Ayurveda management of primary infertility associated with endometriosis - A case report

Asmabi.M.A was the physician responsible for the assessment, treatment plan and interaction with the patient. Jithesh.M.K contributed in data analysis, interpretation, discussion and drafting of the case report. Jyotsna Govindan structured, corrected the draft by spell check and grammar.

A couple presented with primary infertility of 10 years since marriage, in the OPD on 25/5/2017. The semen parameters of the husband were found to be within normal limits. The female patient had a regular menstrual cycle with an interval of 35 days and 4–5 days of duration. Moderate lower abdominal pain during menstruation with severe breast pain (mastalgia) and increased body heat which aggravated a few days prior to the menstrual cycle was also observed. For her, painful intercourse was a serious matter of concern. These symptoms have been present for 10 years but after laparoscopic surgery, lower abdominal pain reduced for a long duration. They had undergone various modern infertility treatment methods including Artificial Reproductive Techniques of, ICSI and IVF-ET, in the past 9 yrs. Hystero laparoscopic procedures were also performed. Meanwhile, they seemed very anxious and stressed due to the sustained subfertility, painful sexual act, and financial problems. Unsuccessful attempt of second IVF-ET procedure on 12/05/2016 they took a gap of one year without any treatment. Then they were opted to explore a cost-effective alternative treatment for the conditions and on 25/05/2017 started Ayurveda treatment. Her due written informed consent was recorded before initiating the treatment.

The female patient was lean with a BMI of 23. No abnormalities were detected on general examination, but her pelvic examination showed mild tenderness on the fornices. The uterus was anteverted. Per speculum examination showed mild erosion in the cervix and moderate discharge which has a physiological presentation. Pap smear was done and reported as mild inflammatory smear.

There are no conflicts of interest.

Nil.

The clinical assessment of patient was periodically done at an interval of one month. The severity of pain in dysmenorrhoea, dyspareunia, and mastalgia was assessed using the Visual Analogue Scale. Other symptoms were evaluated using a self-assessment module. Periodic sonographic monitoring was also carried out. Finally, her menstrual cycle was found delayed by one week and UPT was found positive with LMP on 14/10/2017. On ultrasonography presence of a single intrauterine gestational sac was observed. She delivered a female baby weighing 2.8 kg on11/07/2017 through LSCS.

Ayurvedic treatment modalities can manage primary infertility associated with endometriosis. Even though it is a single case, the result observed in this case is encouraging and the protocol followed in the case may be subjected to a clinical trial in a larger sample.

Laparoscopy is the golden standard in the diagnosis of endometriosis. As per laparoscopic reports, the uterus is fixed posteriorly with both ovaries stretched behind and both tubes are tortuous in the distal end. Right ovary with endometrial cyst (which was removed during laparoscopy). The bowel was adherent to the left uterosacral ligament. As per these laparoscopic reports case was diagnosed as primary infertility due to endometriosis and pelvic adhesions. The right ovarian chocolate cyst was diagnosed and removed by hysterolaproscopic procedure 7 years back. The signs and symptoms of endometriosis and pelvic adhesion persisted at the time of consultation. By analyzing the clinical features and investigations the disease was diagnosed as Vandhyatva due to Vatiki Yonivyapad associated with Paripluta . The predominant doshas were Vata and Pitta.

VThe chief complaint presented by the patient was the inability to conceive. After clinical evaluation, the female patient was diagnosed as having endometriosis. According to Ayurveda, that case was diagnosed as Vandyatva due to Vatiki Yonivyapad along with Paripluta. By analyzing Samprapti (etiopathogenesis) factors, Dosha involvement showed a predominance of Vata and Pitta . While Rasa (assimilated components of digested food), Rakta (Blood tissue), and Mamsa (Muscle tissue) were the vitiated Dushya (which gets vitiated) and Rasavaha (Channels carrying nutrient fluids), Raktavaha (channels carrying blood tissue) and Arthavavaha (includes the channels with physiological importance in the regulation of menstrual cycles) were the Srotas (structural or functional channels) involved. Srotodushti included Vimarga gamana (diversion to the flow of the contents to the improper channels) and Granthi (occurrence of nodular growth in the body channels). Adhishtana (site of manifestation) of the disease was Garbhasaya (uterus) and the status of Agni (digestive/metabolic factors) was found to be Manda (weak). Correction of Agni was the most important initial step. Pachanamrita kvatha (indicated in the second phase of Jwara for the purpose of Ama Pachana which has the predominance of Tiktarasa (bitter taste ), Laghu (light and easy to digest) Ruksha (p roperty which dries up) guna, Ushna Virya (hot potency), and Katu Vipaka (bio-transformed) was prescribed. The presence of drugs that possess Sheetha Virya (cold potency) like Usheera, Parpataka , and Hribera help to maintain the Pitta which was also one of the factors of etiopathogenesis of the disease. Chandraprabha Vati in which Guggulu a nd Silajatu become the chief ingredient is Pachana (enhancing digestion), Lekhana (therapeutic Scraping), Chedana , and Kledasoshana (expels the excessive fluid) with an added indication in Yoni Roga . As the disease was predominant with Vata, Abhayarishta was included to induce Anulomana and maintain the Agni with its Laghu Ruksha and Sukshma gunas (the quality of a substance that is responsible for spreading out). The medicine selected based on dosa predominance, for Snehapana was Shatavaryadi Ghrita which is Vata Pitta Samana and Brimhana (nourishing therapy) in its action. Its predominant rasa is Madhura and Virya is Sheetha . Hence the administration of the drug in a considerably higher dose could facilitate the process of Doshotklesa without causing exhaustion to the patient. It took 6 days to obtain the Samyak Snigdha Lakshana . The next phase was Abhyanga (Therapeutic oil massage) followed by Svedana. The oil selected was Pindataila which is also Vata Pitta Samana in nature. After the Purva karmas, as Sodhanatherapy, Virechana with Avipattichurna which being predominant of Madhura Rasa, Madhura Vipaka, Anushnasheetha Virya, and Pitta Shamana in nature, was administered. Trivrita, one of the chief ingredients of the drug is explained as the best drug for Sukhavirechana. Virechana resulted in 12 vegas (episodes), and the entire process was completed uneventfully. A modified form of Ksheera Basti was administered in the next phase. The basic reference of Ksheera Basti is explained in the treatment of Vatashonita . The specific combination of Shatavaryadi Gghita Ksheera processed with Yastimadhu Kalka , Guduchyadi Ksheera Kashaya and Mahanarayana Taila act as Vata Pitta samana, Anulomana and Brimhana. Uttara Basti is one of the most important local treatment in gynaecological disorders. Mahanarayana Taila which is Brimhan and Vatahara with an added indication in Vandhyatva was the selected medicine. As endometriosis was the basic pathology, we considered this as a Granthi, and hence the need for the action of Tikshana, Ruksha medicine to reach the target site was considered. Kalyanaka Kshara has Tikshana,Ushna , and Ruksha properties which are the essential factors for the required action. Trilavana by their Sukhsma Guna facilitates the entry to the site of action and the drugs like Aruskara, Chitraka, Nagadandi and Gomutra by their Tikshana and Ruksha properties function as Chedana and Lekhana. At the same time, the medium- Mahanarayana Taila improves the quality of endometrium and helps to form a suitable atmosphere for implantation. During the post-ovulatory period, Shatavaryadi Ghrita and Ksheerabala 101 were administered for proper implantation. The menstrual cycle got delayed by one week, so UPT was suggested which turned positive with LMP on 14/10/2017. Within 5 months of treatment, the patient conceived and delivered a female baby on 11/07/2018. Each phase of treatment was monitored and recorded carefully. The result obtained in the case was encouraging and signified the relevance of logical selection of medicines according to the stage along with the judicious combination of internal medicines, procedures, diet, and regimen for the complete cure of the disease.

Internal medicine started with Pachanamrita kvatha [ [ 4 ]15 ml with 45 ml lukewarm water and Chandraprabha Vaṭi [ [ 5 ]1 tab, both morning and evening before food. Abhayarishṭa [3 Chikitsasthana , 8, pp. 648] 25ml morning and evening after food were also prescribed. She was advised to follow the diet with a reduced quantity of oils and spices and avoid the condition of deep-fried food articles as well as suppress natural urges. This set of medicines was continued for a period of 3 weeks. Considering the chronicity of the disease, Sodhana treatments were unavoidable. The modalities adopted were Virechana, Basti , and Uttarabasti as main therapeutic procedures and Snehapana (Internal oleation) and Svedana (Sudation) as preparatory procedures. After the completion of Sodhana therapies, internal medicines were continued. During the post-ovulatory period as internal medicines, Shatavaryadi Ghrta 5 gm in an empty stomach (early morning) and in the evening Ksheerabala (101)-10 drops with warm milk, were also given. No adverse and unanticipated events occurred during course of treatment.

The prevalence of endometriosis is about 10 %. The prevalence is high amongst infertile women (30–40 %) whereas around 40–50 % of patients with endometriosis suffer from infertility. Infertility may be due to associated tubulopathy or ovarian dysfunction. Common signs and symptoms include chronic pelvic pain, dysmenorrhea, painful intercourse (dyspareunia), abnormal menstruation, etc [ 1 ]. The extensive search conducted in portals like PubMed and Scopus found only one case report presented in a conference in the year of 2013 [ 2 ]. The fact that studies published in indexed journals on this subject are relatively few in the field of Ayurveda indicates the importance of this article (see Table 1 , Table 2 , Table 3 ) Table 1 Timeline of events. Table 1 Date Observation/remarks Treatment 1/05/2009 Chocolate cyst with internal echoes on right ovary 6.6 × 3.3 cm Treatment initiated as per modern medicine protocol. 15/06/2009 Right ovarian chocolate cyst Laparoscopy advised. 27/06/2009 Endometrial cyst aspirated; adhesions present on the left uterosacral ligament. Hystero laparoscopy done. 24/12/2015 3 embryos were collected; 1 cryopreserved. ICSI failed. 12/04/2016 Preserved embryo collected IVF-ET failed. No treatment carried out next one year. 25/05/2017 Diagnosed as per Ayurveda Ayurvedic treatment was initiated. 6/06/2017 Dyspareunia, moderate dysmenorrhoea, mastalgia Panchakarma treatment was initiated. 20/07/2017, 24/08/2017 Treatment session after menstruation Ksheerabasti, Utharabasti 26/8/2017 Ovulation occurred Internal medicine revised: 26/11/2017 UPT (Urine Pregnancy Test) is positive with LMP: 14/10/2017. Patient conceived. 11/7/2018 female baby: 2.8kg Patient delivered on LSCS. Table 2 Sodhana therapy Table 2 Procedures Medicines Duration (Days) Snehapana (internal administration of ghee) Shatavaryadi Ghrta [ 3 Utharatantra, 24, pp.899] 6 Abhyanga-Svedana (massage and steam) Pindataila [3 Chikitsasthana , 22, pp.730] 3 Virechana Avipatti Churna [3, Kalpasthana , 2,pp.743] 1 Ksheerabasti Shatavaryadi Ghrta, Yashtimadhu Kalka, Guduchyadi Ksheera Kashaya, Mahanarayana Taila. 3 Uttarabasti Mahanarayana Taila [ 6 ] 3 Ksheerabasti Uttarabasti Two cycles repeated after menstruation Table 3 Assessment and follow-up Table 3 Assessment Details Before treatment After 1 month After 3 month After 4 month Dysmenorrhoea Symptoms 06 04 02 00 Dyspareunia Symptoms 07 04 01 00 Mastalgia Symptoms 08 06 04 02 Ultrasonography Right ovary No dominant follicle 9mm follicle Not done Normal Left ovary 6 × 10mm follicle 17 × 10 mm follicle Not done 20 × 17 mm Endometrial thickness 5.1 mm 5mm Not done 9 mm(trilaminar) Timeline of events. Sodhana therapy Assessment and follow-up The focus of this case was primary infertility due to endometriosis. A direct description of endometriosis in classical texts are not available. Due to the same reason the diagnosis and management of the condition is conducted based on the principles explained in classics, after considering clinical features, management principles of Vandhya and Vatiki Yonivyapad . The associated symptoms like burning sensation, dyspareunia, etc. can be treated by adopting the management principles of Paripluta Yonivyapad . Analyzing the clinical presentations of the patient, the disease condition was diagnosed as Vandhyatva due to Vatiki Yonivyapad [3] associated with Paripluta .