Ayurvedic management of Tubal Block Infertility Associated with Polycystic...

[Full title: Ayurvedic management of Tubal Block Infertility Associated with Polycystic Ovarian Syndrome: A Case Study]

[Find the meaning and references behind the names: Sri, June, Naveen, Pradeep, Seema]

CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 293 Ayurvedic management of Tubal Block Infertility Associated with Polycystic Ovarian Syndrome: A Case Study Roopali R. Shindhe 1 , Naveen V 2 , Seema Pradeep 3 1 Post Graduate Scholar, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India. 2 Associate Professor, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India. 3 Professor and HOD, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India. I NTRODUCTION Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder affecting women of reproductive age, characterized by hormonal imbalances that can lead to irregular menstruation, anovulation, and the Address for correspondence: Dr. Roopali. R. Shindhe Post Graduate Scholar, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India. E-mail: roopalishindhe 1@gmail.com Submission Date: 15/05/2024 Accepted Date: 26/06/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.7.46 development of multiple small cysts on the ovaries. One of the lesser-known complications of PCOS is its association with tubal infertility, where the fallopian tubes are affected either directly or indirectly due to chronic hormonal disruptions [1] Tubal infertility, resulting from conditions like tubal blockages or dysfunction, poses significant challenges to conception, even in the absence of ovarian abnormalities commonly associated with PCOS. Understanding relation between PCOS and tubal factors is crucial in managing infertility in affected individuals, as it demands a multifaceted approach to treatment [2] Infertility impacts approximately 1 in 6 people globally of reproductive age, with consistent prevalence across diverse economic settings. This widespread health concern affects about 17.5% of adults worldwide [3] In India, infertility is estimated to affect 10% to 15% of the A B S T R A C T Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder in women of reproductive age, characterized by hormonal imbalances that cause irregular menstruation and ovarian cysts. A significant but often overlooked complication of PCOS is its association with tubal infertility, resulting from issues such as tubal blockages or dysfunctions, making conception more challenging. Infertility affects roughly 1 in 6 people globally, with about 70% of women with PCOS experiencing infertility, and tubal factor infertility accounting for 25-35% of female infertility cases. This case study examines the management of tubal blockage and PCOS through Ayurvedic treatments. A 36-year-old married woman with a history of PCOS reports no significant issues over the past six years of marriage, with irregular menstrual cycles. Clinical findings from a USG revealed bilateral polycystic ovaries, and an HSG indicated a blockage in the right fallopian tube. This infertility case was treated with a combination of Shodhana and Shamana Chikitsa was given to resolve the underlying Samprapthi from 10/7/2022 to 26/7/2023. After 12 months of treatment, the tubal blockage was resolved, PCOS had decreased, and epileptic attacks were reduced. Additionally, the absence of Reidel's lobe of the liver was noted, and the fatty liver decreased from Grade II to Grade I. The patient received a positive urine pregnancy test result on July 26, 2023, and gave birth on June 6, 2024. In this instance, Ayurveda demonstrated its reliability in treating infertility and PCOS, offering effective and holistic methods for managing these conditions. Key words: Tubal Block Infertility, Polycystic Ovarian Syndrome (PCOS), Vandhyatva, Ayurveda

[Find the meaning and references behind the names: Long, Good]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 294 population, including both primary and secondary infertility cases. Among women with PCOS, infertility affects roughly 70%, while tubal factor infertility accounts for 25-35% of female infertility cases [4] Overall, PCOS is a major public health concern due to its impact on fertility and the associated long-term health complications. Addressing this condition requires awareness, proper diagnosis, and effective management strategies tailored to different populations. In this case study, tubal blockage and PCOS were managed through treatment strategies that included Shodhana (cleansing therapies), a combination of Shamana Aushadhi (palliative medications), and the use of some Ekamoolika Dravyas (single herbs). In Ayurveda, infertility is explained as Vandhyatva . Susrutha explained factors responsible for successful pregnancy ( Garbha Sambhava Samagri ) in detail. They are Rithu , Kshetram , Ambu , and Beejam . Any abnormality in any of these four can lead to infertility. Rithu stands for the fertile period in the cycle. Kshetram represents healthy reproductive organs. Ambu represents proper nutrition after fertilization. It can be correlated with corpus luteal function up to the establishment of the placenta and then onwards placental function. Beejam stands for healthy ovum and sperms [5] Acharya Charaka opines that Soumanasyam (peaceful mind) is the best remedy for getting a progeny [6] So psychological factors are also important in conception. Arunadatta comments ‘ Dimbamsyat Drakta Mamsasya Prasaadaadaantra Sambhava ’. The ovary is taken as Kosthnga by the name Dimba or Dimbham , formed from Rakta and Mamsa [7] PCOS symptoms can be correlated with conditions like Dimba Roga , Jatiharini , Vataja Artava Dusthi , Artava Kshaya , Ksheenartava , etc. In this case study, tubal blockage and PCOS were managed through treatment strategies that included Shodhana (cleansing therapies), a combination of Shamana Aushadhi (palliative medications), and the use of some Ekamoolika Dravyas (single herbs). C ASE S TUDY Patient Information A 36-year-old married woman from Hebbal, Bangalore, Karnataka, visited a private clinic on [31/6/2022] for primary infertility. She had previously experienced two pregnancies, both resulting in abortions (G 2 A 2). Chief Complaints ▪ No issues noted in the past six years of married life. ▪ Complaints of bloating, reduced appetite, increased weight (95 kgs), anxiety, irritation, and fear for the past year. Medical History ▪ PCOS: Since 13 years. ▪ Epilepsy: Since 10 years, under medication (Levacetum 500 mg: (1-0-1) A/F) ▪ Not a known case of diabetes, thyroid, hypertension. Menstrual History ▪ Menarche: 12 years ▪ Irregular Cycles: Present for the past six years with a frequency of 30-60 days and a length of 7-10 days. ▪ Spotting noted in between the cycle for 5-10 days. ▪ Last Menstrual Period (LMP): 10/02/2021 ▪ Amount of Bleeding: Heavy, with 6-7 pads/day on Day 1, 5-6 pads/day on Day 2, and 4-5 pads/day on Days 4 and 5. ▪ Clots: Present on Days 1 and 2. ▪ Dysmenorrhea: Mild. Marital History ▪ Marital History: Since 2016 ▪ Married age: 26 years Personal History ▪ Bowel: Regular ▪ Appetite: Good

[Find the meaning and references behind the names: Anna, Mon, Ana, Anup, Suku]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 295 ▪ Bladder: Regular ▪ Sleep: Normal ▪ Allergy: None ▪ Food Habits: Consumes junk foods, fried food, pastries, and ice cream. Past Illness: None reported. Diagnostic Assessment Transvaginal Scan: 2 nd day of period B/L features of PCOS seen ▪ 30 Gfs <1 cm ▪ ENDOMETRIUM: 4 mm ▪ POD: Clear Hysterosalpingography (HSG) (21/1/22) ▪ No spillage seen on right side. ▪ Impression: Right tubal block Ultrasonography: (4/4/22) ▪ B/L polycystic ovaries ▪ Reidel’s lobe of liver ▪ Grade II fatty liver Treatment History The patient underwent conventional treatments, including two cycles of intrauterine insemination (IUI) and hormonal therapy, both of which were unsuccessful. Hence, approached the clinic on June 31, 2022, for further assistance. SN Treatment Number of days 1. Udvartana 7 days 2. Vamana 16 (including Samsarjana Krama ) 3. Internal Medication (Shamana Aoushadi) 4 months 4. Virechana 16 (including Samsarjana Krama ) 5. Internal Medication (Shamana Aoushadi) 4 months Treatment Plan and Timeline A combination of Shodhana and Shamana Chikitsa was utilized to address the complexity of the case and to resolve the underlying Samprapthi SN Treatm ent Medicines used Numb er of days Commenc ement of treatment Comple tion of treatm ent 1. Udvart ana Triphala, Devadaru, Haridara 7 days 10/7/22 17/7/2 2 2. Vaman a Deepan a - Pachana Hinguvasta ka Churna (½ Spoon with Ghritanna) 3 days 20/7/22 - 6/8/22 Rooksha na Continued with Pathya (Yava, Takra, Upma) 2 days Snehapa na Varunadi Ghritha 4 days Vishram a Kaala Banana, Curd Rice, Dahi Vada, Payasa 1 day Vamana Ksheera, (Akantapa ana) Madanapip pali-10 gm, Yastiphant a, Saindava Jala 1 day Samsarj ana Krama Anna Peya, Vilepi, Yavagu 5 days Shamana Aoushada given after Vamana SN Medici nes Treatm ent/ formula tion Dose Anup ana Commen cement Compl etion Dura tion 1 Kancha nara Guggul u 2-0-2 (after food) With Varu nadi + Suku mara 15/8/22 - 20/12/22 4 mon ths

[Find the meaning and references behind the names: Maha, Aya]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 296 Kash aya 2 Varuna di Kashay a 20 ml- 0- 20 ml (after food) With equal warm water 3 Sukuma ra Kashay a 20 ml- 0- 20 ml (after food) With equal warm water 4. Brahmi Ghrita Pratima rsha Nasya 2 drop s - 0 - 2 drop s Early morni ng and night Virechana Procedu re Treatme nt Ingredients Numb er of days Commencem ent - Completion of treatment Virecha na Deepana -Pachana Musta- Shunti Jala 3 days 5/3/23 - 21/3/23 Snehapa na Maha Kalyanaka Ghritha 4 days Vishrama Kaala Ganji, Pongal With Pomegrana te-1 Each Day Lemon Juice 3 days Virechan a Trivrut Lehya - 50 gm 1 day Samsarja na Krama Laja Peya, Anna Manda, 5 days Vilepi, Yavagu Shamana Aoushada given after Virechana SN Medici nes Treatm ent/ formula tion Dose Anup ana Comme ncemen t Comple tion Durati on 1 Bhrami Taila Shiro Pichu Alter nate days - 25/4/23 - 26/8/23 4 mont hs 2 Bhrami Ghritha Pratima rsha Nasya 0 - 0 - 2 dro ps Night ( Nish i Kaal a ) 3 Yastim adhu Ksheera paaka 50 ml - 4. Yastim adhu +Shata vari Ksheer apaka Ksheera paaka 50 ml - 5. Shatav ari ( rub the fresh root with milk on stone) Lehya 1 tsp Milk 6. Mahak alyanak a Ghritha Ghrita 2 tsp Yasti+ Shata vari Kshee rapaa ka Lifestyle Modification (Based on Dinacharya ) ▪ Regular Yoga practice: 1 hour each morning

[Find the meaning and references behind the names: Deva, Rasa, Medo]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 297 ▪ Abhyanga : Every morning before taking bath ▪ Consuming Satmya Pathya Ahara (healthy food) ▪ Reading books: 1 hour per day ▪ Dhyana/Deva Nama Japa : 30 minutes each early morning and before bedtime ▪ Pada Abhyanga : performed at bedtime O BSERVATIONS AND R ESULTS ▪ No spotting observed ▪ Regularisation of periods with frequency of 30- 35 days ▪ No clots present Ultrasonography (27/3/23) ▪ Grade I Fatty liver ▪ Mild polycystic pattern of both ovaries Hysterosalpingography (Hsg) (21/4/23) ▪ Both tubes are patent with good spillage. ▪ IMPRESSION: Right tubal block. Hsg Report Before Treatment After Treatment Pregnancy Report ▪ Last Menstrual Period (LMP): June 26, 2023. ▪ Urine Pregnancy Test (UPT): Positive on July 26, 2023. ▪ Ultrasound (USG) Report: November 7, 2023. ▪ Estimated Due Date (EDD): June 1, 2024. DISCUSSION PCOS is a disorder involving Kapha-Pitta Doshas, Rasa, Medo, Shukra (Arthava) Dhatu and Rasa, Rakta, and Artava Vaha Srotas. [8] Formulations Such as Hinguvashtaka Churna, Kanchanara Guggulu, Varunadi Kashaya, and Ghritha are used, Especially

[Find the meaning and references behind the names: Karma]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 298 after Vamana. These formulations predominantly feature Katu-Tikta-Kashaya Rasa, Ushna Virya, and Katu Vipaka, with common actions of Kapha- Medohara and Lekhaniya Karma . Research has shown that these formulations can regulate hormonal levels and enhance menstrual regularity. Additionally, their anti-inflammatory properties aid in reducing inflammation, improving insulin resistance in PCOS by boosting metabolism [9] They also help in lowering cholesterol levels, which is beneficial for women with PCOS who often struggle with lipid metabolism and obesity [10] The detoxifying effects can help clear blockages in the reproductive organs, potentially boosting fertility [4] Furthermore, the antioxidants in these formulations reduce oxidative stress and are associated with improved fertility outcomes [11] Additionally, Sukumara Kashaya helps with PCOS and infertility by regularizing menstrual cycles, which improves ovulation and boosts fertility [12] It also enhances blood circulation to the reproductive organs, providing better nourishment, reducing period cramps, and improving overall reproductive health [13] Mahakalyanaka Ghritha was administered as both Shodhana and Shamana Aushadi due to its effectiveness in treating both Vandhyatw a (infertility) and Apsmara (epilepsy) [14] It contributed to reducing epileptic attacks, alleviating anxiety and fear, and enhancing fertility. Research indicates that it has neuroprotective effects, providing a calming and stabilizing impact on the nervous system, and improves fertility by enhancing the quality of reproductive tissues and overall reproductive function [15] Shodhana procedures like Udvartana and Vamana can effectively balance hormonal levels and alleviate symptoms of PMS and PCOS by improving insulin resistance, boosting metabolism, managing weight, and enhancing overall reproductive health [16] These therapies address tubal blockages through Sroto Shodana, Deha and Kshetra Shodhana , and strengthening the Dhatus and Beeja [17] Kashyapa states that Akarmanya Beeja , which is associated with anovulation, is best treated with Virechana . He quotes "Beejam Bhavathi Karmukam ," meaning that Virechana enhances effectiveness or trajectory outcome of the action of the Beeja (sperm and ovum). As a result, it positively affects germ cells and improves their quality [18] Yastimadhu: (Shonithasthapana, Medhya Rasayana) was given in the form of Ksheerapaaka . Yastimadhu is known for its adaptogenic properties, which help in balancing hormones [19] It has phytoestrogens that can mimic the action of estrogen, thus potentially aiding in the regulation of menstrual cycles and improving ovulation and help to ease symptoms of PMS and PCOS. It helps in maintaining a healthy endometrial lining, which is essential for implantation and successful pregnancy [20] Shatavari: (Vrushya, Rasayana). Shatavari is renowned for its uterine tonic properties. It strengthens the uterine muscles and enhances the endometrial lining, which is crucial for implantation and sustaining pregnancy [21] The mucilage in Shatavari tones and protects the mucous membranes of the cervix, helping it produce sufficient mucus to facilitate sperm and egg fertilization [22] Bhrami: (Prajasthapana, Medhya Rasayana) was given in the form Ghritha and Taila Brahmi rich in antioxidants like bacosides supports reproductive health by reducing oxidative damage and alleviating psychological stress, which in turn decreases oxidative stress (OS). It helps regulate the hypothalamicpituitary-ovarian axis and supports ovulation [23] Initially, Shamana Aushadis used before and after Vamana, with Lekhaniya properties, helped reduce weight, leading to a decrease in the size and number of cysts, alleviation of inflammation in the reproductive organs, and clearance of blockages in the fallopian tubes. After Virechana, Rasayana Dravyas , known for their nourishing qualities, were chosen to support the maintenance of the endometrial lining, essential for implantation and successful pregnancy. Additionally, these Dravyas , with their Rasayana and Medhya effects, also contributed to a reduction in epileptic episodes.

[Find the meaning and references behind the names: Liu, Rahmani, Sharma, Singh, Murthy, Krishnadas, Kumar, Jain, Patel, Rao, Med, Prakashan, Mohammadi, Hum]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 299 CONCLUSION Treating the present case with necessary Shodana (purification therapies), along with Ekamoolika Dravyas (single-herb formulations), and incorporating counselling and lifestyle modifications facilitated Samprapti-Vighatana (breaking the pathogenesis) by promoting Aartavajanana (enhancement of menstrual function), Sroto Suddhi (purification of channels), Kshetra Suddhi (purification of the reproductive organs), and Prajasthapana (promoting fertility).Regular monitoring and patient adherence to the treatment plan were essential for achieving successful outcomes. Tailoring treatments according to the patient's progress ensured effective therapy. Following 12 months of treatment, the patient found a positive urine pregnancy test result on July 26, 2023 and gave birth on June 6, 2024. In this instance, Ayurveda demonstrated its reliability in treating infertility and PCOS, offering effective and holistic methods for managing these conditions. Ayurveda also holds potential for further adaptation to address similar cases in the future REFERENCES 1 Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod. 2018;33(9):1602-1618. 2 Palomba S, Falbo A, Russo T, Orio F Jr. Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review. Endocr Rev. 2015;36(1):1-50. 3 World Health Organization (WHO). 4 Liu J, Wu Q. Measuring the global disease burden of polycystic ovary syndrome in 194 countries: Global Burden of Disease Study 2017. [no journal information provided]. 5 Sushruta. Sushruta Samhita, Sharira Sthana. 3 rd ed. Varanasi: Chaukhamba Orientalia; 2007. Chapter 2, Verse 33. 6 Charaka. Charaka Samhita, Sharira Sthana. 3 rd ed. Varanasi: Chaukhamba Orientalia; 2009. Chapter 8, Verse 18. 7 Vagbhata. Ashtanga Hridaya. Translated by K.R. Srikantha Murthy. Varanasi: Chaukhambha Krishnadas Academy; 1995. Shareera Sthana, Chapter 1, Verses 20- 25. 8 Tewari PV. Ayurveda Prasuti Tantra Evam Stri Roga, Stri Roga. Part-II. Varanasi: Chaukambha Orientale; 1996. p. 169. 9 Goyal M, et al. Effect of herbal formulation on hormonal imbalance in PCOS patients. J Ayurveda Integr Med. 2012;3(3):142-147. 10 Singh R, et al. Lipid-lowering and detoxifying effects of Kanchanara Guggulu in PCOS. J Clin Ayurveda. 2013;7(4):293-301. 11 Patel S, et al. Role of antioxidants in reproductive health and PCOS management. Int J Ayurveda Pharm. 2012;4(3):211-217. 12 Rao AR, Sharma PV. Ayurvedic remedies for gynecological disorders. J Ayurveda Integr Med. 1999;7(2):81-90. 13 Jain S, Sharma P. Effects of Ayurvedic remedies on blood circulation and fertility. Int J Ayurveda Med. 2013;6(2):100-110. 14 Vagbhata. Ashtanga Hridaya. Uttarasthana, Chapter 6, Verses 26-33. Varanasi: Chaukhamba Surbharati Prakashan; 2013. 15 Sharma P. Role of Mahakalyanaka Ghritha in the management of Vandhyatwa and Apasmara. J Ayurveda Integr Med. 2016;7(2):115-120. 16 Dhanani SS. Detoxification therapies in Ayurveda. Ayurvedic Med Today. 2020;12(3):33-40. 17 Kumar K, Singh S. Role of Panchakarma in the management of PCOS: A review. J Ayurveda Integr Med. 2014;5(3):153-157. 18 Tewari PV. Kashyapa Samhitha or Vridhajivakiya Tantra. Varanasi: Chowkambha Viswabharati; 2008. p. 266. 19 Visavadiya NP, Narasimhacharya AV. Hypolipidemic and antioxidant activities of Glycyrrhiza glabra (Linn) in rats. Mol Nutr Food Res. 2006;50(11):1080-1086. 20 Mohammadi M, Heidari N, Heidarzadeh M, Asghari Gh, Rahmani MR. The effect of Glycyrrhiza glabra extract on sperm quality and reproductive potential in male rats. Andrologia. 2018;50.

[Find the meaning and references behind the names: Ahmed, Parveen, Borrelli, Jahan, Nil, Green, Chaudhary]

Roopali R. Shindhe et al. Ayurvedic management of Tubal Block Infertility ISSN: 2456-3110 CASE REPORT July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 300 21 Singh R, Sharma J, Goyal R, Sharma A. Phytochemical analysis and estrogenic activity of Shatavari (Asparagus racemosus) in experimental rats. J Ethnopharmacol. 2009;126(1):125-130. 22 Chaudhary R, Jahan A, Ahmed S, Parveen N. Effect of Asparagus racemosus (Shatavari) on cervical mucus and sperm count. Int J Green Pharm. 2012;6(2):152-156. 23 Russo A, Borrelli F. Bacopa Monnieri, a reputed nootropic plant: An overview. Phytomedicine. 2005;12(4):305-317. ******************************* How to cite this article: Roopali R. Shindhe, Naveen V, Seema Pradeep. Ayurvedic management of Tubal Block Infertility Associated with Polycystic Ovarian Syndrome: A Case Study. J Ayurveda Integr Med Sci 2024;7:293- 300. http://dx.doi.org/10.21760/jaims.9.7.46 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/unported [CC BY 4.0]), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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