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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 33-39

Role of ayurveda in the management of female infertility due to poly cystic ovarian syndrome with a history of bilateral ectopic pregnancy, right sided salpingectomy, and left sided hydrosalpinx: A clinical case report


Department of Shalya Tantra, Prasuthi Tantra and Stree-Roga, S. D. M. Institute of Ayurveda and Hospital, Bengaluru, Karnataka, India

Date of Submission08-Feb-2021
Date of Acceptance05-Mar-2021
Date of Web Publication17-Apr-2021

Correspondence Address:
Bharathi Dattaram Anvekar
Department of Shalya Tantra, Prasuthi Tantra and Stree-Roga, S. D. M. Institute of Ayurveda and Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijaim.ijaim_4_21

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  Abstract 


Poly cystic ovarian syndrome (PCOS), fallopian tubal blockage, and repeated spontaneous abortions are some of the causes of female infertility. Hormonal treatment or drilling of ovaries, microsurgery of fallopian tubes, and in vitro fertilization are the accepted standard treatment procedures. In Ayurveda, the condition is correlated with named as Vandhyatva. Acharyas have described the causes as Garbhasrava, Beeja Dushti, and Mithya Ahara Vihara. Here, we report a case of infertility secondary to PCOS with a surgical history of emergency laparoscopic right-sided salpingectomy for ectopic pregnancy. Methotrixate administration for left side ectopic pregnancy, consequently for second time and left-sided hydrosalpinx. The case was treated as per the classical reference which includes virechana karma, kala basthi, marsha nasya karma, and Uttara basthi karma. Music therapy, rasayana chikitsa, and yoga were incorporated as adjuvant therapy to achieve shuddha garbha sambhava samagri (pure factors of fertilization and conception). Adopted treatment plan has given good result with successful intrauterine pregnancy and birth of healthy female baby through cesarean section.

Keywords: Ayurveda, ectopic-tubal pregnancy, infertility, kalabasthi, marsha nasya, music therapy, poly cystic ovarian syndrome, virechana, yoga


How to cite this article:
Anvekar BD. Role of ayurveda in the management of female infertility due to poly cystic ovarian syndrome with a history of bilateral ectopic pregnancy, right sided salpingectomy, and left sided hydrosalpinx: A clinical case report. Indian J Ayurveda lntegr Med 2021;2:33-9

How to cite this URL:
Anvekar BD. Role of ayurveda in the management of female infertility due to poly cystic ovarian syndrome with a history of bilateral ectopic pregnancy, right sided salpingectomy, and left sided hydrosalpinx: A clinical case report. Indian J Ayurveda lntegr Med [serial online] 2021 [cited 2021 Jun 18];2:33-9. Available from: http://www.ijaim.com/text.asp?2021/2/1/33/313996




  Introduction Top


According to the World Health Organization (WHO), infertility can be described as the inability to become pregnant, maintain a pregnancy, or carry a pregnancy to live birth.[1] A clinical definition of infertility by the WHO and ICMART is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”[2] Infertility can further be broken down into primary and secondary infertility. Primary infertility refers to the inability to give birth either because of not being able to become pregnant or carry a child to live birth, which may include miscarriage or a stillborn child.[3],[4]

Polycystic ovarian syndrome (PCOS) is a set of symptoms due to elevated androgens (male hormones) in females.[5],[6] Signs and symptoms of PCOS include irregular or no menstrual periods, heavy periods, excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, mood disorders, and velvety skin.[7] It is the most common endocrine disorder among women between the ages of 18 and 44.[8] It affects approximately 2%–20% of this age group depending on how it is defined.[9],[10] When someone is infertile due to a lack of ovulation, PCOS is the most common cause.[5] PCOS is due to a combination of genetic and environmental factors.[11],[12],[13] Risk factors include obesity, a lack of physical exercise, and a family history of someone with the condition.[9] Diagnosis is based on two of the following three findings: no ovulation, high androgen levels, and ovarian cysts.[14] Cysts may be detectable by ultrasound.[15]

PCOS has no cure.[16] Treatment may involve lifestyle changes such as weight loss and exercise.[17],[18] Birth control pills may help with improving the regularity of periods, excess hair growth, and acne.[19] Metformin and anti-androgens may also help.[19] Other typical acne treatments and hair removal techniques may be used.[19] Efforts to improve fertility include weight loss, clomiphene, or metformin.[20] In vitro fertilization (IVF) is used by some in whom other measures are not effective.[20] Ectopic pregnancy is a complication of pregnancy, in which the embryo attaches outside the uterus.[21] Any sexually active woman of childbearing age is at risk of an ectopic pregnancy and often the reason for the ectopic pregnancy will never be determined. Tubal pregnancy is when the egg is implanted in the fallopian tubes. Hair-like cilia located on the internal surface of the fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the fallopian tubes is likely to lead to an ectopic pregnancy.[22] Women who smoke have a higher chance of an ectopic pregnancy in the fallopian tubes. Smoking leads to risk factors of damaging and killing cilia.[22] As cilia degenerate, the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it does not reach the uterus in time, will hatch from the nonadhesive zona pellucida and implant itself inside the fallopian tube, thus causing the pregnancy.[22] Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy.[23] This results from the build-up of scar tissue in the fallopian tubes, causing damage to cilia.[24] If however both tubes were completely blocked so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur.[24]

A history of a tubal pregnancy increases the risk of future occurrences to about 10%.[24] This risk is not reduced by removing the affected tube, even if the other tube appears normal. Fertility following ectopic pregnancy depends on several factors, the most important of which is a prior history of infertility.


  Case Report Top


A female patient with married life of 6 years from Bidadi, Bangalore, presented with amenorrhea for 1½ month, with a history of irregular, scanty, and painful menstruation. Past medical history revealed twice tubal ectopic pregnancy.

Timeline

Female had developed irregular, scanty, painful menstruation after undergoing IVF in one of the hospitals at Bangalore in 2017. However, IVF was not successful. Ultrasonography of the abdomen and pelvis revealed bilateral polycystic ovarian disease (PCOD). She was treated with oral hormonal pills for 6 months. During the course of oral hormonal treatment, she had regular, but painful menstruation and no signs of conception. She consulted Ayurveda clinic in Mysore for her problems but promising results were not obtained. In June 2018, she consulted our hospital and underwent ultrasonography of abdomen and pelvis (August 2018) which revealed bilateral PCOD. In 2013, she had undergone emergency laparoscopic right-sided salpingectomy under spinal anesthesia, as she was diagnosed very late with right-sided ruptured tubal ectopic pregnancy. In 2015, she had conceived second time which was left tubal pregnancy (5 weeks), termination was done by oral pills and was further treated with methotrixate. She underwent Hystero-Salpingography (HSG) and the report showed, Left tube–hydrosalpinx in ampullary region, fimbrial end clumped. However, free spill was seen. In 2017, once she underwent IVF in Milan Hospital Bangalore which was not successful. Since then she developed irregular menstruation and diagnosed with PCOD in ultrasonography report.

Since June 2018, she came to SDM Institute of Ayurveda and Hospital Bangalore. From August 2018, she was regular in taking medicine and counseling. Menstruation was found to be irregular (50–90 days usually gets after taking hormonal pills she used to get her menstruation), scanty, painful, 3–4 days-dark blackish red, more clots than liquid bleeding and required 1 pad/day, but she changed 2 pads/day to maintain hygiene. Her inner garment used to get stained during menstruation.

Diagnostic focus and assessment

Per Vaginal Examination revealed – uterus - AVNS, vagina was bathed in yellowish – white discharge. Per speculum examination revealed – cervical erosions all over the cervix with severe yellowish-white discharge adhered to the cervix and vagina. HSG in 2015 - Left tube – hydrosalpinx in ampullary region, fimbrial end clumped. However, free spill was seen. After analyzing, with the Ayurvedic principles, it was diagnosed as “Vandhyatva” “Secondary Infertility” due to PCOS (PCOD, Pimples, Hair loss).

Therapeutic focus and assessment

Chikitsa was aimed to achieve the following objectives

  1. Shuddha garbha sambhava samagri (pure factors of fertilization and conception)
  2. Shuddha arthava (purity and alignment in menstrual cycle and endocrinal co-ordination)
  3. Shalyas - Physical, Mental, Emotional, and social Stressful factors, to attain prassannatmendriya mana (satiation of body, mind, and spiritual)
  4. To attain health in mother at all levels (physical, mental, emotional, spiritual, and social) and to obtain healthy progeny.


The chikitsa (treatment) schedule planned was Deepana Pachana chikitsa (digestive and assimilative medicine given before shodhana chikitsa), Shodhana chikitsa (detoxification treatment), Virechana karma (detoxification – Medical purgation treatment), Sarvanga Abhyanga and Swedana (medicated oil massage and steam), Kala basthi karma (medicated enema), Nasya karma (medicated nasal drops), Uttara basthi (medicated intrauterine treatment), music therapy, counseling and yoga – mohana raga, surya namaskara, chinmudra pranayama and meditation, and omkara recitation. Local treatment adopted for cervical erosion were Yoni prakshalana-medicated vaginal wash (vaginal douch), Yoni dhoopana (medicated vaginal fumigation), and Yoni pichchu dharana (medicted vaginal tampon). Regular counseling was planned as per the changes, and feedback was collected from the lady and her husband. The treatments were carried out as scheduled in [Table 1],[Table 2],[Table 3],[Table 4].
Table 1: Treatment scheduled (August 2018-October 2018)

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Table 2: Virechana karma sthanika chikitsa sarvadaihika chikitsa (from last week of October 2018 to 1st week of November 2018)

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Table 3: Kala basthi karma sarvadaihika chikitsa (from last week of November 2018 to 1st week of December 2018)

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Table 4: Nasya karma chikitsa (in 1st week of January 2019)

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  Results Top


After the virechana karma followed by kala basthi, she had her menstruation on December 28, 2018 (after 6 months of amenorrhea). Menstruation was uneventful that is she did not suffer with any pains, and liquid part was more than the clots in menstrual bleeding. Color of menstrual bleeding was light blackish red. Her inner garments were not stained. 5-day bleeding with less small clots was observed by the patient. Her weight also increased by 2 kg after the kala basthi (from 58–60 kg). By this time, pimples had reduced completely. She was happy as her face was clear and chubby cheeks.

After the sthanika chikitsa (local per-vaginal treatment) through vaginal route, cervical erosion healed and healthy cervix noted.

The two follow-up examination showed – P/V-uterus–AVNS, no white discharge was seen. P/S-Cx–healthy. She missed her menstruation on January 28, 2019. On February 22, 2019, urine test for pregnancy was positive. It was confirmed as intrauterine pregnancy with gestation sac and yolk sac, in ultrasonography of abdomen and pelvis. Repeat scan was done on March 14, 2019 which showed CRL-1.95 cm, yolk sac was seen, and fetal heart pulsation seen 178 beats/min. Intrauterine pregnancy of 8 weeks 4 days.


  Discussion Top


Discussion is a detailed treatment of a topic in speech or writing, in order to reach a decision or to exchange ideas. Herewith, I have tried to analyze the ayurvedic samprapthi and treatments for the infertility due to PCOS and ectopic pregnancy, with the help of our proud Acharya's principles. It has been explained in our samhitas, the purity of arthava (menstrual flow) is the primary unit for garbhotpatti (fertilization and conception). Our acharyas have highlighted that the menstrual blood does not leave any stain on the cloth.[25] This is the sign of purity in menstrual blood and indicates the forthcoming ovulation.

It was noted that, after course of deepana, pachana, virechana karma, and kala basthi karma, menstruation was uneventful, that is she did not suffer with any pains and liquid part was more than the clots in menstrual bleeding. Color of menstrual bleeding was light blackish red. Her inner garments were not stained. 5-day bleeding with less small clots was observed by the patient. This indicates the purity of the arthava menstrual bleeding.

Her weight also increased by 2 kg after the kala basthi (from 58–60 kg). By this time, pimples had reduced completely. She was happy as her face was clear and chubby cheeks. In Charaka Samhita Shareera Sthana 4th chapter named Mahati garbhavakranthi, commentator of Charaka Samhitha, Acharya Chakrapani has explained that, garbha gradually enters garbhashaya. However, if there is vikara in garbha, by the time, it reaches kukshi or garbhashaya, it may get destroyed (kukshau jayamana; kukshau vinasham prapnoti) and brings in death (katsnyernavinashyan iti marana gachchan).[26]

Our Acharyas have written in sutra form. While explaining the early growth of fertilized ovum, Acharya Charaka has used the term kheta bhuta which means shleshma sadrashya-slippery in nature,[27] which is quiet similar to Zona pellucida-outer layer of the zygote. This layer helps the zygote, to slide down with its slippery nature, from fallopian tube to the intrauterine cavity of the uterus for the implantation. One of the etiological factors for the tubal pregnancy is premature loss of the layer zona-pellucida, loss of kheta bhuta can be compared to sthanika shleshma ksheena, when the fertilized ovum is in the ampulla part of the fallopian tube, as the fertilization occurs in the ampulla. Thus, the zygote gets fixed to the fallopian tube, leading to rupture of the tube and destruction of the zygote if goes unnoticed by the medical faculty. Thus, tubal pregnancy gets destroyed and increases the mortality rate of the mother.

Subserosa layer of the fallopian tube is composed of loose adventitious tissue, blood vessels, lymphatics, an outer longitudinal and inner circular smooth muscle coats. This layer is responsible for the peristaltic action of the fallopian tubes. In turn, this peristaltic movement helps in the gliding movements of zygote toward the intrauterine cavity of the uterus. These movements can be compared to apana-vata, which is present in shroni pradesh and is responsible for all the movements in the shroni. There is apana vata vigunata (improper function of apana vata). This is exhibited in the form of, irregular menstruation, sometimes meno-metrorragia other time oligomenorrhea, dysmenorrhea.

The inner layer of fallopian tube is a single layer of simple columnar epithelium. The columnar cells have microscopic hair-like filaments (cilia) predominantly throughout the tube but are most numerous in the infundibulum and ampulla. Estrogen increases the production of cilia on these cells. Between the ciliated cells are peg cells, which contain apical granules and produce the tubular fluid. This fluid contains nutrients for spermatozoa, oocytes, and zygotes. This can be compared to shleshma, rasadhatu. Tubal fluid flows against the action of the cilia, toward the fimbrial end. The fertilized ovum, now a zygote, travels toward the uterus aided by activity of tubal cilia and activity of the tubal muscle. Again these movements are responsibility of apana-vata.

The early embryo requires critical development in the fallopian tube. After about 5 days, the new embryo enters the uterine cavity and on about the 6th day implants on the wall of the uterus, which is again co-ordinate activity of vata-kapha-pitta in shroni and minute srotas in shroni.

Fallopian tube obstruction is associated with infertility and ectopic pregnancy. Risk factors for ectopic pregnancy include: PID, often due to chlamydia infection, tobacco smoking, prior tubal surgery, a history of infertility, and the use of assisted reproductive technology. Those who have previously had an ectopic pregnancy are at much higher risk of having another one. Most ectopic pregnancies (90%) occur in the fallopian tube, which are known as tubal pregnancies.[28]

The presence of multiple pimples, heavy perspiration in palms and soles, often suffering from cold, constipation, irregular menstruation (more often amenorrhea), anxiety, and depression indicates the reduced immunity, accumulation of free-radicals in the body, disturbances at mental, emotional, spiritual, and social levels due to loss of zygote in twice ectopic tubal pregnancies and unsuccessful IVF. Our acharyas have highlighted the importance of shuddh garbha sambhava samagri (pure sperm, ovum, uterus, and bod fluids) to obtain a healthy garbha. And shuddhata of shareera and manas (pure body and mind) is also equally important.

Acharya Sushruta while explaining swastha laxana has given equal importance to equilibrium at physical level –- shareera (samadhosha, samagni, samadhatu, sama mala, and kriyas of dosha-agni-dhatu-mala), spiritual level – prasannata of atma (satiation or brahmananda), mental level – prasannata of mana (happiness in all situations), and emotional level – prasannata of indriyas (liveliness jnyanendriyas and karmendriyas). In jathaharini adhyaya, it has been mentioned that, to get a healthy progeny, the couple have to follow “Dharma palana (Dharanath dharmaha)” that is good conduct to maintain health at physical, mental, emotional, spiritual, and social levels.

By considering the abovementioned etiological factors, the exclusive treatment schedule was planned to target health at physical, mental, emotional, spiritual, and social level. The plan is shown in the following [Table 5]. After the Deepana Pachana for 2 months, virechana karma was done after the samyak snigdha laxana with trivruth leha and gandharva hasthadi taila, respectively, on 9th and 10th day. On 15th-day follow-up after the virechana karma, her pimples had subsided. Sweating in palms and soles had reduced completely. Sneezing, running nose, and cold had been subsided completely. Up to 1 month, same health was maintained.
Table 5: Treatment plan

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In second course, kala basthi karma – Anuvasana basthi – was done with Phala ghrita 75 ml - for 9 days. On 6th and 12th day of kala basthi karma, Gandharva hasthadi taila 50 ml - for 2 days was used for Anuvasana basthi karma. Niruha basthi-was done with Honey 50 ml + Saindhava lavana10 g + Shatapushpa churna10 g + Phala ghrita75 ml + Eranda mula churna kashaya - 300 ml - for 5 days. After the completion of kala basthi karma, lady had her menstruation (after 6 months of amenorrhoea) on December 28, 2018. Lady reported that, her menstruation was uneventful, without any pains. Consistency wise liquid part was more than the clots in menstrual bleeding. The color of menstrual bleeding was light blackish red. 5-day bleeding with less small clots was observed by the patient. 3 pads/day changed by the lady. Arthava (menstrual bleeding) highlights about homeostasis in the body, as arthava is the upadhatu (subpart) of rasa dhatu. Homeostasis was attained. It also indicates the forthcoming ovulation.

Activeness, good healthy rapport with family and friends, involvement in her daily chores and smiling face throughout the day in lady (observed by her husband, friend, and in follow-up checkup). This indicates the stress-free body, mind, emotions, spiritual, and social well-being in lady. Music therapy, surya namaskara, and chinmudra pranayama are the parts of rasayana chikitsa. They have succeeded in returning her regular dinacharya. Music and yoga are the part and parcel of our daily work. For manasika shalya harsha, chikitsa is indicated.

From 8th day of menstruation that is on January 5, 2019, marsha nasya karma was started with anu-taila. The nasya treatment was done up to January 11, 2019. Counseling and music therapy were carried out on 5th and 11th January 2019. She missed her menstruation in January 2019. On February 22, 2019, urine test for pregnancy was done at home by patient herself, which was positive for pregnancy. It was confirmed as intrauterine pregnancy with gestation sac and yolk sac, in ultrasonography of abdomen and pelvis. Repeat scan was done on March 14, 2019 which showed CRL-1.95 cm, yolk sac was seen, and fetal heart pulsation seen 178 beats/min. Intrauterine pregnancy was 8 weeks 4 days.

Patient consent

Informed consent regarding documentation and publication of the case study was obtained from the lady and her husband. Her husband has written about this case in review column in SDMIAH.


  Conclusion Top


Quality of life was hampered in patient due to irregularity in consuming food, sleep pattern, stress in day today life. Hampered quality of life had negative effect on shuddha garbha sambhava samagri, leading to ashuddha garbha sambhava samagri (impure factors of fertilization), irregular menstrual cycles and irregular flow, scanty flow. She was unable to conceive child. She had a history of bilateral ectopic tubal pregnancy and losing one tube in salpingectomy and the other tube with hydrosalpinx. Adopted Ayuveda has played very important role through dinacharya, virechana karma, kala basthi and marsha nasya karma, music therapy, yoga and pranayama, in obtaining shuddha garbha sambhava samagri (pure factors of fertilization) in the form of delivering a healthy female child through elective cesarean section.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and her husband have given their consent for images and other clinical information to be reported in the journal. The patient and her husband understand that name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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