Infertility is one of the oldest problems faced by human beings. Basic instinct of any animal is to survive and procreate. Any hindrance to these basic instincts causes huge physical, psychological and social problems. Human beings are no different, irrespective of the country or race, proving our ability to procreate is an innate urge.
Based on data provided by the Society of Assisted Reproduction, infertility in 2008 affects about 10 to 14 percent of the Indian population. Infertility among the urban Indians is comparable to the prevalence in developed countries. Stigmatisation of infertility, more so in rural India disproportionately affects women. Discrimination and stigmatisation is also prevalent in the western world.
Initially like every doctor I was sceptical and thought it was another “Old wives’ tale”. However, on spending a few hours and analysing the ritual as an endocrinologist, it dawned on me that the advice is the same as I would have provided my patients in the United Kingdom.
In this article, I will be discussing folklore from northern India and provide an Endocrinologists interpretation of this story of fertility treatment and also discuss how someone with infertility could benefit.
The Story of “Hole in the Rock”
Mukteshwar is a village in one of the northern states of India called Uttarakhand. This remote village, rests among the hills at an altitude of about 2070 metres (7500feet). There is Hindu temple, in Mukteshwar which is claimed to be 350 years old. This has also been mentioned in Jim Corbett’s book “The temple tiger” and ‘Man eater of Kumoan”. There is a rock formation close to the temple called “Chauli ki Jali”. ‘Chauli’ means rock and ‘Jali’ means hole in local Indian dialect.
There is a hole in the rock, and the story is that on an auspicious day of the year, if women climb the rock and enter the hole and come out the other side, they can improve their fertility and will get pregnant. The hole in the rock formation is about a kilometre above the land nearby. Women have to climb at least 900 metres before they can reach the hole.
The whole family supports the woman, who is keen on getting pregnant. Preparation to climb this rock and attend this festival starts at least a year before. They start to eat healthy and improve their fitness. The family as a whole started to practice rock climbing, to support her.
The science behind improving fertility by climbing into the “Hole in the rock”
Women folk continue to get to this mountain range and climb to get through this hole in the rock to get pregnant. So, what is the science behind improvement in fertility?
Well, as an endocrinologist and bariatric physician, I think, they are able to achieve their goal by following the steps, which one should follow for successful long term sustained weight loss.
The five steps to success include:
1. Motivation and focus
3. Improving cardiovascular fitness
4. Heart and lung conditioning
5. Reduction in Body Mass Index and waist circumference
Motivation and focus
In the first instance they stay motivated and focussed on getting pregnant and having a baby in a year’s time.
So, they follow the so-called SMART (Specific; Measurable; Attainable; Relevant and Time-bound) goal. In my 20 years’ experience in endocrinology and obesity, I have noticed that people who engage regularly with any evidence-based weight loss plan, lose weight. Those who engage regularly also sustain their weight for a longer duration. In most weight loss programmes, the dropout rates are around fifty percent. No wonder, so many people do not succeed in weight loss or they regain the weight they have lost. In fact, after a diet, some people can regain more weight than they have lost.
This age-old ritual in the village of Mukteshwar, is constantly reminded of the women planning to climb the rock. Her activity, meals, sleep and mood are monitored by most of the family members. She is well supported in achieving her intermediate goals, so as to achieve her ultimate goal successfully.
People in the village discuss regularly about the families with women planning to get pregnant and those who would be visiting the temple that year. So, she is accountable to the whole family and local community. Being focussed, motivated and accountable plays a major role in reaching her goal, more so a weight related goal.
Participants in reality television shows like the “Biggest loser”, show people losing a considerable amount of weight during the period of shooting. This again is due to accountability to the family, television viewers and probably the price money. This leads to increased motivation. I am sure participants who lose motivation after the show is terminated invariably regain the weight they have lost.
Improving cardiovascular Fitness and Heart/lung conditioning
The next step is conditioning your heart and lungs to higher altitudes. As you go to higher altitudes, air becomes thinner. There is less oxygen and pressure is far less in higher altitudes. In order for your lungs to breathe air without any effort, the pressure of the air around you should be higher than inside your body. However, at high altitudes, the outside air pressure is considerably lower. So, mountain climbers spend several weeks and months to gradually get accustomed to the thinner air at higher altitudes and make an ascent gradually.
Before they get to the “Rock in the hole”, women have to get acclimatised. All this is factored in their rituals. Women have to go to several of the smaller temples situated at lower altitude once a month. Women in this village practice climbing smaller hills and go to these temples regularly.
Heart and lung conditioning are important for a successful pregnancy. Pregnancy alters lung function and could worsen any pre-existing respiratory problems. Pregnant women with respiratory problems like asthma pose a huge challenge to the growing baby in the womb. Similarly, pregnancy puts strain on the heart and circulatory system. During pregnancy, blood volume can increase up to 50 percent, in order to ensure the baby is well nourished.
In addition, labour and delivery adds to the strain on the heart and lungs, more so when the woman is pushing during labour.
Reduction in waist circumference and Body Mass Index (BMI)
We all know obesity contributes to infertility for both men and women. Weight loss helps improve fertility. It is not just weight loss alone, but also reduction in waist circumference.
Increased waist circumference indicates excess visceral adipose tissue. Visceral adipose tissue is known to increase the risk of infertility, heart attack, stroke, diabetes and other serious cardiometabolic conditions. Visceral adipose tissue contributes to several metabolic functions in the body. Reducing waist circumference helps reduce visceral adipose tissue and thereby reduces the risk of several medical conditions.
So, why does increasing weight lead to infertility?
In women, increasing weight leads to an imbalance in hormones. Predominantly the male hormone testosterone is higher. Adipose or fat tissue, produces several chemicals and hormones. Fat tissue promotes insulin resistance. Increased levels of insulin in the body promote testosterone production by the ovaries. Thereby female hormones, oestrogen is relatively less, contributing to infertility.
In men, obesity not only physically impairs sexual activity and promotes performance anxiety but also reduces testosterone levels. The scrotum is outside the body, so as to keep the testicles, two degree centigrade below the body temperature. However, in an obese man, the scrotum is kept warm with the protuberant belly and thighs. This results in inadequate testosterone being produced, contributing to erectile dysfunction and thereby infertility.
When the women are planning to go to the “Hole in the rock”, her husband also supports her and he accompanies her in all her activities and improves his exercise tolerance and loses weight.
How can you sort infertility, if you cannot go to the “Hole in the Rock”?
Not all of us can travel to the “Rock in the hole.” However, we can learn from the folks in the Himalayas.
To improve fertility, for both men and women, follow the top 10 tips:
1. Get to a healthy weight.
2. Stop smoking
3. Reduce alcohol intake to less than 14 units a week.
4. Ensure you have good quality sleep
5. Ensure sexually transmitted disease if any is ruled out and treated.
6. Exercise regularly and improve fitness
7. Reduce caffeine intake.
8. Have a balanced meal with fruits and vegetables.
9. Reduce stress and adopt relaxation techniques.
10. Avoid processed food with high sugar and salt.
Weight loss, cardiovascular fitness, good sleep hygiene and a stress-free life would improve a women’s chances of fertility. There are, however, several other causes of fertility which needs to be investigated and may not help by just going to the “Hole in the Rock.” Most importantly, her man has to be healthy and have good and adequate sperm count. In addition, he should not have any structural problems of his sex organs and should be free of any hormonal problems. Infertility may also arise due to genetic defects and anatomical defects of the uterus, ovaries or fallopian tube.
Before any one embarks on a detailed investigation for infertility, follow a regime, similar to the women in the Himalayan village.
Wishing good luck to you and your patients!