, gluteal and abdominal muscles when doing the pelvic floor muscle contraction.  A licensed PT can guide on how to recruit these muscles without substitution via our manual and biofeedback therapies.

Pelvic Floor Strength Exercise: Contract the pelvic floor muscles (squeeze the anal and vaginal regions) for up to 10 full seconds (one – one thousand, two -one-thousand, etc). Then, more importantly, relax,  completely let go of the contraction, softening for up to 20 seconds. If 10 second contraction and 20 second relaxation is too much, start with 5 seconds contraction and 10 second relaxation. Do this exercise 10 times, once in the morning and once at the end of the day. They can be performed in lying, sitting even standing (once you are good at the exercise).

2) To reduce pelvic pain, breathe and relax your pelvic floor muscles.  Slow deep breathing, produces a calming effect on your muscles, heart, and brain activity. It also gently massages the abdominal contents. If you have pelvic/lower back/hip/groin or abdominal pain, consult with your doctor first and then see a pelvic physical therapist for our targeted therapies and exercises to reduce pain and regain function.

Diaphragmatic Breath Exercise:  Inhale for 5 seconds, hold the inhale for 5 seconds, exhale for 5 seconds. Repeat 2 times, twice a day or as needed.  During your inhalation, allow your stomach to expand or balloon to allow the diaphragm to descend which  fills the lungs with oxygen. As the stomach expands, think letting the pelvic floor muscles widen, soften (no pushing outward!).  As you exhale, allow the stomach to contract and see if you can keep your pelvic floor muscles relaxed.

3) To reduce your belly post baby, reduce the DR or “diastasis rectus”, which is the separation of the two long rectus abdominal muscles as the baby grew in utero, you can wear a compression garment and strengthen your lower abdominal muscles.  The abdominal binders and/or compression shorts that support the pelvic floor can be worn daily during and after delivery to prevent further widening of the DR.

Core Exercise: Breathe in. Breathe out and think of zipping up a tight pair of jeans.  There should be no major movement of your spine, just the lower abdominal region moving “up and in” as it tightens. Hold this for 5 seconds. Breath in as you release.  Breathe out as you tighten and hold.  Repeat 10 times. Do this 5 times throughout the day.  A physical therapist can help with your DR by modifying the exercise. This can be done during pregnancy to minimize the DR and keep a strong core.

4) To prevent binding of fascia, abdominal restrictions and  pain, mobilize your C-section scar.

Scar Tissue Massage: Gently press your fingers against the scar and pull the scar in a upward direction and hold the end range for a minute. Then move downwards, to the R, and L sides, holding the end range of each direction for a minute, until you feel less burning, less tension. Eventually you can try to pick up the scar up in-between your thumb and fingers to lift the scar away from your body, affording more stretch.  For perineal scars, your physical therapist can perform manual therapies and guide you in self perineal stretches and use of a dilator to help increase the flexibility of the scar.

5) To return to pain free intercourse, if painful due to episiotomy scar, your physical therapist can perform intravaginal manual therapy, scar mobilization and teach you how to gradually and painlessly stretch your vaginal area with dilators.

Along with postural exercises, instruction on how to lift, carry and feed baby, your physical therapist can help you regain your body, prepare for another child and most importantly, prevent the pain and other issues that so many of our mothers took for granted as a “normal part of having babies”.