This fall is turning into a busy one for us here at EMH! Not only do we have Dr. Echenberg joining us this October, but we will be hosting an event at the end of November for new and expectant moms. In addition to getting to meet other moms, this event will be a talk by our very own therapists, Kirsten Hober and Charissa Morrisroe on the effect pregnancy has on the pelvic floor, how your body changes both during and after pregnancy, and some exercises and posture techniques that are easy to implement while caring for your baby.
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 (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:
- Myofascial Release to decrease restricted muscles and fascia (the web-like covering that surrounds all organs, muscles and nerves of the body)
- Visceral Mobilization to improve organ mobility and function
- 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.
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.
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”.