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'tussin tots?

Meghan O'Brian with her husband, Jon, and daughter Mila. Ms. Obrian said she was 'pretty damned surprised' when they conceived after 'skeptically' trying Robitussin.Amy O'Brian

Meghan O'Brian had been trying to get pregnant for more than a year and a half when a test flashed her a positive result last July. Just 29 years old at the time, she had seen fertility specialists, undergone ultrasounds and blood analysis, and even had a procedure to see if her fallopian tubes were blocked. She had been given constant and often contradictory advice: to give it time and relax, or to go straight to in-vitro fertilization and hormone treatment. But when she finally found out she was pregnant, there was one word that flashed through her mind: "Robitussin."

Ms. O'Brian and her husband, Jon, a doctor of emergency medicine, welcomed their daughter, Mila, on Wednesday in Vancouver. They credit the baby's conception to an unlikely factor, an everyday cough syrup that is celebrated as a fertility aid by a community of women who describe themselves as TTC - "trying to conceive."

"The one month I skeptically took it, it worked. We were pretty damned surprised," Ms. O'Brian said. "There was some serious disbelief for a good long while."

How an off-label application of over-the-counter cold medicine found a shelf life as a conception tool widely promoted online is a story marked with skepticism and disbelief. Robitussin's effectiveness has been debated on chat forums, and references to its impact can be found in bestselling pregnancy books. In a time when fertility treatments cost thousands of dollars, it's not surprising that a $5 solution has intrigued women for more than 20 years. But it is unusual that despite almost three decades of word-of-mouth debate, there's little scientific evidence to prove that it works - or that it doesn't - leaving it in a strange realm somewhere between old wives' tale and unsung miracle drug.

According to the Canadian Fertility and Andrology Society, infertility affected 10 to 20 per cent of the population in 2009, or one in six Canadian couples. The same year, assisted reproductive technology was involved in 3,500 births. But technological intervention is not cheap, with the average cycle of in-vitro fertilization costing $5,700, with no guarantee of its success.

Diane Allen, who runs the Canada-based Infertility Network, an online support community with 10,000 subscribers, said she has many members who arrive looking for information on Robitussin or other possible fertility aids, unwilling or unable to immediately pursue medically advanced treatments.

"We see people who come to the support group who seem to be rushed into IVF without a real assessment," she said. "They feel so desperate that if somebody told them to stand in the corner or cut off their arm or something - if they thought they'd have a child out of it - maybe they'd do it."

The magic ingredient

The "maybes" surrounding Robitussin start with an ingredient called guaifenesin, a tree-bark extract first discovered by the native population of the Bahamas to work as a natural expectorant, thinning the mucus in the lungs and making it easier to breathe. Adopted and exported by European explorers, the drug has been used in Canadian cough and cold medication since 1940.

In the 1980s, some women reported to their doctors that the product seemed to also effect cervical mucus, leading to speculation that it could facilitate the passage of sperm. The idea is not that far-fetched. Progesterone-based birth control pills work, in part, by producing the opposite effect, thickening cervical mucus to prevent sperm from getting through.

Thirty years ago, a diagnosis of "hostile mucus" was commonplace for women having trouble conceiving, and patients were subjected to postcoital testing to see how much of their partner's sperm had made it up the genital track.

A Pennsylvania doctor, Jerome Check, published an article called "Improvement of cervical factor with guaifenesin" in the Journal of Fertility and Sterility in 1982. It documented a study of 40 couples who had been attempting unsuccessfully to conceive for at least 10 months.

The women were given 200 milligrams of guaifenesin three times a day, from the fifth day of menstruation through to ovulation. Dr. Check found that 23 of the women showed "marked improvement in postcoital tests after treatment, while seven showed slight improvement," meaning that their cervical mucus was noticeably thinner.

More important, of those 23 couples, Dr. Check wrote that 15 became pregnant while testing the regimen. One patient with only mild improvement in her mucus levels also conceived. Dr. Check concluded that guaifenesin is "one of the simplest and cheapest treatment methods of addressing the cervical factor."

You might expect such a declaration to produce an instantaneous ad campaign showing beaming women sipping cough syrup and rubbing their bellies, swollen with child.

But in nearly 30 years since his initial experiment, Dr. Check's study has been met with silence, both within the scientific community and from pharmaceutical companies that make the product.

Pfizer Canada, which manufactures Robitussin here, would not comment on its reputation as a fertility aid.

Caroline Hey, the communications manager for Reckitt Benckiser Group PLC, which makes the U.S. equivalent, Mucinex, said the product should be used only according to package directions.

"We do not have any data for the use of Mucinex for fertility issues nor do we recommend its use for this purpose," she said in an e-mail.

The medical disconnect

The lack of data on Robitussin's off-label reputation is surprising in an era when everything from road rage to sleep apnea has been the subject of scientific study, and in a market where antidepressants have been repackaged as smoking-cessation tools and birth control is used as acne medication.

But when it comes to fertility, in-vitro fertilization appears to have become the first and final word for women attempting to conceive.

Anthony Cheung, a reproductive endocrinologist and medical director of the in-vitro fertilization program at the University of British Columbia's Centre for Reproductive Health, is familiar with the theories surrounding Robitussin, but he believes they're esoteric in the grand scheme of fertility issues. "If it was that easy, I would think couples really wouldn't need anything," he said. "I think it's interesting and I don't think we should write it off completely, but like all things, it should go through the same trials to prove or disprove it."

And therein lies the problem, he said. Since the 1980s, postcoital investigations of fertility issues have lost favour as scientific standards have become more rigorous. There is really no way to standardize what is "normal" when it comes to conception. How much mucus is too much? How thin does it need to be for sperm to get through? The answers could be different for every couple.

So the medical community has moved on, propelled by advances in technology that have seen in-vitro fertilization become standard treatment for fertility problems. "Cervical mucus can be overcome by doing insemination, so it doesn't even matter," Dr. Cheung said of Robitussin's possible effect.

But women prefer to conceive naturally, and the rapid push toward medical intervention can be unsettling.

When Meghan O'Brian began asking doctors about her inability to conceive, she was quickly directed toward more invasive, expensive procedures such as hormone therapy and in-vitro insemination, even though tests showed no obvious barriers to natural conception. When she questioned the need to take such a big step at her age, she was told by one doctor not to come back until she was serious about getting pregnant. When her sister told her about Robitussin, she and her husband decided to give it a try. "It just seems like such an easy first step," she said. "In our case, it was like, 'Why not?'"

For Jennifer, a 40-year-old Toronto security specialist and mother of two, hearing that someone had a positive experience with Robitussin means more than any study or clinical trial. She and her husband are trying for a third child, and their age makes it unlikely that they will conceive without considerable luck and effort.

She heard about Robitussin on one of her TTC forums, which she says operate as unofficial peer-review boards. Immediately after she began taking the stuff, late last year, Jennifer said she noticed a difference in her levels of cervical mucus. After three months, she conceived, although she suffered an early miscarriage. She is certain that Robitussin played a role in helping her get pregnant, however briefly.

"Believe me, I chart whatever I used that month," she said. "There are thousands of women who do the same thing."

Colette Bouchez, a U.S. medical journalist and co-author of the bestselling book Getting Pregnant, believes there are simple remedies that can be effective for certain couples.

"It's not a cure-all for every fertility problem," she said of Robitussin. "If you have a tubal problem, or an infection, or a different type of hormone imbalance, this is not going to help you get pregnant."

The first edition of her book came out in 1988, and has contained a chapter on guaifenesin ever since. She says she has heard hundreds of anecdotes about its effectiveness.

Despite the references to Robitussin in her work, Ms. Bouchez says she has never heard from a pharmaceutical company asking her to share her research, or asking her to stop talking about it.

Those companies are in the business of curing coughs and colds, she said, not addressing infertility. And while the number of women struggling with conception is by no means small, Ms. Bouchez says it is "infinitesimal" compared with the population suffering from coughs and colds. Robitussin reeled in $199-million (U.S.) in 2008 alone.

Besides, she says, guaifenesin's reputation is established, and the blessing of its manufacturers would probably have little impact. "Even if a study comes out and proves it doesn't work, I see women continuing to try for a long time," she said. "The truth is, for many women, it works."