Effect of Brihatyadi Yapana Basti and Shivalingi (Bryonia laciniosa Linn.) seed powder in the management of female infertility (Vandhyatva) due to anovulatory factor: An open-labelled randomized clinical trial.

Infertility is failure to conceive within 1 or more years of regular unprotected coitus.[ 1 ] The male is directly responsible in about 30%-40% and the female in about 40%-55% and both are responsible in 10% in the cases of infertility. According to the FIGO manual (1990), causes of infertility are tubal and peritoneal factor (25%–35%), ovulatory factor (30%–40%) and endometriosis (1%–10%).[ 2 ] Infertility varies across the regions of the world and it has been estimated to affect 8%-12% couples world wide. The WHO has estimated the overall prevalence of primary infertility in India to be between 3.9% and 16.8%[ 3 ] It is of two types: primary infertility refers to couples who have not concieved after at least 1 year having sex without using birth control methods and secondary infertility refers to couples who have been able to concieve at least once but are unable later. In Ayurveda , Acharya Sushruta describes four essential factors for healthy progeny such as Ritu (ideal time for conception), Kshetra (uterus) , Ambu (proper nutrition to foetus) and Beeja (healthy gametes)[ 4 ] Fulfillment of all the above essential factors ensures motherhood. Deficiency in the above factors impedes the conception. Among them, Beeja is the core stone of the female reproductive process and in its absence, conception can not achieved in spite of all the other factors. Here, Beeja is taken as Antahpushpa i.e., ovum. Hence, anovulation is considered as absence of Beeja . The act of ovulation is regulated by Vata , especially Apana Vayu (mechanism responsible for proper expulsion of ovum). Hence, in Ayurveda classics, Basti is indicated for correction of A pana Vayu which is the main vitiating factor of the reproductive system. Yapana Basti is indicated in infertility by Acharya Charaka in Siddhisthana .[ 5 ] Shivalingi seed powder is having properties like Balya (giving strength) , Brihaniya (nourshing/increasing body strength) , Deepana (appetizer) , Pachana (digestive) , Putrajanana (responsible for reproduction) , Yonishodhana (regulate female reproductive system), Rutupravartana (induce menstruation) and Prajasthapana (promotes conception). It also has hepato-protective and anti-oxidant properties, which ultimately helps in regulation of ovarian cycle. Hence, in this study Brihatyadi Yapana Basti and Shivalingi seed powder were selected. Primary objective of the study was to evaluate and compare the efficacy of Brihatyadi Yapana Basti and Shivaling seed powder administered orally in the management of female infertility w.s.r to anovulatory factor Secondary objective was to evaluate the efficacy of Brihatyadi Yapana Basti and Shivalingi seed powder on menstrual abnormalities such as irregular menses or dysmenorrhea. Primary objective of the study was to evaluate and compare the efficacy of Brihatyadi Yapana Basti and Shivaling seed powder administered orally in the management of female infertility w.s.r to anovulatory factor Secondary objective was to evaluate the efficacy of Brihatyadi Yapana Basti and Shivalingi seed powder on menstrual abnormalities such as irregular menses or dysmenorrhea.

From the present study, it can concluded that Brihatyadi Yapana Basti is comparatively more effective in promoting the growth of graffian follicle to its target size, inducing ovulation and in achieving conception than the Shivalingi seed powder. Thus, it is a promising intervention for future practices of Ayurvedic gynaecologists for managing female infertility due to anovulatory factor. IPGT&RA, Jamnagar. There are no conflicts of interest.

Nowadays, infertility is a problem of global proportion, affecting on an average 8% 12% couples worldwide.[ 6 ] In Ayurveda classics, Vandhyatva has not been described as a separate disease, but all the gynecological disorders are included in twenty Yonivyapadas (vaginal disorders). Hence, Vandhyatva can be understood from the point of view of Yonivyapada . Vandhyatva is described in classical texts with a wide view including etiology and management; however, the etiological factors held responsible for infertility according to modern science cannot be correlated with etiology factors mentioned in Ayurveda. Similar, is the case of treatment. Hence, many treatments have been given in Ayurvedic texts for Vandhyatva , but in which type of infertility or on which factors of infertility it will be effective is not mentioned clearly. Hence, it is the need of time to evaluate the role of drug specifically in this regards. So, to study the effect of Brihatyadi Yapana Basti and Shivalingi seed powder on anovulatory factor, which is the most common cause of infertility in females was under taken. To assess the abnormal state, one must know the normalcy of the same. In Ayurveda , Tridosha are the basic pillars of the physiology of the human body. Most of the authors of Ayurveda gynaecology consider the ovulation as a result of physiological action of Pitta , while the growth of the follicle as a function of Kapha . Kapha is considered responsible for follicular growth, while Pitta for the rupture of matured follicle [ Figure 1 ]. About etiology - pathology of probable Tridoshika involvement in the ovarian cycle Deepana - Pachana (appetizer-digestives) property of Amapachana Vati helps to bring the normality of Dosha and thus aids in bringing Dosha to their sites i.e., Koshtha from which can be easily removed by mild purgation like Eranda Bhrishta Haritaki . The process of Deepana - Pachana (appetizer-digestives) also correct Agnimandya and thus prevents Ama formation which can further lead to the process of Avarana or Srotorodha (obstruction of action of Apana Vayu ) which is the main factor involving in the pathogenesis of anovulatory cycle. Abhyanga and Swedana (oil massages and hot fomentation) are very important procedures and are used as both the Pradhana Karma (main procedure) as well as Poorva Karma (pre-operative procedure) of several Panchakarma procedures. Although classics have not specifically emphasized much upon Snehana (oleation) and Swedana (fomentation) before Yapana Basti , this approach seems to be genuine and appropriate. The drugs, which are used in preparation of Brihatyadi Yapana Basti , help in the regulation of ovulatory cycle through their combined effect. Moreover, the advantages of Basti are also achieved [ Figure 2 ]. Probable mode of action of Brihatyadi yapana basti To understand the possible mode of action, the route of administration, its absorption, concept of enteric nervous system (ENS) that stimulate the central nervous system (CNS) and endogenous opioids, and systems biology concept can be considered [ Figure 3 ]. Probable mode of action of Brihatyadi Yapana Basti according to modern concept Basti is not merely the enema one which exerts local cleansing effect; rather, it is a highly complex, sophisticated and systemic therapy having a wider range of therapeutic actions and indication. It exerts its action by endcolonic (action inside the colon), encolonic (action on tissues of the colon) and diacolonic (for systemic action) ways. Shivalingi seed in the form of powder was administered in group B. Agnimandya , production of Ama at the tissue level, vitiation of Vata, Srotorodha (obstruction of the channels) , Avarana of Vata by Kapha and Pitta and Dhatukshaya resulting in poor state of nourishment of Dhatu may be the major events in the pathogenesis of Vandhyatva w.s.r to anovulation . While considering Rasa (taste) , Veerya (potency) , Vipaka (transformation) , Guna (quality) and Doshaghnata (pacifying effect) collectively, it has Tikta Rasa (bitter taste) , Sheeta Veerya (cold potency) , Madhura Vipaka (sweet transformation) , Laghu Guna (light property) , Deepana (appetizer) and Tridoshaghna (pacifying effect on Tridosha ) action . This drug is having hepatoprotective and antioxidant properties, which ultimately help in the regulation of ovarian cycle.

The females attending the OPD of Prasuti Tantra and Stree Roga, IPGT&RA, Jamnagar, with the history of infertility and fulfilling the criteria of selection, were registered in the study irrespective of caste and religion. Before starting the clinical trial approval was taken from Institutional Ethics Committee vide letter no. PGT/7/-A/Ethics/2016-17/2676 Before starting the clinical trial approval was taken from Institutional Ethics Committee vide letter no. PGT/7/-A/Ethics/2016-17/2676 (dated 16/11/2016). The study has been registered in CTRI (CTRI/2017/04/008360). Informed written consent from each patient willing to participate before starting the study was taken. The detailed history was filled up in the specially prepared proforma. Ingredients of Brihatyadi Yapana Basti were procured from pharmacy of Gujarat Ayurved University, Jamnagar and Shivalingi seed was purchased from Ayurvedic store of local market of Jamnagar and identified in the pharmacognosy laboratory of IPGT&RA, Jamnagar. The females attending the OPD of Prasuti Tantra and Stree Roga, IPGT&RA, Jamnagar, with the history of infertility and fulfilling the criteria of selection, were registered in the study irrespective of caste and religion. Before starting the clinical trial approval was taken from Institutional Ethics Committee vide letter no. PGT/7/-A/Ethics/2016-17/2676 Before starting the clinical trial approval was taken from Institutional Ethics Committee vide letter no. PGT/7/-A/Ethics/2016-17/2676 (dated 16/11/2016). The study has been registered in CTRI (CTRI/2017/04/008360). Informed written consent from each patient willing to participate before starting the study was taken. The detailed history was filled up in the specially prepared proforma. Ingredients of Brihatyadi Yapana Basti were procured from pharmacy of Gujarat Ayurved University, Jamnagar and Shivalingi seed was purchased from Ayurvedic store of local market of Jamnagar and identified in the pharmacognosy laboratory of IPGT&RA, Jamnagar. Married females having age between 20 to 40 years and having active married life of minimum of 1 year with at least 2 or more consecutive anovulatory cycles. Female with primary or secondary type of infertility due to anovulatory cycle or with immature ovarian follicle Patients eligible for Basti . Married females having age between 20 to 40 years and having active married life of minimum of 1 year with at least 2 or more consecutive anovulatory cycles. Female with primary or secondary type of infertility due to anovulatory cycle or with immature ovarian follicle Patients eligible for Basti . Females having age less than 20 years and more than 40 years Patients suffering from systematic disorders such as hypertension, diabetes mellitus, hypo or hyper-thyroidism and severe anemia, reproductive tract disorders such as tuberculosis, carcinoma, congenital deformities or having sexually transmitted diseases were excluded. Patient not eligible for Basti . Females having age less than 20 years and more than 40 years Patients suffering from systematic disorders such as hypertension, diabetes mellitus, hypo or hyper-thyroidism and severe anemia, reproductive tract disorders such as tuberculosis, carcinoma, congenital deformities or having sexually transmitted diseases were excluded. Patient not eligible for Basti . General investigations Hematological – Hemoglobin%, total leucocyte count (TLC), different leucocyte count (DLC), erythrocyte sedimentation rate and packed cell volume were carried out before and after the treatment Random blood sugar was also done before and after the treatment Serological – HIV (human immunodeficiency virus), venereal disease research laboratory and HBsAg (hepatitis B surface antigen) were done before treatment only Urine (routine – microscopic) examination was done before and after the treatment. Specific investigations: Transvaginal Sonography (TVS) for the diagnosis of anovulation was done on 12 th , 14 th , 16 th and 18 th days of menstrual cycle Tests for Serum follicle-stimulating hormone, luteinizing hormone, prolactin and thyroid-stimulating hormone were done before treatment and after the treatment. General investigations Hematological – Hemoglobin%, total leucocyte count (TLC), different leucocyte count (DLC), erythrocyte sedimentation rate and packed cell volume were carried out before and after the treatment Random blood sugar was also done before and after the treatment Serological – HIV (human immunodeficiency virus), venereal disease research laboratory and HBsAg (hepatitis B surface antigen) were done before treatment only Urine (routine – microscopic) examination was done before and after the treatment. Hematological – Hemoglobin%, total leucocyte count (TLC), different leucocyte count (DLC), erythrocyte sedimentation rate and packed cell volume were carried out before and after the treatment Random blood sugar was also done before and after the treatment Serological – HIV (human immunodeficiency virus), venereal disease research laboratory and HBsAg (hepatitis B surface antigen) were done before treatment only Urine (routine – microscopic) examination was done before and after the treatment. Specific investigations: Transvaginal Sonography (TVS) for the diagnosis of anovulation was done on 12 th , 14 th , 16 th and 18 th days of menstrual cycle Tests for Serum follicle-stimulating hormone, luteinizing hormone, prolactin and thyroid-stimulating hormone were done before treatment and after the treatment. Transvaginal Sonography (TVS) for the diagnosis of anovulation was done on 12 th , 14 th , 16 th and 18 th days of menstrual cycle Tests for Serum follicle-stimulating hormone, luteinizing hormone, prolactin and thyroid-stimulating hormone were done before treatment and after the treatment. In the present study, the patients were randomly divided into two groups (group A & group B) as per the computer generated randomization chart. Before starting the treatment for the purpose of improving appetite and proper digestion ( Deepana – Pachana ) and for bowel cleaning ( Koshtha Shuddhi ), Amapachana Vati (2 Vati thrice daily before meal) and 5gm of Erandabhrishta Haritaki powder once at bed time with warm water was given for initial three days. In the present study, the patients were randomly divided into two groups (group A & group B) as per the computer generated randomization chart. Before starting the treatment for the purpose of improving appetite and proper digestion ( Deepana – Pachana ) and for bowel cleaning ( Koshtha Shuddhi ), Amapachana Vati (2 Vati thrice daily before meal) and 5gm of Erandabhrishta Haritaki powder once at bed time with warm water was given for initial three days. Basti was stopped on the day of ovulation, that was confirmed by series of TVS done from USG report Group A: 400ml of Brihatyadi Yapana Basti was administered per rectum after the completion of menstrual cycle for 15 day in the morning for two consecutive cycles. Group B: Shivalingi seed powder was administered 3gm twice a day (8:00 am and 8:00 pm) with cow milk for 2 month before meal. Group A: 400ml of Brihatyadi Yapana Basti was administered per rectum after the completion of menstrual cycle for 15 day in the morning for two consecutive cycles. Group B: Shivalingi seed powder was administered 3gm twice a day (8:00 am and 8:00 pm) with cow milk for 2 month before meal. For the preparation of Basti , 60 ml of Madhu (Honey) was taken in mortal and then Saindhava (rock salt) 10gm was added and was mixed well for 10 min. Thereafter Tila Taila (Sesamum oil) -60ml, Go - Ghrita (cow ghee)-60ml, cow milk- 240ml, paste of Pippali ( Piper longum linn) , Madanaphala ( Randia dumetorum lam) , and Yashtimadhu ( Glycyrrhiza glabra linn.)-15gm, was added and in the end decoction of Brihati ( Solanum indicum linn.) , Kantakari ( Solanum xanthocarpum schrad. & wendle) , Guduchi ( Tinospora cordifolia (willd) miess) , and Shatavari ( Asparagus recemosus willd)-60ml was added and mixed well. This warm mixture was used in the Basti . Pre-operative - Before Basti procedure massage with Bala Taila and Nadi Swedana was done on abdomen and back for 15-20 min in all the selected patients. Operative - Patient were asked to lie down in left lateral position after evacuating the urine and stool and then Basti was administered slowly and steadily This, 400ml of Brihatyadi Yapana Basti per rectum was given with the help of Basti Netra (nozzle) and Basti Putaka (canula). after the completion of menstrual cycle for 15 day in the morning for two consecutive cycles. Post-operative - Patient was asked to lie down in supine position for at least 30 minutes and hot water bag was given to keep on abdomen and back of the patient for fomentation purpose. Pre-operative - Before Basti procedure massage with Bala Taila and Nadi Swedana was done on abdomen and back for 15-20 min in all the selected patients. Operative - Patient were asked to lie down in left lateral position after evacuating the urine and stool and then Basti was administered slowly and steadily This, 400ml of Brihatyadi Yapana Basti per rectum was given with the help of Basti Netra (nozzle) and Basti Putaka (canula). after the completion of menstrual cycle for 15 day in the morning for two consecutive cycles. Post-operative - Patient was asked to lie down in supine position for at least 30 minutes and hot water bag was given to keep on abdomen and back of the patient for fomentation purpose. Intercourse during Rutukala (ovulatory period) To avoid mental stress To take simple food such as Mudga (green gram), Yava (barley), Raktashali ( Oryza punctata ), Shigru (drumsticks), Shasthishali ( oryza sativum ) and Paraval (Trichosanthes dioica ) To have taken more cow milk To perform Yogas postures and Prayanamas such as Bhramari Pranayama, Hastapadasana, Janu Shirasana, Baddha Konasan a etc. Lukewarm water was advised for drinking and bathing. Intercourse during Rutukala (ovulatory period) To avoid mental stress To take simple food such as Mudga (green gram), Yava (barley), Raktashali ( Oryza punctata ), Shigru (drumsticks), Shasthishali ( oryza sativum ) and Paraval (Trichosanthes dioica ) To have taken more cow milk To perform Yogas postures and Prayanamas such as Bhramari Pranayama, Hastapadasana, Janu Shirasana, Baddha Konasan a etc. Lukewarm water was advised for drinking and bathing. Follow-up was done after the completion of treatment for 2 months on 12 th , 14 th , 16 th and 18 th days of menstrual cycle Follow-up was done after the completion of treatment for 2 months on 12 th , 14 th , 16 th and 18 th days of menstrual cycle The efficacy of the therapy was assessed on the basis of follicular study by TVS on the 12 th , 14 th , 16 th and 18 th days of menstrual cycle and/or on the basis of conception achieved. To assess the overall response of therapies, a special scoring method according to size of follicle was adopted. [ Table 1 ] The efficacy of the therapy was assessed on the basis of follicular study by TVS on the 12 th , 14 th , 16 th and 18 th days of menstrual cycle and/or on the basis of conception achieved. To assess the overall response of therapies, a special scoring method according to size of follicle was adopted. [ Table 1 ] Scoring Pattern for follicle size Overall effect of therapy was assessed on the basis of parameters as mentioned in [ Table 2 ]. Overall effect of therapy The obtained data was analyzed for statistical significance using Student’s t -test. The level of “ P ” between 0.05 to 0.01 and P 0.05), results were taken as insignificant. In this present study, 30 patients were registered and effect of therapy was assessed on 29 patients as one of the patient dropped out in group B. In group A, out of 15 patients 15 patients completed the treatment and in group B out of 15 patients 14 patients completed treatment along with the follow-up. In group A, maximum number of the patients, i.e., 53.33% were from the age group of 26 to 30 years while in group B 40% were from this age group. In group A, 33.33% of the patients had primary infertility and 66.66% of the patients had secondary infertility and in group B, 60% of the patients had primary infertility and 40% of the patients had secondary infertility. In group A, 53.33% of the patients had chronicity of infertility of 1–5 years and in group B, 93.33% of the patients had chronicity of infertility of 1–5 years. In group A and group B none of the patients had the family history of infertility and all had proper development of secondary sex characters with timely onset of menarche. None of the patients had history of taking contraceptive pills. In group A, 33.33% of the patients had regular menstrual cycle with moderate flow of menstrual. The 40% of the patients, did not have any pain during menstruation with duration of menstruation of 2–5 days in 53.33% of the patients, with an interval of >35 days in 46.66% of the patients and in group B, 40% of the patients had regular menstrual cycle with moderate flow of menstruation in 46.66% of the patients, most of the patient did not have any pain during menstruation, with duration of menstruation of 2–5 days in 53.33% of the patients, with an interval of >35 days in 46.66% of the patients. In group A, intercourse for <2 times/week was found in 73.33% of the patients, irregular menstrual history was reported in 66.66% of the patients, 46.66% of the patients had Body Mass Index of 26–30 (Grade 3) while in group B, intercourse for <2 times/week was found in 86.66% of the patients. Irregular menstrual history was reported in 60% of the patients. Body Mass Index of 21–25 (Grade 2) was found in 46.66% of the patients. The anteverted & anteflexed position of the uterus was found in 86.66% patients and in group B, 93.33% of the patients, whereas all the patients in both the groups had normal-sized uterus, with mobility and clear fornices. Before treatment, the size of follicle was 0–12 mm in nine patients (60.00%) and >12–19 mm in five patients (33.33%), whereas one patient, i.e., (6.66%), had >19 – 23 mm size [ Table 3 ]. Effect of Brihatyadi Yapana Basti on follicular growth and ovulation (Group A) ( n =15) BT: Before treatment, DT: During treatment, AT: After treatment In the first cycle of the treatment, the follicular size was 0–12 mm in one patient (6.66%) and >12–19 mm in three patients (20%), two patients (13.33%) had >19–23mm size follicle, whereas rupture of follicle was found in nine patients (60%). In the second cycle of the treatment, the follicular size was 0–12 mm in none of the patient and >12–19 mm in three patients (20%). Two patients (13.33%) had >19–23 mm size follicle, whereas the rupture of follicle was found in ten patients (66.66%). After treatment (follow up), 13 patients (86.66%) had ovulation. One patient (6.66%) had >12–19 mm and one patient (6.66%) had >19–23 mm size follicle. None of the patients had follicle size of 12 mm. Before treatment, the size of follicle was 0–12 mm in nine patients (46.66%) and >12–19 mm in two patients (20.00%), whereas four patients, i.e., (33.33%), had >19 – 23 mm size [ Table 4 ]. During first cycle of the treatment, four patients (28.57%) had 0–12 mm size, three patients (21.42%) had >12–19 mm size, two patients (14.28%) had >19–23 mm size follicle, whereas rupture of follicle was found in seven patients (35.17%). Effect of Shivalingi Beeja powder on follicular growth and ovulation ( n =14) (Group B) BT: Before treatment, DT: During treatment, AT: After treatment In the second cycle of the treatment, two patients (14.28%) had 0–12 mm size follicle, three patients (21.42%) had size >12–19 mm, two patients (14.28%) had size >19–23 mm size follicle, whereas rupture of follicle was found in seven patients (50.00%). After treatment, nine patients (64.28%) had ovulation, two patients (14.28%) had >12–19 mm and three patients (21.42%) had >19–23 mm size follicle. In group A, the initial mean score of follicular size was 2.533 which was 0.267 after the treatment and was statistically highly significant ( P < 0.001) [ Table 5 ] Whereas, in group B, the initial mean score of follicular size was 2.429 which was 0.429 after the treatment and was statistically highly significant ( P < 0.001). Effect of therapies on follicular size AT: After treatment, BT: Before treatment, SD: Standard deviation, SE: Standard error In group A, 12 patients (80%) had rupture of follicle, i.e., ovulation occurred, whereas three patients (20%) had unruptured follicle after the treatment [ Table 6 ]. In group B, nine patients (64.28%) had ovulation and five patients (35.72%) did not have ovulation after the treatment. In groupA, ten patients, (66.66%), had irregular menses before treatment, whereas after treatment, three patients, (20%) had irregular menses. Total effect of therapy on ovulation This above data reveals that in group A, 70%, relief was found in irregular menses. Whereas, in group B, nine patients, (64.28%) had irregular menses before treatment, whereas after treatment, four patients, (28.57%) had irregular menses. In the present study, the 26.66% achieved conception in group A while it was nil in group B. In group A, after follow-up of 1 st month, one patient (6.66%) had follicular size >12–19 mm and three patients (20%) had follicular size >19–23 mm or cystic formation. 73.33% of the patients i.e., 11 patients, had ovulation, In the 2 nd -month follow-up, one patient (6.66%) had follicular size >12–19 mm and one patient (6.66%) had follicular size 19–23 mm or cystic formation and 86.66% of the patients, i.e., 13 patients, had ovulation. In group B, after 1 st month follow-up, two patients (14.28%) had follicular size >12–19 mm and two patients (14.28%) had follicular size >19–23 mm. 71.42% of the patients, (10 patients) had ovulation. In the 2 nd -month follow-up, one patient (7.14%) had follicular size >12–19 mm and one patient (7.14%) had follicular size >19–23 mm and 85.71% of the patients, (12 patients) had ovulation. Data reveals that in group A ( Brihatyadi Yapana Basti ), 26.66% of the patients could conceive. Excellent response, i.e., ovulation, was found in 80.00% of the patients, whereas 13.33% of the patients had marked response and 6.66% of the patients had moderate response. In group B [ Shivalingi seed powder] none of the patients conceived. In this group excellent response, i.e., ovulation, was found in 64.28% of the patients, whereas 21.42% of the patients markedly improved and 14.28% of the patients had moderate improvement.