Yoga: an adjunct to infertility treatment Hari Kaur Khalsa

Abstract
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The use of complementary and alternative medicine (CAM) is becoming increasingly popular in the United States. In general, the quality of the evidence supporting the efficacy and safety of most CAM therapies is poor. To provide better care and foster an improved doctorpatient relationship, physicians should become informed about CAM, be able to provide educated advice to their patients, and help them integrate any CAM therapies shown to be safe and effective into their health care. SRM will strive to educate and inform, emphasizing the scientific evidenceor lack of itwhen evaluating the safety and efficacy of CAM therapies. The appearance of articles on CAM in SRM should not necessarily be seen as an endorsement of the pratice or therapy. CAM therapies should be subjected to the same scientific scrutiny as traditional medicines, while recognizing that existing standards for judging treatments can be vulnerable. The Editors Yoga and meditation can help women experiencing the challenges of infertility. The practice of meditation and relaxation can help increase the clarity of the mind, maintain healthy body chemistry, and give patients the patience to undergo the rigors of infertility treatments. When one understands and can attain physical relaxation, one tends to feel better about the body itself, and begins to treat the body with more respect. This understanding can lead to healthier lifestyle habits as well as increased sensitivity regarding symptoms and body processes. This is beneficial to both doctor and patient as the patient can report with more clarity and sense cycles and physical issues more readily.

Article outline

Abstract Yogic philosophy of deep relaxation Testimonials Illustrations References Copyright

Yoga and meditation can help women who are experiencing the challenges of infertility. This article will define yoga and discuss how yoga helps women relax and how relaxation may help women conceive, make more satisfying decisions, communicate more clearly with doctors, and sustain treatment with a more positive perspective. The practice of meditation and relaxation can help increase the clarity of the mind, maintain healthy body chemistry, and give patients the patience to undergo the challenge of infertility treatments. Many people think yoga is just exercise and gymnastic postures designed for young people in great shape. But yoga is much more than physical exerciseit is a scientific system of altering the brain and body chemistry to support a heightened state of sensitivity and clarity. The techniques of yoga include exercise (both gentle and rigorous), breathing techniques, meditation (visualization, mantra, concentration), and relaxation. As you read on, you will see how yoga approaches the science of relaxation and how it can help women in treatment for infertility. Indeed, the physical and mental state of relaxation that yoga can induce can help women through all transitions of their lives. Yogic philosophy of deep relaxation

Relaxation is achieved through the process of Rebound effect Synchronization Core alignment The results of deep relaxation include: Feelings of physical well-being and health leading to healthier lifestyle habits; Focused mind for clear communications with ones partner and medical personnel; and Patience to withstand the stress of treatments and maintain daily life. Deep relaxation is viewed as a state of potential in yoga. This means that if you are relaxed, you can go to sleep, orjust as easilyplunge into a challenging project with energy and focus. Yoga (specifically Kundalini Yoga as taught by Yogi Bhajan) is a practice of posture, exercise, rhythm and sound/chant, meditation, and relaxation. When practiced together, these elements provide a foundation for deep relaxation and selfrealization for the practitioner. All aspects of yoga practice lead to a state of deep relaxation in which the mind and body experience calmness. The rebound effect The exercises and postures in yoga have a unique role in bringing the practitioner into a relaxed state. As one practices a sequenced set of yoga exercises and postures, beginners will be asked to rest for 1 to 3 minutes between each posture/exercise. This is an important aspect of yoga practice, as it trains the body and mind to distinguish between effort and non-effort. Sustained effort without release can be referred to as stress. The

back-and-forth practice between the effort needed for the exercises and postures (the energy applied to maintain a posture or repeat an exercises sequence) and the release or rest between postures can cause the practitioner to stop expending needless energy. Many yoga postures are challenging, both physically and mentally, so the release is a relief and the distinction between rest and effort becomes obvious to both body and mind. Continuous training in this effort-release process can result in an educated mind and body that will be sensitive to the triggers of sustained effort and remind the body/mind to release/relax. When yoga students learn thisand they often do so quite quicklythey report that they begin to use yoga techniques while waiting in line, waiting for doctor's appointments, during arguments, during medical procedures, and at other times of stress. They have trained themselves in the rebound effect so well that instead of staying in the stress response, they move toward release and calm. When one understands and can attain physical relaxation, one tends to feel better about the body itself, and begins to treat the body with more respect. This understanding can lead to healthier lifestyle habits (diet, exercise) as well as increased sensitivity regarding symptoms and body processes. This is beneficial to both doctor and patient as the patient can report with more clarity and sense cycles and physical issues more readily. Synchronization Due to the physical and psychological effects of infertility treatments, a patient's stress level increases and his or her ability to handle the daily challenges becomes a quality-oflife issue. The scattered feelings of keeping up with jobs and day-to-day life in addition to the challenge of treatments can create a heightened emotional approach and keep patients in a state of stress. The process of synchronization in yoga practice directly addresses this issue. When practicing yoga postures, breathing techniques, or rhythmic exercises, the practitioner is directed to either focus on the sound and sense of the inhalation and exhalation of the breath, and/or chant a mantra either silently with the breath or aloud. Bringing the elements of exercise (body), breath (body/mind), and sounds (mental focus) together in a synchronized way brings a sense of harmony to the individual. No longer are you thinking one thing, doing another, and speaking a third (like being on the phone, cooking dinner, and watching the news), but you are synchronized into a point of focus. All parts are moving in harmony with each other toward a common goalthe still point. The process of rhythmic movement and repeated mantra (or focus on the breath) followed by concentrated stillness results in a heightened state of awareness. In this state, you can experience a stillness of both mind and body. This stillness can be described as the sense of oneness between your finite self and divine self. It represents a deep state of relaxation and calm. Briefly, from a scientific point of view, by tuning out the extraneous sensory stimuli and activating the temporal lobe, the intense focus leads to heightened emotions. An intense focus also decreases input from the hippocampus to the orientation area of the parietal lobe, the area that tells us where our self ends and the rest of the world begins. Add to this an activation of the parasympathetic nervous system and you have an explanation of how yoga helps to achieve relaxation and a heightened sense of spirituality (1). A relaxed mind is a focused mind. A focused mind can be attentive to the present realities and put future fears in the background. This can be a foundation for clear communication between all involved in the treatment for infertility. Patients and their families can express their feelings more accurately and make more informed decisions. They can more easily hear what the doctors are saying without the overlays of emotional fears and concerns. Core alignment

Core alignment occurs when you experience yourself as a whole and complete person, despite any limitations or stress. You can manifest your ideas in the world, and are part of a bigger picture. Each individual action is part of the larger action of your life. You experience yourself as a work in progress with opportunities, challenges, and possibilities constantly arising. You are the part of a unique play of the universe. This type of experience can be described as the experience of your soul, your reality. Amid the desires and attachments of the world is a calm center of being, which is you. Hard as it may be to accept it when situations are not going your way, the flow of your life has meaning in itself. This inner knowledge comes from having a direct experience of how your mind works. You can learn how to monitor the flow and effect of your thoughts, and how to direct your mind toward calmness despite the stress of outer circumstances. This is the art and science of meditation. Some regard this as a belief system. In reality, it is a real experience beyond any one belief or approach. The practice of yoga, especially meditation, can give the practitioner this experience of oneness. When a person feels his or her essence and a center of calmness, despite the challenges such as infertility (or the challenges of transitions such as menopause and other life situations), the person can more easily relax and have patience. People can open up to the possibility of their lives beyond medical procedures, thwarted expectations, and disappointments. This does not mean that they will not be sad or angry. But perhaps their depression won't be as deep or long lasting, and the future can be brighter with possibility. Perhaps they can have more patience, to stay relaxed for the next round of treatments. From the yoga perspective, conception occurs when the woman is in a state of receptivity. The body and mind can be more receptive if the chemistry is healthier, the person feels safe and, ultimately, relaxed. The physical effect of stress is well documented to affect the body adversely. The blood chemistry of someone whose body and mind are under prolonged stress is profoundly different from the blood chemistry without stress. Each woman and man can benefit from being in the best possible health for conception. Through the rebound effect, synchronization, and core alignment, deep relaxation can be achieved. The practice of yoga is not mysterious. It is practical and beneficial for everyone. Simple exercises, postures, and meditations can yield deep and lasting effects. Here are a few quotes from yoga students regarding yoga and infertility. Testimonials

I started yoga to help with an injury, never expecting how big an impact it would have on my life. Yoga is now an important part of my childbearing; from my decision to have children, through conception, pregnancy, birth, and beyond. Being an older woman and having had two surgeries for endometriosis, I used yoga as a way to keep peace and not be consumed by my fears of infertility. I meditated at night and throughout my day tried to remember the ideas of being centered and open to the universe. Yoga helped me to enjoy the process at each point and not be focused on where I wanted to be. I am fortunate to have a healthy son. For me, it has made all the difference. NZL Yoga has been instrumental to my well-being during my struggle with infertility. Throughout the last 3 1/2 years of fertility drugs, IUIs, IVFs, miscarriage, and surgery, yoga has been a safe haven for me. During a particularly difficult transfer in my last IVF cycle, the doctors were having trouble transferring my embryos and were talking about me as if I weren't there as if I were under anesthesia and couldn't hear the things they were

saying. The transfer was very physically and emotionally painful and throughout the procedure I was able to call upon the meditation techniques learned in Kundalini Yoga to help quiet my mind and detach myself a bit from the pain. Even better, because my husband and I do yoga together, he was able to chant quietly in my ear to help keep me focused. In my experience, reproductive endocrinologists are very good at what they do. They help women get pregnant. But they do not focus on a woman's total health or well-being. There are times when I had to put a stop to treatments and take time to focus on yoga and acupuncture instead of shots and procedures. Without yoga and meditation, I believe my level of stress would be out of control and that would inhibit the ability of the doctor to help me get pregnant. In addition, if I am unable to get pregnant in the future, I believe that yoga will help me in my journey and in coming to terms with that reality. SDG Illustrations

Figures 1 through 4 are examples of gentle yoga postures and exercises that can help women relax. Yoga does not have to be rigorous or demanding and can create a deeply relaxing state of body and mind. The spinal flex Sit cross-legged on a mat on the floor, or in a chair. Practice flexing your spine forward (Fig. 1a) and backward (Fig. 1b). Inhale a short breath as you flex forward and exhale a short breath as you flex backward. Keep your head and chin stable with your chin remaining parallel to the floor. Continue flexing for 13 minutes. To end, inhale and hold your breath briefly as you straighten your spine. Exhale and relax. This exercise can help build strength and release tension from the lower back. The rhythmic motion of the exercise, linking the breath and movement helps create relaxation of mind and body.

Fig. 1a. The Spinal Flex (forward).

Fig. 1b. The Spinal Flex (backward). Knees to chest

Resting on the back, gently bring your knees toward your chest, holding them steady with your hands (Fig. 2). Either breathe long, slow, and deep breaths or allow your breath to relax, as you hold the posture, for 13 minutes. To end, release your knees and relax on your back. This exercise gently stretches your lower back. Each breath massages the back, and releases tension from the entire spine. This is an excellent posture for all women. It can be done in bed in the morning and at night for a more comfortable sleep.

Fig. 2. Knees to Chest. Relaxation pose Lying on your back, allow your arms to rest by your sides, palms facing upward (Fig. 3). Allow your legs and feet to relax and keep your head facing upward. This is a relaxation pose. If this posture is hard to hold, try stretching the back first using the previous exercises, or placing a pillow under your legs to help your back relax. This is the favorite yoga posture of many students. It is said to deeply relax the nervous system so you can let go of mental and physical tension. It is as important as any yoga exercise and embodies the essence of yoga practice.

Fig. 3. Relaxation Pose. Meditation Figure 4 is an example of a meditation posture. Meditation is an elegant and powerful practice that can bring inner strength and calmness. Meditation is essential to yoga practice.

Fig. 4. Meditation. Conclusion Yoga can help women cope with the challenges of infertility. A yoga practitioner can achieve deep relaxation through the processes of the rebound effect, synchronization, and core alignment. This type of deep relaxation can create a healthy foundation for a positive treatment outcome. The practice of yoga can help the patient communicate more clearly with doctors, maintain a healthier lifestyle, and be patient during the process of treatments.

The best combination of yoga, meditation, and relaxation is based on the preferences of the patient and her belief system, openness, and willingness to participate. There are programs that include meditation, yoga exercises, relaxation along with lifestyle suggestions, and traditional behavioral stress management approaches. These overview programs can help with support groups that often continue beyond the program duration. These patients often seek out yoga classes that meet their needs after programs of limited duration. They seek out yoga classes for women, classes they can attend with their husbands, or classes that include meditation and relaxation. Adding yoga or meditation to any program may seem like a difficult task for those unfamiliar with yoga, meditation, and relaxation teachers. For your infertility patients or for your stress management program, find a highly qualified yoga teacher (one that specializes in teaching meditation and relaxation as well as postures and exercise)I suggest a teacher that holds a 500-hour Registered Yoga Teacher qualification from the National Yoga Alliance. This guarantees a certain foundation of training. Offering yoga programs or recommending a gentle yoga class to patients undergoing treatment for infertility can be a positive part of a program to give women the best chance at successful treatment. References 1. Seibel M, Kaur Khalsa H. A woman's book of yogaembracing our natural life cycles. New York: Penguin Putnam 2002 Article footnote * Yoga and meditation can affect body chemistry The ancient practice increases physical self-awareness Deep relaxation makes treatments easier to tolerate
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* Hari Kaur Khalsa, R.Y.T., 124 Boston Avenue #1, West Medford, MA 02155, USA
doi: 10.1016/j.sram.2004.02.024

2003 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved