Unveiling Ayurveda Perspective in Successful Treatment of Adenomyosis-Related Primary Infertility

Infertility remains to be a women’s social burden despite all the recent advances in the field of reproductive medicine. Infertility is defined as failure of conception even after regular unprotected vaginal intercourse for 12 months or more. It is estimated to affect between 8 and 12% of reproductive-aged couples worldwide.[1] Primary infertility is an obvious worldwide concern wherein the couple is accused by society as “childless” which may be caused by a range of underlying pathologies. Uterine adenomyosis is one of such pathologies of the uterus, in which there is ingrowth of the endometrium, both the glandular and stromal components directly into the myometrium.[2] It generally manifests as menorrhagia, dysmenorrhea, pelvic pain, and infertility. As per recent studies, adenomyosis is being diagnosed with rising incidences of associated infertility.[3] Although Ayurveda does not directly involve references regarding adenomyosis, it contains an elaborate description in the context of infertility and menstrual abnormalities. A disease entitled as ‘Asrigdara’ in Ayurveda is characterized by excessive or prolonged menstruation with or without intermenstrual bleeding. Taking into consideration, the clinical presentation of adenomyosis, a diagnosis of Asrigdara was made, and its management principle was adopted. In the present study, we report the case of primary infertility associated with adenomyosis, treated successfully with Ayurveda shamana therapy and panchakarma. The report offers evidence of encouraging results of Ayurveda in the management of primary infertility associated with adenomyosis. Case Report Patient information A Jaipur-based 33-year-old married female patient (height- 161cm and weight- 64 kg) reported Prasutitantra Striroga outpatient department (OPD), NIA hospital on June 19, 2021, complaining of heavy menstrual bleeding for 6–8-day duration, painful menstruation since December 2018, i.e., 2.5 years, and inability to conceive even following regular unprotected sexual intercourse for the past 3 years. The semen analysis of her husband dated on April 18, 2021, revealed no significant abnormality. Associated complaints The patient also reported to experience loss of appetite and nausea during menses for the last 2 years. Last menstrual period - 08.06.2021 Menstrual history On inquiring about menstruation details, the patient had onset of menarche at the age of 13 years. She developed menstrual abnormalities, i.e., heavy and painful menstruation for the last 2.5 years. The duration of her menstrual cycle was 6–7 days with an interval of 25 days with a flow of clots approximately equal to the size of 50 paisa coin (Indian currency) for the first 2 days of periods and severe pain during menses that she made her unable to perform any activity but just to lie on the bed. Pad history To assess the amount of bleeding during menstruation, a significant pad history was taken. Day 1 to 4 – 4 pads/day, fully soaked Day 5 to 7 – 3 pads/day, fully soaked Color- Blackish Red (Maroon in patient’s language) Touch- Hot, associated with burning Obstetric history Her obstetric history revealed that the patient was nulligravida. Married life: 3.5 years. Active married life: 3.5 years. Coital History: 3–4 times/week. Contraception History: Nil Previous contraception history revealed the use of condoms by the husband for 6 months after marriage. History of present illness The patient was asymptomatic 3 years prior visiting NIA OPD for the first time. Six months later, since December 2018, she developed complaints of heavy menstrual bleeding for 6–8 days and severe pain during menstruation for which she consulted a Jaipur-based gynecologist and was prescribed allopathy medication. She also complained of wants issues for the past 3 years. Since no improvement was felt, she visited a gynecologist located at Ahmedabad in year 2019. Still, there was no improvement, so she reported to Striroga OPD, NIA hospital for further treatment. Other existing illnesses or comorbidities There was no significant comorbidity or illness noted. Furthermore, there was no significant past medical as well as surgical history present. Family history and social history The patient had a family history of hypertensive disorder in her mother as well as her father. She belonged to an upper-middle-class family. The couple had no addiction history. Occupational details The patient was working in a bank and her husband was working as an engineer. History of past illness No significant past illness was noted. Clinical examination - GC- fair - BP- 120/70 mm of Hg - PR – 94/min - BMI- 24.7 kg/m2. Diagnostic focus and assessment The data received from the diagnostic tests were as following: Ultrasonography examination report A USG report dated on 02/27/2021 revealed focal fundal adenomyoma measuring 37 mm × 27 mm in the fundal region on the right side with loss of endomyometrial junction [Figure 1]. Uterine size: 90 mm × 53 mm × 43 mm ET: 4 mm. Hormonal analysis AMH report dated on 12/28/2018 showing a level of 0.84* ng/ml. Hematological reports Complete blood count showing hemoglobin- 10.6 gm/dl White blood count – 10,400 U/L Ayurvedic Interpretation of Patient’s Condition Diagnosis Based on the detailed analysis of history, clinical manifestations, and objective parameters, the patient was diagnosed with primary infertility with adenomyosis. In view of Ayurveda science, based on subjective parameters, the condition can be correlated with Anapatya Vandhya associated with Asrigdara. Samprapti Ghataka: Dosha: Tridosha (Pachaka Pitta, Apana vata, Kledaka Kapha) Dushya: Rasa, Rakta, Mansa Agni: Dhatwagni Srotasa: Rasavaha, Raktavaha, Mansavaha, Artavavaha Udbhavasthana: Aampakwashaya Srotodushti: Atipravritti Rogmarga: Abhyantara Vyaktisthana: Garbhashaya Rogvinishchaya: Asrigdara Sadhyasadhyata: Sadhya Therapeutic Focus and Assessment This section contains the detailed protocol and guidelines regarding prescribed medication and virechana along with its mode of action. Plan of treatment - Shamana Karma [Table 1][1] Includes set of internal Ayurveda medicine prescribed for 3 months. - Shodhana Karma [Tables 2 and 4] Involves the details of panchakarma – Virechana procedure carried out. - Diet modification Avoiding overeating, excessive sour eating, and eating oily foodstuffs. - Lifestyle modification Avoiding stress, day sleeping, and late nights.

A timeline of events and results is described in a tabular form [Table 5].[3] Follow-up and outcomes Satisfactory improvement in the complaints was noticed as early as two cycles of the therapy. The patient missed her periods in the 4th month of the treatment and got her Urine Pregnancy test positive. Pregnancy was continued without any complications and she delivered a live female child of weight 2.9 kg through full-term cesarean section uneventfully. The timeline of the patient’s progress against the given interventions is detailed in Tabular form [Table 4 and Figures 1, 2a and b].

Primary infertility is a condition wherein the woman has never been diagnosed with a clinical pregnancy and fulfills the criteria of being classified under the category of infertility. The prevalence of infertility in reproductive-aged women has been estimated to be one in every seven couples in the Western world and one in every four couples in developing countries.[1] This issue is concerned with a lot of emotional and social problems for couples such as low self-esteem, frustration, lack of sense of well-being, and increasing grieving for children along the age. Out of the number of underlying causes, adenomyosis is lately seen associated with infertility in nulliparous women. Most of the recent studies reported that there is poor reproductive outcome after ART in infertile cases associated with adenomyosis that emerges the scope of Ayurvedic medicine practices in this field.[3] There is no direct description of adenomyosis in Ayurveda classics but it is enriched with a comprehensive and meticulous discussion regarding menstrual abnormalities and infertility. In view of this, Acharya Charaka opined that the diseases are uncountable and therefore, the de novo discoveries of the disease should be understood based on Prakriti (nature), Adhishthana (site), Linga (Symptoms), and Ayatana (Causative agent).[4] Following this principle, the clinical manifestations of the case such as heavy menstrual bleeding, painful menses, and passing of large-sized blood clots were taken into account to understand its pathogenesis. In correlation, it seemed that the manifestation is similar to the description of Asrigdara in Ayurveda classics and adenomyosis in modern. Asrigdara is characterized by Rajah Pradirana – excessive and/or prolonged menstruation which is cyclic or not, in which there is altered menstrual blood that can be referred to the menorrhagia (70%) in adenomyosis and is associated with severe pain which can be referred to the dysmenorrhea manifestation of adenomyosis. Hence, the case was diagnosed with Asrigdara and based on the following correlation, the involvement of tridosha was considered in the pathophysiology [Table 6]. The principle of management in Asrigdara suggested by Acharya Charaka is the use of raktastambhaka (hemostatic) drugs and treatment just like raktayoni considering the association of dosha based on the color and smell of blood.[5] Whereas Acharya Kashyapa suggests the use of purgation while managing all menstrual disorders.[6] In asrigdara, heavy menstrual bleeding leads to the poor general condition of the patient which does not allow vigorous treatment such as shodhana (purification) therapy. Following these principles, treatment plan including Shamana therapy initially for 3 months to control the bleeding and improving the general condition of the patient, followed by Shodhana – virechana karma (Purgation) was planned. Shamana therapy As per Ayurveda, Vatadosha is responsible for the vibhajanakarma[7] (Division) which can be viewed as vitiated in case of adenomyosis wherein there is no differentiation between the endometrial and myometrial layer at the site of the lesion. The formulation Kushmanda rasayana indicated in raktapitta in ashtanga hridaya[8] text was prescribed here to treat Asrigdara (heavy menstrual bleeding) as well as to correct Vata vitiation by virtue of Medhya property of Kushmanda (Benincasa hispida). Taking into account, the alteration of complexion and consistency in previously normally flowing menstrual blood, raktaprasadana with raktaprasadaka hima was planned. Hima kalpana, the one among panchavidhaKashaya kalpana is the best pitta pacifying formulation. Raktaprasadaka hima contains Solanum nigrum Linn. Hemidesmus indicus R. Br., Phyllanthus urinaria Linn., Rubia cordifolia Linn., and Vetiveria zizanioides Linn.[9] These constituents possess potent raktaprasadana (blood purification), Dahaprashamana (reduce burning sensation), and shothahara (anti-inflammatory) properties. Shivagutika is a standalone polyherbal formulation indicated in various types of pradara, yoniroga, arbuda. Shilajit, its main ingredient is reported to possess potent anti-inflammatory and analgesic properties that are recommended in adenomyosis cases. Besides, it is rasayana (Rejuvenating),[10]balya (strengthening), vrishya (aphrodisiac), and scraps off unhealthy tissue. Hence, it was prescribed to promote fertility, remove unhealthy endometrial growth inside myometrium, and replace it with newly generated healthy tissue by its rasayana effect. The case also manifested as painful menstruation. The underlying pathology is adenomyosis- the presence of endometrial tissue in myometrium which can be understood as vimargagamana of artava following apanavata vaigunya. Anulomana (regulation) is the choice of therapy indicated to correct apanavata vaigunya and vimargaga artava. Haritaki[11] is appraised as the supreme drug for anulomana whereas Eranda taila has antagonistic action to vitiated vata.[12] Therefore, Eranda taila bhrishta haritaki (Terminalia chebula fried in castor oil) was prescribed. Shodhana therapy Once raktasthapana was achieved to an optimum level and the patient’s general condition was improved, it was planned to go ahead with shodhana therapy. The predominant Dosha in Asrigdara is Pitta, whereas Raktadushti is involved in pathogenesis, for which Virechana serves as the supreme Shodhana procedure.[13] Furthermore, Apanavritta pitta is the leading causative agent of Asrigdara and Virechana is the choice of therapy to correct vitiated Apana Vata.[14]Trivrit Avalaeha is a virechana dravya with tikta rasa and raktaprasadana, malashodhana and dahaprashamana properties. Hence, Virechana using Trivrit avaleha was planned in this case.[15] To attain nirama avastha prior snehana, it was decided to opt for deepana-pachana with Shankha bhasma and Gandhaka vati. Abhyantara snehana, followed by Sarvanga snehana and swedana, was the next step as per protocol. Virechana was administered on the next day which resulted into Madhyama shuddhi and so, samsarjana karma[16] for 5 days was advocated following shodhana. Virechana in the study served to correct the vitiation of pitta. Trivritlehyam may have served to correct the altered menstrual flow and restoring the normalcy of blood in this study. (Ch.Su. –26) Virechana drugs act by virtue of Adhobhagahara prabhava which can be thought of to correct the pelvic region pathologies presented in the study. Acharya Sushruta emphasized the presence of healthy Kshetra (uterus and other reproductive organs) and Beeja (Aartava) for achieving conception. Virechana acts by two-fold mechanism- purifies kshetra i.e. uterus by getting absorbed and transported through micro channels and purifies beeja i.e., Aartava. These might have helped synergistically to correct Asrigdara and achieving conception in the present study.

The present report unveils the Ayurveda perspective in the successful treatment of adenomyosis-related primary infertility. The success of the therapy lies in achieving conception in the 4th month of the treatment course following 3 months of shamana therapy. However, the protocol followed here should be subjected to larger sample size for validation of results and generating strong evidence. Patient consent Couple gave written consent for the purpose of publication of their case-related clinical work. Patient perspective on the treatment Monthly feedback from the couple regarding the therapy suggested gradual improvement in subjective parameters such as bleeding and pain during menstruation. The feedback taken by the end of 4th month revealed that the couple was completely satisfied and happy with the conception achieved long 3 years after marriage and has doubled the faith in Ayurveda than before. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Authors’ contribution statement DDP: Conceptualization, study design, data acquisition, data analysis, manuscript drafting, editing, and final review. S: Conceptualization, study design, supervision of the clinical study, data analysis, manuscript drafting, editing, critical review, validation, and resource provision. VK: Study design, supervision, validation, data analysis, manuscript editing, validation, and resource provision. Data availability statement All data obtained during the study have been securely stored, either in physical or electronic form as appropriate. All datasets are maintained without personal identifiers and are retained by the corresponding author, who will provide access upon reasonable request and under appropriate conditions. Declaration of AI use in scientific writing The authors used OpenAI-based tools solely for grammar and language refinement. Following this, all content was thoroughly reviewed and edited by the authors, who take full responsibility for the accuracy, integrity, and originality of the final manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Adenomyosis; Asrigdara; ayurveda; primary infertility; Virechana