FEMALE INFERTILITY: A STUDY OF PHYSICAL TREATMENT BY THE METHOD OF L. MOJZISOVA FOR FUNCTIONAL DISTURBANCES OF THE PELVIC REGION
The Journal of Orthopaedic Medicine 23 2001 47-49
Of 166 women suffering from some type of funktional infertility 118 were followed up. They were divided into 5 groups. Group A and (lter) group E were treated and trained according to the method of Mojzisova. The method consists of mobilisation techniques, postisometric relaxation, and soft tissue techniques. Treatment lasted for 6 months. The number of women succesfully treated was significantly higher in those who were treated by the method od Mojzisova as compared to the controls.
Keywords: female infertility, functional disturbances of lumbar spine and pelvic ring, mobilisation techniques, postisometric relaxation
MATERIAL AND METHOD
The study population consisted of a group of 166 women who had been treated unsuccesfully for an average of 4 years. Suitability for the study was assessed with the aid of a questionaire filled in by a gynaecologist. The following criteria were applied:
- age between 22 and 30 year
- normal quality and quantity of sperm of partner
- patency of fallopian tubes
The women were randomly allocated to groups A, B or C. Furthermore groups D and E were made up, details of which will be considered in a later section. Treatment was scheduled on a monthly basis for 10 women at a time from groups A, B and C. The same was repeated for the following months.
At the rehabilitation unit the women were:
- informed about the effect of the methods of rehabilitation,
- given further information regarding the treatment routine (temperature measurements, fluid intake, necessity to preform exercises twice daily, etc.)
- examined by the female physiotherapist for: posture, pelvic distortion, leh length, pressure sensitivity of vertebrae and costosternal joints, rib fixations and muscle tightness, signs of hypertonicity of the pelvic floor musculature, etc.)
- gynaecologically examined by Dr. J. Navratilova.
The succes of treatment (pregnancy) was determined as described bellow:
- Number of women treated succesfully in group A following the treatment and exercises of Mojzisova
- Number of women treated succesfully by a different therapeutic regime and different exercises (group B)
- Number of untreated women in group C who did not follow an exercise regimen.
GROUP A (n = 50)
In this group women were treated by the method of Mojzisova, which specially included treatment of the lumbar spine and pelvis. Both areas have a close association with sexual organs.
Method of treatment 1-4
- Stretching and relaxation of lumbar and pelvic musculature, postisometric relaxation (PIR) buttock and pelvic floor muscles as well as strenghtening of muscles of the chest. Exercises were explained to the women on their initial visit and instructions were given to perform these at home twice daily for the following 4-6 weeks.
- In the first half of the menstrual cycle the female physiotherapist also:
- relaxed pelvic floor muscles: after initial warm-up PIR, internal rectal massage and coccygeal treatment were performed
- following this, mobilisation of hypomobile areas in the sacroiliac joints, lumbar spine, and ribs was performed
- the home exercise program was checked and corrected. Futhermore additional exercise with the purpose of trenghtening pelvic floor, buttock and abdominal muscles were prescribed.
During the course of the next menstrual cycle the last two points were repeated. Relaxation of pelvic floor musculature was only performed if clear indication of hypertonicity existed. If, for whatever reason (illness, holidays), one of women missed a treatment, this appointment was delayed to the next menstrual cycle. The course nof a treatment ended after 6 visits and was considered succesful if a pregnancy occured in this study period.
GROUP B (n = 50)
For this group a different set of actic¨ve and passive axercises was performed than that of group A (designated "nongenuine" exercises in the following text). Care was taken so that these exercises did not affect the areas involved in Mojzisova method. The women were blinded to the fact that exercises were non-effective.
This group also differed from group A with respect to the organisation of check-up examinations at the rehabilitation department. During the two year study period Mojzisova´s method was already well known among laymen. Due to technical difficulties it was impossible to completely separate the two groups in waiting rooms and corridors so that it was possible for women to discover differences between prescribed exercises and treatments. Therefore monthly check-ups of group B were organised in small groups in advance. This allowed the creation of an isolated group. The goal of this group was to prevent information about treatment in group A to become known to other subjects.
These condiditons lead to other unforeseeable differences:
- Missed appointments could not be re-scheduled and were missed completely
- due to mothly group meetings the women were able to develop relationships, talk about their exoperiences with the treatment and some women only attended to announce their pregnancy.
The above conditions put group B into an advantageous position as compared to women in the other gropus who attended check-ups individually.
In accordance with group A the treatment of group B consisted of following:
- active "non-genuine" home exercises (4 weeks)
- monthly group meetings not taking into account timing of menstrual cycle. Firstly home exercises were repeated and seconf¨dly "non-genuineL passive exercises were performed individually. these meetings took place sex times and were deemed succesful if pregnancy occured in that period.
GROUP C (n = 50)
This group did not exercise although the initial talk and gyneacological examination were the same as for the other groups. Date and time of the next appointment were negotiated so that the women knew thet treatment was merely delayed by six months.
The puropse of this group was to schedule the possibility of a psychological effect on the number of pregnancies due to expectation of treatment. the observation period was also six months and possitive outcomes were pregnancies wchich occured between the initial examonation and before commencement of treatment.
GROUP D (n = 16)
Due to timing difficulties it was impossible to integrate this group into group B.
Treatment consisted of active home exercises which were not checked regularly by the medical rehabilitation unit. Also passive exercises ("non-genuine", group B) were not performed.
Although the treatment period was only three months, the results are of interesr and will therefore be discussed. Pregnancy within three months of commencing exercises was designated as success.
GROUP E (n = 76)
Women in this group were those who did not become pregnant after prforming etiher "wrong" exercises (groups B and D) and those who did not exercise at all (group C). Treatment lasted six months and followed Mojzisova´s protocol (group A).
These women therefore were not disadvantaged, but treatment and possible following pregnancy were merely delayed by six months. This is in agreement with medical ethics.
Again treatment was conducted after 6 check-ups and success was described as pregnancy during treatment period.
Results are shown in table 1. It can be clearly seen that the success rate was significantly higher in those women treated with Mrs. Mojzisova´s method (groups A and E)) as compared to those who were not (groups B to D). In the light of these results it would be interesting to compare effectiveness of thos method with other reflex therapeutic protocols (mobilisation techniques, acupuncture, reflexology, massage). Statistical analysis was performed by Dr. V. Novak nad Dr. H. Koukalova.
The x2 test was used for statistical analysis taking into account the number of pregnancies in individual groups. Firstly an overview table will be shown (table 1).
In table 1 x2 = 13.543 which correlates with p<0.01. The number of pregnancies is therefore in statistically significant relation to treatment in individual groups. Since results of group B, C and D are similar, succes rates od these three groups were established in the same way, yielding a x2 = 0.012 which correlates with p>0.975 i.e. the groups are almost identical. For this reson these groups were summarised into one group, which was compared to groups A and E (table 2).
In table two x2 = 12.179 correlating with p<0.0005, and in table three x2 = 9.262 correlating with p<0.005.
There is a highly statistically significant relationship between pregnancies and treatment method insofar as groups A and E showed higher numbers of pregnancies than groups B, C and D.
Comparison of groups A and E showed x2 = 0.503 (p>0.45). This signifies that treatment in these hroups did not differ statistically.
A larger group of patients was treated by Mojzisova´s method subsequently, giving further information about the typical symptoms and signs of this group of people with infertility. Typical symptoms other than infertility were: painful menstruation, menstruation bleeding with clots, dyspareunia, back pain and headache. On examination the following were frequent findings: bad posture with scoliosis, sacroiliac dysfunction, asymmetrical intergluteal line, weakness of the caudal third of the gluteal muscles wwith unsufficient contraction of both the gluteal muscles and the levator ani: reflex spasm and/or tenderness of the adductors, of the coccyx, of the sacroiliac joints, of the lumbar erector spinae, of the lower part of the abdominal wall between the umbilibus and the groin, all usually on the right, and between the umbilicus and the anterior iliac spine usually on the left.
The succes rates for pregnancy in this larger uncontrolled group, according to age group, was:
- ages 20-24: 46.58%
- ages 25-29: 40.94%
- ages 30-34: 30.96%
- ages 35-39: 24.73%
- ages 40-44: 11.11%
Statistical analysis using the ?2 test showed a statistically significant higher proportion of pregnancies in groups A and E, whoch were treated and exercised following Mojzisova´s protocol as compared to (control) groups B, C and D. There was no significant difference between the number of pregnancies when comparing groups A and E.
Experience with the physiotherapeutic treatment of some types of functional female sterility at the physiotherapy ward of the Teaching Maternity Hospital KÚNZ , Brno
H. Volejníková, P.Krupička
1st gynaecological-obstetric clinic MU, Brno, headed by prof. MUDr. Z. Čupr, DrSc.
1st physiotherapy ward of the Teaching Hospital and Clinic (FNsP KÚNZ), Brno, headed by prim MUDr J. Svobodová
A report about potential treatment of some types of functional female sterility using physiotherapy and about its results was presented by assistant professor MUDr. E. Čech, CSc, at the National Scientific Conference in April 1983 in Bratislava. The results presented by the authors had been so interesting that we decided to verify them through our own survey. Based on a consultation with the authors of the method (Čech – Mojžíšová), two physiotherapists from the Teaching Maternity Hospital in Brno were trained in autumn 1983 at the Faculty of Physical Education and Sports of the Charles University in Prague. The treatment using the method started in September 1983.
Having consulted with the authors of the method and with experts in the field, we established criteria for the physiotherapeutic treatment: the surveyed group included women examined by gynaecologist who had been treated for primary or secondary sterility for different periods of time and who met the following conditions:
- A normal spermiogram of the partner or at the lower limit of the standard finding.
- Finding of biphasic basal temperatures. However, we also included women with occasional anovulations where we expected the physiotherapy to adjust the hypotalamo-hypophysis-ovarial axis and subsequent ovulations.
- The tubal factor of sterility was excluded while passability of tubes was demonstrated by laparoscopy or using HSG. In case of only one passable tube the woman was included in the groups "passable tubes".
- Women were received for treatment based on a recommendation by gynaecologist.
The women suitable for physiotherapeutic treatment were put on a list and invited for the first visit. The waiting time to start the treatment depended on the number of received applications (questionnaires) and on material and human resources of the ward - from the moment the patient was first received up to one year.
At the first session a group of 12 women was instructed about the general principles of treatment, effects of physiotherapy on the organism and the hygiene of correct posture. Each woman was examined to expose deviations from the correct posture and to determine rotation position of pelvis, relative length of lower limbs and palpation sensitivity of individual backbone segments. We also monitored signs indicating probable spasms of musculi levatoris ani, such as the asymmetry of gluteal clefts, delayed response of gluteal clefts, delayed response of gluteal muscles, spasms of hip joints adductors etc. A file was kept about each of the women involved. Women were asked to exercise at home following instructions in a printed leaflet for 4-6 weeks. The exercises were selected to relax and stretch ligaments and muscles in the area of sacrum and lumbar backbone. The women were informed about the importance of regular exercising at home throughout the treatment period.
In the first half of the menstruation cycle the first individual session was arranged by phone with each woman. She underwent relaxation of musculi lavatories ani using a massage and postisometric relaxation. We have described the method in connection with treatment of urine retention after gynaecological surgeries (2). The women also went through a series of passive exercises and mobilization of lumbal and sacral segments of backbone in order to remove functional blockades.
If it was demonstrated by palpation that blocked positions of the segments persist the treatment scheme was not changed until the following session and the procedure was repeated in the first half of the following menstruation cycle.
As soon as the functional blockades were removed the woman was asked to do exercises consolidating and strengthening the muscular corset of the backbone: abdominal muscles, back muscles, gluteal and pelvic floor muscles in order to prevent recurrence of blocked positions in the concerned segments.
Each woman was monitored in this way for several months. As soon as the blocked positions failed to recur she continued to exercise on her own.
If the woman got pregnant she informed the physiotherapy ward, either in written or by phone. In the course of her pregnancy she continued to perform strengthening exercises. After the delivery she filled out a printed questionnaire.
Computer technology was used to evaluate the structure of the group of treated women and the achieved results. The method was not based on a statistical principle but only on evaluation of treatment results from the viewpoint of the monitored factors which were presumed to affect results of the treatment.
The following factors were chosen for the evaluation:
- woman’s age
- number of years of previous treatment
- number of sessions at the physiotherapy ward
- personal history a) hormonal treatment, b) basal temperature, c) gynaecological inflammations, d) orthopaedic disease, e) abortions, f) gynaecological surgeries
The evaluation within one group was always performed for all women so it was possible to evaluate particularly the ratio of treatment results in women with favourable and unfavourable status of some of the factors. Based on this we were able to establish the level of importance of the individual factors. The processing algorithms made it possible to perform the evaluation in any combination of the monitored factors.
We performed a detailed statistical investigation of the monitored group of women using computer technology available at the Economical and Organizational Department of Incotex, state enterprise Brno, the programs for the evaluation on the computer EC 1033 were developed by Ing. P. Krupička.
From September 1983 until June 1989 1625 women showed their interest in the treatment (Fig. 1). From this number 842 women, i.e. 51,8 %, were excluded from the treatment (Fig. 2) for various reasons.
783 women were accepted for the treatment (Fig. 3). From among them 500 were treated for at least 6 months and the submitted results relate to the last mentioned group.
The personal histories of the 500 examined women have shown the following:
Fig. 4. Rate of successful treatment - numbers of pregnancies of the treated women depending on the age (150 women got pregnant in total - the numbers and percentages in the columns always relate to the respective age groups)
Analysis of the Results
The following conclusions may be drawn from the evaluation of treatment results based on the selected factors:
- The factor of woman's age: with the increasing age the rate of success of the physiotherapeutic treatment decreased (Fig. 4) from 44.6 % in the group up to 25 years of age to 22.6 % in the group 31 - 35 years of age. In the group 36-40 years of age the success rate increased to 33.3 %. So far we have not been able to explain the increase.
- The factor of years of previous treatment: with the increasing time of previous treatment the number of pregnancies decreased exponentially (Fig. 6) This means the factor is significant.
- The factor of number of sessions at the physiotherapy ward: it is interesting to compare the number of years of previous treatment and the number of sessions ( Fig. 5), i.e. the time of treatment necessary for a woman to get pregnant. It is interesting to compare the groups of women where the treatment was and was not successful (the groups of women who got pregnant and failed to get pregnant). In the group of successfully treated women the number of years of previous treatment was on average 4.1 years and the number of sessions 5.6 while in the group of women who failed to get pregnant the number of years of previous treatment was on average 6.1 years and the number of sessions was 7.8.
- The factor of personal history: based on the comparison of rates of success for favourable and unfavourable individual personal histories one may conclude that:
A significant decrease in dysmenorea and dorsalgia was observed in the treated women
- surgeries of ovaries, womb, uterus suspension system and orthopaedic diseases did not demonstrate any effect on the treatment, while
- surgeries of tubes, inflammations, ITP, hormonal treatment, basal temperatures and the fact of primary or secondary sterility had an effect on the treatment.
The comparison of our results with those obtained by the authors of the method at the workplace in Prague: the Prague workplace surveyed a group of selected 102 women with demonstrated ovulation, biphasic basal temperatures, normal sperm of the partners, women who did not have any surgeries and did not have any palpation findings on the tubes. They did not set any age limit either. The number of pregnancies was 51% and higher for secondary sterility (1).
Fig. 6 The effect of years of previous treatment on the rate of success of physiotherapeutic treatment - % of pregnancies.
The results found at the workplace in Brno for a group of women, who were treated regardless of the limitation criteria listed above, were 30% of pregnancies, which is essentially in agreement with the findings of the workplace in Prague. Our results also confirmed that the treatment was more successful in case of secondary sterility. The results from the workplace in Brno further expanded some of the existing findings - e.g. that the age limit was significant. The use of computer technology in the survey has made it possible to take into account a number of other aspects which may be investigated further and partial conclusions may be gradually drawn from them.
We present our experience with treatment of some types of functional female sterility using a physiotherapeutic method at the Teaching Maternity Hospital in Brno - which resulted in 30% of pregnancies. The results of the treatment were evaluated using computer technology, they were in agreement with the results achieved by the authors of the method at the workplace in Prague and further expanded some of the existing findings.
1. Mojžíšová, L. Physiotherapeutic treatment of some types of functional female sterility.
Prakt. Lék. Praha 68, 1988, page 925-927
2. Huvarová, M. Volejníková, H.: Urine retention after gynaecological surgeries and the influence of relaxation of pelvic floor muscles. Čs. Gynek, 52, 1987, pages 668-670