By: Alina Salamatina, DO
Editor’s Note: Dr. Alina Salamatina was a fourth-year medical student when she summarized an interesting study published by Rice et al. [1] Their retrospective chart review assessed a manual physical therapy protocol used in patients with various mechanical causes of infertility involving adhesions. The results of this conservative, noninvasive approach bring hope to a patient population in need of additional options before invasive and/or costly treatments are pursued.
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Introduction
The prevalence of infertility has increased in recent years in the United States and globally. Some causes of infertility in women include blocked fallopian tubes, endometriosis, elevated levels of follicle-stimulating hormone (FSH), polycystic ovary syndrome (PCOS), and premature ovarian failure (POF). In some cases, the cause may be due to male factors or it is never determined. Although there are treatment options specific to each etiology, no single treatment method has been found to be globally effective across this broad range of etiologies. Manual physical therapy has been shown to be effective for other medical conditions by decreasing adhesions and improving mobility. The study by Rice et al [1] summarized below reviewed the role manual physical therapy could play in the management of infertility due to mechanical causes from various etiologies.
“Some causes of infertility in women include blocked fallopian tubes, endometriosis, elevated levels of follicle-stimulating hormone (FSH), polycystic ovary syndrome (PCOS), and premature ovarian failure (POF).”
Methodology
This was a retrospective study that included patients previously diagnosed with infertility and treated at the Clear Passage Physical Therapy (CPPT) site between 2002 and 2011. Treatments followed the Clear Passage Approach (CPA) protocol using various manual physical therapy techniques focused on improving motility to structures impacting the reproductive system. Patient follow up was via annual questionnaires.
The researchers classified the patients and measures of treatment success based on the previously mentioned etiologies of infertility: blocked fallopian tubes, endometriosis, elevated FSH, PCOS, POF, and unexplained infertility. Success for the blocked fallopian tube category was defined as at least one patent fallopian tube or confirmed pregnancy. Success for the elevated FSH category consisted of a decrease in FSH levels. Success for endometriosis, PCOS, POF, or unexplained infertility was defined as a confirmed pregnancy. Rates of success were compared to previously published rates of success with standard medical treatments for each diagnosis. The study also evaluated possible predictors of outcome such as age, past medical history, treating therapist, and year of treatment.
Results
In patients with blocked fallopian tubes (n=235), CPA was found to be as effective or better than the standard treatment method of surgery in opening at least one fallopian tube. In patients who had successful CPA treatment, pregnancy rates were comparable or higher than the rates of patients who underwent the standard treatment method. Previous surgery to open fallopian tubes was found to be a statistically significant predictor of a negative outcome with CPA treatment in this group; however, it did not influence pregnancy rates for the group in which CPA treatment was successful in opening at least one fallopian tube.
In patients with endometriosis (n=299), CPA was found to be as effective or better than the standard medical intervention such as surgery, oral contraceptives, or a combination of these two treatments. Age was a statistically significant predictor in this group, with patients under the age of 35 being more likely to achieve pregnancy. Among patients with endometriosis, the pregnancy rate was 42.8%.
“In patients with endometriosis (n=299), CPA was found to be as effective or better than the standard medical intervention (and) … the pregnancy rate was 42.8%.”
In patients with elevated FSH on day 2-5 of the menstrual cycle (n=122), CPA was found to decrease FSH levels in 49% of patients and the pregnancy rate was 39%. Since there was no standard treatment method for this etiology, a comparison could not be performed.
In patients with POF (n=5), the success rate of CPA was 20%. Statistical analysis or comparison could not be performed due to the small sample size and no standard medical treatment.
In patients with PCOS (n=28), CPA was found to be as effective compared to the standard treatments of clomiphene and surgical intervention, and significantly more successful when compared with metformin.
In patients with unexplained infertility (n=12), the success rate of CPA was 25%, which was similar to previously published rates within this category.
In patients who underwent in vitro fertilization (IVF) after treatment with CPA, the overall success rate of IVF was found to be significantly higher compared to national IVF success statistics.
Discussion
The review article by Rice et al [1] presented a less invasive option to treat infertility due to mechanical causes involving adhesions. Compared to many of the standard methods focused on treating specific etiologies of infertility, the physical therapy Clear Passage Approach offers a potential treatment method that can be tailored to the unique needs of each patient. CPA could also improve final outcomes as an adjunctive method to support other treatment options such as IVF. Future studies should assess the safety and effectiveness of these CPA methods when used prior to surgical interventions, especially if more invasive methods are associated with a decreased success rate with CPA as suggested in this study.
The strength of this study is the relative consistency of treatment across patients. All patients were treated at the same site, a private physical therapy clinic, and their treatment followed the same guidelines. Furthermore, the researchers considered other variables that could impact infertility that were accessible in patients’ charts and conducted statistical analysis to evaluate whether other factors impacted success or failure rates.
Some aspects of the study raise concerns regarding the reported success rate of CPA intervention. The ten-year longitudinal course of the study and the retrospective approach leave space for outside influences to contribute to the outcomes studied; it was also unclear how thoroughly the follow-up questionnaire accounted for this. Additionally, the high attrition rate from patients who did not follow up — up to 65% in one category — could indicate a potential overestimate of success.
Despite these limitations, this review article highlighted an additional treatment option in patients with infertility. It is encouraging that the manual physical therapy approach is well tolerated by patients, not invasive, and does not require technology that is difficult to access. Considering the many professionals already trained in manual physical therapy approaches, such as physical therapists and osteopathic physicians, there is potential to implement this approach broadly.
The authors also noted the potential for manual physical therapy to contribute to hormone balance. It would be interesting to study how CPA impacts irregular cycles, PCOS, and endometriosis, and whether this modality could help alleviate symptoms of these and other reproductive issues.
“This review article highlighted an additional treatment option in patients with infertility … (as well as) the potential for manual physical therapy to contribute to hormone balance.”
Future research is needed in manual physical therapy techniques to treat infertility and to identify other similar approaches that may benefit patients. This study could be expanded across multiple centers implementing more manual physical therapy techniques to further support the findings from the study by Rice et al and to evaluate efficacy across a broader range.
References
[1] Rice AD, Patterson K, Wakefield LB, et al. Ten-year Retrospective Study on the Efficacy of a Manual Physical Therapy to Treat Female Infertility [published online ahead of print, 2015 Feb 17]. Altern Ther Health Med . 2015;at5233.
ABOUT THE AUTHOR
Alina Salamatina, DO
Alina Salamatina, DO wrote this review as a fourth-year medical student at Touro University California College of Osteopathic Medicine in Vallejo, CA. She completed her undergraduate education at the University of California San Diego, where she studied biochemistry and cell biology. Dr. Salamatina is now a resident in family medicine and has a special interest in women’s health. She enrolled in the FACTS elective to gain a better understanding of natural family planning methods to offer her patients more options when making reproductive health decisions.
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