Ayurvedic management of endometriosis-associated subfertility: A case report

Endometriosis is a pathological condition defined by the presence of endometrial tissues in ectopic locations, which primarily includes ovaries, pelvic peritoneum, and rectovaginal septum.[] Endometriosis affects about 10% of women in the reproductive age group.[] Ovarian endometrioma, also known as a chocolate cyst, a form of endometriosis, is found in 50% of women complaining of infertility.[] Theories to explain the pathogenesis of endometriosis include retrograde menstruation theory, metastasis theory, stem cell theory, and embryogenetic theory.[] Endometriosis manifests clinically as chronic pelvic pain, dyspareunia, dysmenorrhea, and subfertility, affecting fertility by multiple mechanisms.[] The pathogenesis can be expressed as immunological responses, reduced endometrial receptivity, hormonal imbalances, and decreased embryo competence.[] The increased production of reactive oxygen species from endometriotic lesions can have a detrimental effect on the oocyte, implantation, and developing embryo.[] In diagnosed endometriosis, fertilization rate, blastocyst formation, implantation rate, and progress of a healthy pregnancy are hindered.[] Apart from infertility, endometrioma may affect the pregnancy outcome due to rupture and can create a surgical emergency.[] Females with bilateral ovarian endometrioma have an increased risk of ovarian injury.[] Persistent chronic inflammation causes increased levels of prostaglandins and cytokines that can disturb embryo development and hinder pregnancy outcome.[] The four factors essential for conception described in Ayurveda are Ritu (~appropriate time for conception), Kshetra (~female reproductive system), Beeja (~male and female gametes), and Ambu (~nourishment factor).[] The female reproductive system affected by endometriosis can be considered as Kshetra Dushti (~vitiation of Kshetra) as it prevents providing an optimal medium for fertilization, implantation, and growth of the embryo. In Ayurveda, most of the ailments of the female reproductive system are described under Yonivyapada (~gynecological disorders) and Artavadushti (~menstrual disorders). An exact description of endometriosis is not found in Ayurveda, but an in-depth understanding of its Samprapti (~pathogenesis) allows its correlation with long-term complications of Udavartini (~dysmenorrhea with frothy discharge). These gynecological disorders can lead to infertility as a complication.[] The treatment principle in gynecological disorders is Sodhana-Karma (~purificative procedure) followed by local procedures and Shamana-Ausadha (~palliative medicine).[] For the management of Udavartini Yonivyapada, Astanga Sangraha recommends oral administration and Anuvasana Basti of “Dashamula Trivrit Sneha” along with Mamsarasa (~meat soup). As most case reports on Ayurvedic management in endometriosis primarily focus on symptomatic relief or reduction of endometrioma size, this case highlights the potential role of Ayurvedic interventions in achieving conception and a favorable pregnancy outcome in endometriosis-associated subfertility. Patient Information A 29-year-old woman, married for 5 years, presented to the Prasuti Tantra and Stree Roga (Gynecology and Obstetrics) Outpatient Department (OPD) in April 2023 with secondary subfertility and dysmenorrhea for 2 years’ duration. The couple had been attempting conception without contraception during this period. She had a known diagnosis of recurrent endometriosis with bilateral ovarian endometriomas. Her menstrual cycles were regular (30–32 days interval) with 3–4 days of menstrual flow. She reported moderate dysmenorrhea (Visual Analog Scale [VAS] score: 5/10) that interfered with daily activities and required analgesics. She had undergone laparoscopic cystectomy for an ovarian endometrioma in January 2021, followed by recurrence. Her obstetric history included one missed abortion at 8 weeks’ gestation in July 2021, managed by dilatation and evacuation. She had not received assisted reproductive treatment before presentation. Her spouse’s semen analysis was normal. She had no history of chronic medical illnesses, pelvic inflammatory disease, tuberculosis, thyroid disorders, or other significant comorbidities. Clinical Findings Astavidha Pariksha (~eightfold examination) revealed a Kapha–Vata dominant Nadi; Mala (~bowel habits) and Mutra Pravriti (~bladder habits) were normal, tongue was slightly coated, Shabda and Sparsha were normal, eyes appeared clear and lustrous, and the patient had a moderately built body. Dashavidha Pariksha (~tenfold examination) revealed Kapha–Vata predominant Prakriti, Rasa Sara, Madhyama Samhanana, Avara Satva, Madhyama Satmya, Avara Aharashakti, Madhyama Vyayamashakti, and Madhyama Vaya. On general examination, the patient weighed 71 kg with a body mass index of 29.21 kg/m2. She was afebrile, hemodynamically stable, and her general physical examination was unremarkable. Systemic examination, including the cardiovascular, respiratory, abdominal, and neurological systems, revealed no clinically significant abnormalities. Per-speculum examination showed a healthy cervix with no abnormal vaginal discharge. Bimanual pelvic examination revealed an anteverted, nontender uterus with a firm cervix and restricted uterine mobility, suggestive of pelvic adhesions. Hysterosalpingography performed in April 2022 demonstrated a uterine cavity of normal size and contour and bilateral tube patency, evidenced by free peritoneal spill. Diagnostic Assessment The findings of hysterosalpingography, along with bimanual pelvic examination that revealed restricted uterine mobility, were suggestive of pelvic adhesions. Transvaginal ultrasonography performed on April 25, 2023 [Table 1], demonstrated bilateral ovarian endometriomas measuring 28 mm × 26 mm in the right ovary and 40 mm × 40 mm in the left ovary, along with features suggestive of pelvic adhesions. These findings were consistent with recurrent endometriosis that is associated with secondary subfertility. From an Ayurvedic perspective, the condition was diagnosed as Vandhyatwa (subfertility) associated with Kshetra Dushti (functional impairment of the female reproductive system). Timeline The chronology of the patient’s clinical course, therapeutic interventions, and follow-up outcomes is summarized in Table 2. Therapeutic Intervention Treatment comprised a sequential Panchakarma protocol followed by oral Ayurvedic medication. The intervention included Anuvasana Basti with Mahatiktaka Ghrita, Dashmuladi Yoga Basti, Dasmuladi Kala Basti, and Virechana Karma after appropriate Deepana–Pachana and Snehapana, followed by maintenance therapy with Matra Basti and oral medications. The treatment schedule, formulations, dosage, and duration are presented in Table 3. Dashamuladi Yoga Basti consisted of alternate administration of Anuvasana Basti using Dashamula Taila and Niruha Basti prepared with honey, rock salt, Dashamula Taila, herbal paste (Kalka), and Dashamula decoction. The complete composition of the Niruha Basti is provided in Table 4. All ingredients were sequentially mixed to obtain a homogeneous emulsion before administration. The schedule of Dashamuladi Yoga Basti is given in Table 5. Dashamuladi Kala Basti was administered after the following menstrual cycle for 16 days. It included 10 Anuvasana Basti and 6 Niruha Basti [Table 5]. Follow-up and Outcomes The patient first attended the PTSR OPD in April 2023 with regular but painful menstruation (VAS score: 5), requiring analgesic medication. She was followed up at 2-week intervals throughout the treatment period. Following successive Basti cycles, menstrual pain progressively reduced with VAS scores declining to 3 and 2 after the first and second treatment cycles, respectively. No adverse drug reactions or treatment-related complications were reported during follow-up. After completion of 3 months of therapy, including three Basti cycles, the patient achieved complete relief from dysmenorrhea (VAS score: 0) and experienced a total weight reduction of 4 kg. Following Virechana, she reported subjective improvement in digestion and a feeling of bodily lightness, accompanied by an additional weight loss of 2 kg. Ovulation monitoring performed in November and December 2023 demonstrated ovulation on the 13th and 14th day of the menstrual cycle, respectively, with endometrial thickness of 10.0 and 10.6 mm. The patient was advised to attempt conception during the peri-ovulatory period in both cycles. On January 5, 2024, she presented with amenorrhea of 1 month and 5 days. A urine pregnancy test was positive, and transabdominal ultrasonography confirmed a viable intrauterine pregnancy. Serial antenatal ultrasonographic examinations were unremarkable. The nuchal translucency scan performed at 13 weeks’ gestational age (February 29, 2024) revealed a nuchal translucency measurement of 1.4 mm, with visualization of the nasal bone. Anomaly scan conducted at 21 weeks 5 days of gestation (April 30, 2024) demonstrated appropriate fetal growth, a posterior placenta, adequate amniotic fluid, and an estimated fetal weight of 509 g ± 50.9 g. The pregnancy remained uneventful without maternal or fetal complications. In August 2024, she delivered a healthy full-term neonate weighing 3.62 kg by uncomplicated vaginal delivery.

As per Ayurveda, Endometriosis can be understood as Tridoshaja Vyadhi (~disease with involvement of three Doshas) with vitiation of Rasa (~nutrient fluids), Rakta (~blood tissue), and Mamsa (~muscular tissue) with Sanga (~obstruction/adherence) type of Srotodushti (~vitiation of body channels). It can be correlated with complications of Udavartini (~dysmenorrhea with frothy discharge). Anuvasana Basti with Mahatiktaka Ghrita[] was administered to pacify vitiated Vata and Pitta, promote Raktasodhana (~blood purification) and combat inflammation. Manjisthadi Kasaya as described in the Bhaishajya Ratnavali primarily acts through its therapeutic effects through Raktashodhana, contributing to the management of inflammatory conditions. Phalatrikadi Kasaya as described in Chakradutta was administered orally for its potent Shothahara (~anti-inflammatory) and Pitta–Kapha Shamaka (~Pitta and Kapha pacifying) properties. These actions contributed to the reduction of inflammatory responses in the ovary and peritoneum for Kshetrasuddhi. The retrograde menstruation theory supports the concept of Udavartini. Due to holding of natural downward urges like flatus,[] the upward movement of Vata (~body humor responsible for movement and cognition) and Rajas (~menstrual blood) in the reproductive tract, that is, toward the uterus, fallopian tubes, and peritoneum, may trigger inflammation, adhesions, and growth of endometriosis lesions.[] Thus, to normalize this alleviated Vata, Dashamuladi Yoga Basti and Dashamuladi Kala Basti were given in subsequent months. Relief in dysmenorrhea attained after these three cycles of therapeutic enema indicates that inflammation may have subsided. Then, Virechana was planned to achieve systemic Sodhana as well as local Kshetrasuddhi, and to enhance the potency of Beeja. Dashamula Trivrit Taila,[] as indicated in the treatment of Udavartini,[] has anti-inflammatory and analgesic properties. Saptasara decoction corrected Agnimandya (~poor digestive fire), provided Anulomana (~promoting the natural flow), Shoolaghna (~pain relief), and Strotoshodhana (~cleansing of channels) actions. Purana Guggulu Powder, by its anti-inflammatory, Balya (~increasing strength), and Rasayana (~rejuvenative and revitalizing) properties, helps in breaking the pathogenesis and preparing for conception. Several case reports have described Ayurvedic management of endometriosis, predominantly focusing on symptomatic relief and reduction in the size of endometriomas. However, reports documenting successful fertility outcomes remain limited. This case demonstrates not only improvement in endometriosis-associated symptoms but also successful conception following Ayurvedic management, culminating in an uneventful pregnancy and full-term vaginal delivery of a healthy neonate. While this case provides preliminary evidence supporting the potential role of Ayurveda in the management of endometriosis-associated subfertility, its findings should be interpreted with caution, as conclusions cannot be drawn from a single case. Furthermore, well-designed clinical studies with larger sample sizes are required to evaluate the effectiveness, safety, and reproducibility of this therapeutic approach.

This case report describes the successful management of endometriosis-associated subfertility with an individualized Ayurvedic treatment protocol, culminating in conception, uneventful pregnancy, and the full-term vaginal delivery of a healthy neonate without any reported adverse events. While the findings suggest the potential of Ayurveda as a therapeutic approach in the management of endometriosis-associated subfertility, they are based on a single case and should be interpreted accordingly. Furthermore, well-designed clinical studies are warranted to evaluate the effectiveness, safety, and reproducibility of this treatment approach. Patient perspective I am extremely happy and satisfied to have conceived and delivered a healthy baby after undergoing Ayurvedic treatment. After 5 years of marriage and the emotional setback of a previous abortion, becoming a mother has been a life-changing experience. I am deeply grateful for the care and support I received throughout my treatment and pregnancy. Declaration of patient consent The authors certify that appropriate written informed consent was obtained from the patient for publication of this case report and the accompanying clinical information. The patient understands that her name and initials will not be published and that all reasonable efforts will be made to conceal her identity; however, anonymity cannot be guaranteed.

We extend our sincere gratitude to the team of the Prasutitantra Stree Roga Female Ward of the Institute for their valuable support and cooperation. Author contributions All authors have reviewed and approved the manuscript, fulfilled the authorship criteria outlined in this document, and affirm that the work presented is an honest representation of their research. Declaration of generative artificial intelligence The authors declare that they have used ChatGPT (OpenAI) solely for language editing, grammar correction, and improving the readability of the manuscript. The authors carefully reviewed and verified the content after artificial intelligence-assisted editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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