Bagali C S.pdf

“ CLINICAL STUDY ON APRAJA VANDHYA (PRIMARY

INFERTILITY) BY AN INDIGENOUS COMPOUND W.S.R TO

OVULATORY DYSFUNCTION”

By Dr.Smt.BAGALI.C.S

A dissertation submitted to the

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In partial fulfillment

of the requirements for the degree of

AYURVEDA DHANVANTARI- M.S.

(AYURVEDA)

In

PRASUTI TANTRA & STREE ROGA

Under the guidance of Dr. Susmita Priyadarshinee Otta

M.S (P.T.S.R)

POST GRADUATE DEPARTMENT OF PRASUTI TANTRA

& STREE ROGA

N.K.J. AYURVEDIC MEDICAL COLLEGE & PG CENTRE, BIDAR. 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE

NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR

POST GRADUATE DEPARTMENT

OF PRASUTI TANTRA & STREE ROGA

Certificate by the guide

This is to certify that the dissertation entitled “ Clinical Study on Apraja

Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory

dysfunction” is a bonafide clinical research work done by Dr. Smt Bagali C.S.

in partial fulfillment of the requirement for the degree of M.S. (Ayurveda) in

Prasuti Tantra & Stree Roga.

Signature of the Guide Dr. Susmita Priyadarshinee Otta

MS(P.T.S.R.) Asst.Prof. Dept.of Prasuti Tantra & Stree Roga

NKJ Ayurvedic Medical College & PG Centre Bidar – 585403

Karnataka.

Date : ________ Place : BIDAR

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR.



Endorsement by the HOD, Principal/Head of the institution

This is to certify that the dissertation entitled “Clinical Study on Apraja

Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory

dysfunction”” is a bonafide clinical research work done by Dr. Smt Bagali C.S.

under the guidance of Dr. Susmita Priyadrashinee Otta, Asst. Professor, Post

Graduate Department of Prasuti Tantra & Stree Roga, N.K.J Ayurvedic

Medical College & P.G. Centre, Bidar.

Seal and signature of the HOD Prof.Dr.L.V.RATHNAKAR.A

M.D,(K.B)(B.H.U) NKJ Ayurvedic Medical College & PG Centre

Bidar – 585403 Karnataka

Date : _________ Place : BIDAR .

Seal and signature of the Principal/Dean Prof. Dr.K.V.L.N. ACHARYULU M.D (SIDDNTA) NKJ Ayurvedic Medical College & PG Centre

Bidar – 585403 Karnataka Date : _________ Place :BIDAR .

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE

NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR



Declaration by the candidate

I here by declare that this dissertation/ thesis entitled “Clinical Study on

Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to

Ovulatory dysfunction”is a bonafide and genuine research work carried out by me

under the guidance of Dr.Susmita Priyadarshinee Otta, M.S. (P.T.S.R) Asst. Prof.

PG Department of Prasuti Tantra & Stree Roga.

Date : _________ Signature of the candidate

Dr. Smt.Bagali C.S. Place : BIDAR

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

N.K.J. AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR



Copyright

Declaration by the candidate

I here by declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall declare the rights to preserve, use and disseminate this dissertation/

thesis in print or electronic format for academic/ research purpose.

Date : __________ Signature of the candidate Dr. Smt. Bagali C.S.

Place : BIDAR

DEDICATED TO

My Father and Mother

Late Shri. Siddappa.B.Bagali

and

Smt. Gurubai.S.Bagali

ACKNOWLEDGEMENT

With The blessing of Shri Siddharoodha Mahaswamiji. I wish to record my

gratitude towards the revered President. His Holiness Sri Shivakumar Swamiji for

his mangnanimous support.

I owe a special debt of gratitude to my guide Dr.Susmita Priyadarshinee

Otta M.S (PTSR) Assistant Professor, Post Graduate studies in Prasooti Tantra for

her scientific advice, constructive suggestions, constant encouragement & kind

cooperation throughout my period of research work.

“A good suggestion says the first word of everything.”

I will feel short of my duties if I fail to acknowledge Prof. Dr Prabha

Sharma,M.D,PhD( B.H.U)former H.O.D Dept of Prasooti Tantra ,who helped me in

selecting the topic guided me in clinical work .

I am extremely grateful to my teacher Dr. L.V Rathnakara Professor & Head

of Department of P.G studies in Prasooti & Streerooga & Koumara Bhritya N.K.J

A.M.C. P.G Center Bidar for his timely help.

I wish to external my heartiest thanks to the Principal Prof Dr.

K.V.L.N.Acharyulu & vice Principal Dr. P.V.Savanur N.K.J.Ayurvedic medical

College & P.G Center for providing the necessary facilities in the college for

conducting research work.

I express my thank to Dr. V.S Patil Medical Director of N.K.J.Ayurvedic

medical College & P.G Center for his advise and momentary support.

I humbly express my indebtedness to Dr. Shankar Deputy Medical

Superintendent & staff of Shri Siddharoodha Charitable Hospital for their help.

I am thankful to Dr. Bandeppa.S Head of the Department, Dr. Praveen

Simpi & Asst Mohan Reddy, Channappa of Rasa shastra & Bhaisajya kalpana Dept

N.K.J A.M.C Bidar for their constant guidance in the preparation of medicine for the

clinical study.

Any amount of thankfulness will be in adequate for all the faculty members &

of my Department namely Dr.Sridevi Swamy, Dr.Sheela Halli, & Dr.Manisha

Bhandari for providing all possible guidance & support.

I am very thankful to Dr. T.P.Sahu M.D (Dravya Guna) for his expert

guidance in identifying the plant Shivalingi.

I express my gratitude & regards to Dr. Y.P.Shamarao, Dr.Murthy,

Dr.Kotur, Dr.Mulimani, Dr.Tripathy, Parmeshwar Bhat & Dr.Halli. For their

timely advice.

I am deeply indebted to Sri M.Suranagi Ph.D(Statistics) Asst Prof

Veterinary College Bidar for his valuable help, co-operation & guidance in data

processing.

In addition to this I am also very grateful to my batch mates or Dr.Vivek,

Dr.Pradeep, Dr.Mahesh, Dr.Gourish & Junior Dr.Joyti. H& Departmental Seniors

& Juniors for their mental support which enabled me to complete the dissertation.

My special thanks to my friends Dr.Jayasheela Goni, Dr.Vandana

Galiyawar & Dr.Anita Murki for their support.

I extend my gratefulness to library staff of N.K.J AMC Mr. Kadam,

Mr. Rajkumar &Smt. Saku Bai for their help & co-opration during my research

work.

I offer my sincere thanks to all the staff member of N.K.J AMC College Sri

Bagali, Sri Ramesh, Sri Kaddi, Sri Chandrakant, Sri Reddy, and Sri Gururaj.

For their help & co-operation on during my study.

I cannot forget my brother Sri Bhimashankar Bagali & Nephew Kr.Sagar

& Sri Ravikant Bagali and sisters Smt. Sharada, Smt Shobha, Smt Manjula for

their incessant love and who always act & a source of energy to me in this world of

uncertainty.

I express my deep sense of love & gratitude to my husband Dr. Anil. K

Bagalkoti & my beloved son Chi. Prateek & others family members who efficiently

shouldered my responsibilities for fulfilling the dissertation work.

Last but not least. I express all sense of gratitude to my well wishers and

patients who helped me directly or indirectly throughout the study.

Place :- BIDAR.

Date: - Dr.Smt. Bagali.C.S

LIST OF ABBREVIATIONS

RV - Rigveda

AV - Atharvaveda

AH - Ashtang Hrudaya

AS - Ashtang Sangraha

BP - Bhava Prakash

B.R - Bhaishajya Ratnavali

BRN - Bhava Prakash Nighantu

Cha. S. - Charaka Shareer sthana

Cha.Chi - Charaka Chikitsa sthana

D.N. - Dhanvantri Nighantu

Ha.S - Harita Samhita

Kas.S - Kashyapa Samhita

kalp kalpasthan

Kas.S - Kashyapa Samhita

Siddhi Siddhisthana

M.N. - Madhava Nidhana

N.A - Nighantu Adarsha

RN - Raja Nighantu

Sha. S. - Sharangdhar Samhita

Su. S . - Sushruta Samhita

Su.Sha - Sushruta Sharisrsthana

Su.Su - Sushruta Sutrasthana

Su.Utt - Sushruta Uttarsthana

YR. - Yoga Ratnakara

LIST OF ABBREVIATIONS

FSH = Follicular Stimulating Hormone

LH = Luteinizing Hormone

GnRH = Gonadotropin Releasing Hormone

CRH = Corticotrophin Releasing Hormone

TSH = Thyroid Stimulating Hormone

IGF-II = Insulin like Growth Factor-II

IUCD = Intra Uterine Contraceptive Devices

PID = Pelvic Inflammatory Disease

SCMCT = Sperm Cervical Mucus Contact Test

hMG = Human Menopausal Gonadotrophin

PCR = Polymerase Chain Reaction

USG = Ultra Sonography

HSG = Hystero Salpingo Graphy

HCG = Human Chorionic Gonadotrophin

LUF = Luteal Unrupturad Follicle

Mg = Milligram

Mm = Millimeter

Ng = Nanogram

ABSTRACT

Primary Infertility with a correlation to Apraja vandhya is one of the common

gynecological problem faced in daily practice.

The most common cause of infertility is ovulatory disorder characterized by

anovulation or by infrequent & / or irregular ovulation. Menstrual disorder like

oligomenorrhoea or complete amenorrhoea usually indicates ovulatory disorders.

30 patients being diagnosed as primary Infertility according to inclusion &

exclusion criteria where divided in to two groups of 15 each.

Group A where treated with Indigenous Compound Ghanasatwa.

Group B where treated with placebo drug.

The entire patients were assessed clinically, pathologically & sonographically

at the end of each cycle & finally the results were analyzed statistically before

treatment & after each cycle & at the end of three cycles.

Finally the effectiveness of the trial drug was assessed 84.85% in the

Infertility. During the treatment no side effect was observed.

KEY WORDS

Infertility, anovulation, apraja vandhya, shivalingi, putramjivaka.

TABLE OF CONTENTS

PAGE No.

1) INTRODUCTION 1-3

2) OBJECTIVES 3

3) REVIEW OF LITERATURE

a. Historical Review 4-6

b. Ayurvedic Review 7-23

c. Modern Review 24-

56

d. Drug Review 57-76

4) CLINICAL STUDY

a. Material & Method 77-81

b. Observation 82-110

5) DISCUSSION 111-117

6) CONCLUSION 118

7) SUMMARY 119-120

8) BIBLIOGRAPHY 121-123

9) REFERENCES 124-128

10) ANNEXURE

a. Research Case Performa

LIST OF TABELS

Table No. Name of the Table Page

No.

Table No. 1 Showing method day of cycle observation 35

Table No. 2 Showing 30 Patients According to Age. 83

Table No. 3 Showing 30 Patients According to Marital Status. 84

Table No. 4 Showing 30 Patients According to Occupation. 85

Table No. 5 Showing 30 Patients According to Socio Economic Status. 86

Table No. 6 Showing 30 Patients According to Educational Status. 87

Table No. 7 Showing 30 Patients According to Infertility Duration. 88

Table No. 8 Showing 30 Patients According to Menstrual History. 89

Table No. 9 Showing 30 Patients According to Bleeding Duration 90

Table No.10 Showing 30 Patients According to Interval Period. 91

Table No.11 Showing 30 Patients According to Character of Bleeding. 92

Table No.12 Showing 30 Patients According to Dysmenorrhoea. 93

Table No.13 Showing 30 Patients According to Oligomenorrhoea. 94

Table No.14 Showing 30 Patients According to Uterurine Position 95

Table No.15 Showing 30 Patients According to Fornix 96


No.

Table No.16 Showing 30 Patients According to Vaginal Discharge 97

Table No.17 Statistical Analysis of Dysmenorrhoea in Group-A 98

Table No.18 Statistical Analysis of Dysmenorrhoea in Group-B 98

Table No.19 Comparison between Dysmenorrhoea of two groups. 99

Table No.20 Statistical Analysis of Oligomenorrhoea in Group-A 99

Table No.21 Statistical Analysis of Oligomenorrhoea in Group-B 100

Table No.22 Comparison between Oligomenorrhoea of two groups 100

Table No.23 Statistical Analysis of Bleeding Duration in Group-A 101

Table No.24 Statistical Analysis of Bleeding Duration in Group-B 101

Table No.25 Comparison between Bleeding Duration of two groups 102

Table No.26 Statistical Analysis of Interval duration in Group-A 102

Table No.27 Statistical Analysis of Interval duration in Group-B 103

Table No.28 Comparison between Interval Duration of two groups. 103

Table No.29 Statistical Analysis of Cervical mucus Viscosity in Group-A 104

Table No.30 Statistical Analysis of Cervical mucus Viscosity in Group B 104


No.

Table No.31 Comparisons between Cervical mucus viscosity Duration of

two groups

105

Table No.32 Statistical Analysis of Cervical mucus Ferning in Group-A 105

Table No.33 Statistical Analysis of Cervical mucus Ferning in Group-B 106

Table No.34 Comparisons between Cervical mucus Ferning of two

groups.

106

Table No.35 Statistical Analysis of Cervical mucus Spin Barkeit in

Group-A

107

Table No.36 Statistical Analysis of Cervical mucus Spin Barkeit in

Group-B

107

Table No.37 Comparisons between Cervical mucus Spin Barkeit of two

groups

108

Table No.38 Statistical Analysis of Follicular study in Group-A 108

Table No.39 Statistical Analysis of Follicular study in Group-B 109

Table No.40 Comparisons between Follicular study of two groups. 109

Table No 41 Overall Effect of Result 110

LIST OF FIGURES

Figure No. Name of the Figures Page No.

Figure No. 1 Internal Structure of ovary 24

Figure No. 2 Musali 74

Figure No. 3 Daruharidra 74

Figure No. 4 Bala 74

Figure No. 5 Palasha 74

Figure No. 6 Dhataki 75

Figure No. 7 Shivalingi 75

Figure No. 8 Misreya 75

Figure No. 9 Putranjeevaka 75

Figure No.10 Prepared trial drug powder 76

Figure No.11 Capsules of Ghansatwa 76

LIST OF GRAPHS

Graph No. Name of the Graphs Page No.

Graph No. 1 Distribution of patients according to Age 83

Graph No. 2 Distribution of patients according to Marital Status 84

Graph No. 3 Distribution of patients according to Socio-economic status 85

Graph No. 4 Distribution of patients according to Education 86

Graph No. 5 Distribution of patients according to Infertility duration 87

Graph No. 6 Distribution of patients according to Menstrual history 88

Graph No. 7 Distribution of patients according to Occupation 89

Graph No. 8 Distribution of patients according to Bleeding duration 90

Graph No. 9 Distribution of patients according to Interval period 91

Graph No.10 Distribution of patients according to Character of bleeding 92

Graph No.11 Distribution of patients according to Dysmenorrhoea 93

Graph No.12 Distribution of patients according to Uterus position 94

Graph No13 Distribution of patients according to Fornix 95

Graph No14 Distribution of patients according to Oligomenorrhoea 96

Graph No 15 Distribution of patients according to Vaginal discharge 97

Graph No 16 Over all Result of Group A 110

Graph No. Name of the Graphs Page No.

Graph No 17 Over all Result of Group B 110

Introduction

Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction 1

INTRODUCTION

Existence of the human race revolves around the women to whom is also

assigned the name “Janani” because of her power to bring a new life in the universe.

Women are the makers of the home, the nation and world. It is indeed the woman who

shapes the generation.

Women is placed in a high position in society since the time immortal , but

when a lady never conceives for some period it is a curse for her. She looses all her

name, fame, faith & belief from family for being barren. This makes a gap in the

relation.

Motherhood is a great dream for a woman in her life, but when a couple is

unable to initiate the reproduction after one year marital relations, they are said to be

Infertile.

Infertility is a major problem in our society. Now a days the rate of infertility

is steadily increasing, because of change of life style of human begins.

People wants to lead luxurious life for that they are running behind the money

& thus people get more stressed & tensed out at work.

Delayed marriage, higher education & high ambitions are the cause for

infertility.

Today’s life is very fast, the food habits are also changed, the intake of fast

food, junk food & adulterated food also impacts fertility.

Infertility does not cause any serious effect on the body; the psychoneurotic

upset resulting from infertility affects her physical as well as mental health. The

Introduction


problem of female infertility is more serious than the problem male infertility in the

male dominating society of India.

In Ayurveda we know four important factors are helpful in conception. That

are Rutu, Kshetra, Ambu, Beeja ( Pumbeeja or sperm & stree beeja or ovum) are the

important factors among all. With the help of modern techniques we are detecting the

condition of sperm & ovum. Now a day so many defects in these two may lead the

infertility, which needs correction & fruitful result. Defective ovulation is increasing

day to day due to global warming, taking of synthetic food articles, stress & other

hormonal imbalance conditions.

Statistical analysis shows in 40-60% of female infertility about 20% are due to

ovulation defect.

The treatment of ovulation defects in general practice are mainly starts with

hormonal treatment for ovulation, which has other side effects. In this clinical study a

non-hormonal, herbal, safe remedy to treat menstrual irregulaties & ovulation defect

is conducted. The observation, assessment & results were taken using modern &

Ayurvedic techniques to study the efficacy of the trial drug & presented in the form of

thesis.

Objective of the study

OBJECTIVE OF THE STUDY

1. To assess the efficacy of Ayurvedic remedy in the management of infertility

2. To conduct conceptual study of female infertility and to establish the

correlation with Apraja vandhya (Primary infertility)

Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction

3

Review of Literature


AAYYUURRVVEEDDIICC RREEVVIIEEWW

HISTORICAL REVIEW :

History of any particular subject enables us to understand the origin, progress

and other aspects of that subject. Vandhyatva has been a long standing problem of

human community right from ancient period up to this modern era.

If we think the antiquity of the Vandhyatva, we can see the praise of the

women having children and slander of the barren women and the solutions to her

barrenness are also mentioned in the Vedas, Upanishadas and Puranas.

VEDA KALA

The Vedas are considered as most ancient literature available in the world.

There are four vedas Rig-veda, Yajur-veda, Sama-veda, and Atharva-veda. Ayurveda

is considered as the Upaveda of Atharva-veda.

We find the references of Vandhyatva & its treatment even in Vedas, Puranas

& Upanishadas. The oldest epic Rig-veda describes about the miraculous work of

Ashwinee kumars, the divinely physicians, as it is written that Ashwinee kumar's

treated infertile Badh-rimatee & she was blessed with a son named Hiranya Hasta1.

In Atharva-veda 'Purandhriyosha' is mentioned which means that when a man

enters into Grihasthashrama he prays to God, & he wishes that his wife should be

"Purandhriyosha"( pregnant). In this we find descriptions regarding conception by

enchanting mantra.2&3. Mantras are also advocated to cure the Garbha dosha 4.

Emphasis has been put on the herb Apamarga to procedure a male child 5



PURANA KALA.

In Padma Purana it is mentioned that a woman having one child is called as

"Kaka Vandhya"6.

In Brahma Purana, while explaining the importance of "Sri Krishna Durga

Strotra", it is said that a woman who as a Vandhya, Kakavandhya, Mrtavatsa or

Durbhaga can conceive by reciting this strotra, within one year6.

SAMHITA KALA

Caraka and Vagbhata, have referred Vandhya due to abnormality of Bijamsa

and mentioned as the Upadrava of Yoni Vyapada.7&8

In Sushruta Samhita, Vandhyatva has been described under the title of

Vandhya Yonivyapada, which is included amongst twenty gynaecological disorders

(Yoni vyapada) 9

In Kasyapa Samhita under the description of Jataharinis, he has mentioned

one Puspaghni having useless Puspa and certain others characterised with repeated

expulsion of foetus of different gestational periods 10

In Harita Samhita, Harita has described Vandhyatva as a disease, in eighty

VatajaVyadhi. He has defined Vandhyatva as a failure to achieve a child rather than

pregnancy, because he has included Garbhasravi, Mritavatsa also under the

classification11

In Madhava Nidana, the types of Vandhyatva have been described12 In

Sarangadhara Samhita, Rasaratna Saumuccaya, Yoga Ratnakara and Bhaisajya

Ratnavali etc. have described some therapeutics of Vandhyatva.



VANDHYATVA AS A DISEASE :

We does not find unequivocal description of Vandhyatva in any of the

Ayurvedic classics except Harita Samhita. But in Harita Samhita also, he has given

classification only, no specific etiology or pathogenesis was explained. Vandhyatva

as a disease is only given by Harita while describing eighty Vataja Vyadhi. While

other Acharyas has not considered it as a independent disease, rather a cardinal

feature of so many diseases.

Apart from this they have not used word Vandhyatva, but it is the only

symptom i.e.failure to achieve pregnancy, has been referred under various conditions

like coitus with old, young or diseased woman; coitus in abnormal posture, woman

having diseased yoni or abnormality of Artava etc.

In Kasyapa Samhita he mentioned that, the couple having number of children

with proper growth and development due to effect of nature (Savbhavat) or their own

deads (Svakarmaparinamat) are fortunate, otherwise should be treated, i.e. it will be a

disease condition which needs Chikista.

Acarya Harita in classification of Vandhyatva includes Garbhasravi, Mrtavatsa

etc. From above references we can consider Vandhyatva as a disease. Vandhyatva

may be defined as the inability of a couple to achieve child rather than pregnancy by

their Svabhava and Svakarma.



DISEASE REVIEW(AYURVEDIC)

VYUTPATTI:

Vandhya:

The word "Vandhya" is derived from the root "Vandha" with 'Yak' suffix

which means barren, unproductive, fruitless and useless.

NIRUKTI: rÉxrÉÉ aÉpÉïkÉÉUhÉ qÉÉaÉïÂmÉ oÉlkÉlÉÇ xÉÇmrÉÌiÉ xÉ

uÉlkrÉÉ | ( zÉ.Mü.SìÓqÉ 395)

The woman in whom there is hindrance of any kind to the normal process of

conception is Vandhya

DEFINITION:

A woman whose Artava is perished is called Vandhya9

SYNONYMES:

Vasa VIphala

Nisphala Aprajashv

Aparyasunyago Avatoka

Avakesi Sravatgarbha

Aphala

CLASSIFICATION:

Vandhyatva has been classified in the following ways according to different

Acarayas.

Caraka Samhita: In Caraka Samhita, classification is not given but considering the

references together it can be as follows:



(1) Vandhya - Vandhya refers to incurable congenital or acquired abnormalities

resulting into absolute sterlity.

(2) Apraja : Infertility in which woman conceives after treatment13

(3) Sapraja : Sapraja is a condition in which woman in her active reproductive age

does not conceive, after giving birth to one or more children.

Harita : Harita has described six types of Vandhya11

(1) Garbhakosabhanga - During childhood in case there is Garbhakosabhanga

(injury to the uterus) and loss of Dhatus, woman never conceive.

(2) Kakavandhya - one child infertility.

(3) Anapatya - No child

(4) Garbhasravi - Repeated abortion

(5) Mritavatsa - Repeated still births

(6) Balaksaya - Infertility due to loss of Bala.

Rasaratna - Samuchaya : He classified Vandhyatva in nine types14

(1) Adivandhyatva (2) Vataja

(3) Pittaja (4) Kaphaja

(5) Sannipataj (6) Bhutaja

(7) Daivaja (8) Raktaja

(9) Abhicaraja

MADHAVA NIDANA:

Madhavakara has described nine types of vandhya12.

(1) Adivandhya (2) Raktaja



(3) Vataja (4) Pitaja

(5) Kaphaja (6) Tridoshaja

(7) Bhutaja (8) Daivaja

(9) Abhicharaja.

Avandhya--The word Avandhya suggest a childless woman, but capacity to

conceive with quite delay ( Chakrapani).

Kasyapa samhita The available portion of kashyapa samhita presents an

unique chapter in its kalpa sthana as “Revati Kalpadhyaya". In this chapter thirty

different types of Revaties inflicting various disorders to females are described.

NIDANA OF VANDHYATA

In classics specific causitive factors of Vandhyatva are not given. To get the

complete picture of Nidana, the subject matter from all related places are recapulated

here. First of all we will see the factors responsible for fertility / conception.

Acarya Susruta15 equating germination of seed with achievement of

conception quoted that if Ritu (period near ovulation i.e. Rtukala), bija (ovum and

sperms), Ksetra (female reproductive system) and Ambu (nourishment) assemble

together the conception will definitely occurs.

While Caraka16 quoted that when both male and female after observing the

advocated dietetic regimen and other mode of life and perform coitus and ejaculated

unvitiated sukra, passing through healthy yoni, reaches healthy garbhasaya and gets

mixed with disease free sonita, then conception is definite.

Vagbhata has given importance to Ksetra and Bija. while Vagbhata II17 has

emphasize that besides healthy Garbhashaya, Marga, Rakta (ovum), Sukra, properly



functioning Vayu and normal psychological status (happy mood) are also essential.

Summarizing the above description it can be said that for achievement of

conception,

(1) Healthy and properly functioning female reproductive system (Yoni). i.e

includes ovary, fallopian tubes, uterus, cervix, vagina.

(2) Healthy sperms and ovum

(3) Proper functioning Vayu

(4) Normal psychology

(5) Healthy partners

(6) Proper nursing factor

(7) Proper coitus

(8) Healthy Diet

When these factors are in favorable condition cause conception, but the diseased

condition of any one or many of these factors cause Vandhyatva.18

NIDANA OF VANDHYATVA W.S.R. TO ANOVULATION:

Failure of the ovary to produce a matured ovum is anovulation. Menstrual cycle

without having a mature ovum is called as anovulatory cycle, and is the main cause of

infertility. Some conditions with their Nidanas, are available in classics, which seems

to be related with anovulation causing vandhyatva are being mentioned here:

(1) Revati Jatharini (Puspaghni):10

Under the description of jatharinies Kasyapa has mentioned one Puspaghni, the

woman affected menstruates in regular interval, but is unable to conceive. The other

symptoms given are, she has corpulent and hairy cheeks.



(2) Astartava Dusti:

Acharyas have mentioned that Astartava Dusti if remains untreated or not

properly treated then it causes Abijata i.e. it is unable for Prajotpadana19.

Susruta, just after describing eight disorders of Sukra, has enumerated eight

disorders of Artava.

Dalhana has clarified that the clinical features of Artava are identical to those

for Sukra. Both the Vagbhatas have expressed similar views20.

Disorders of Artava have been classified by Susruta on the basis of

predominance of Dosas and disorders of Sukra on the basis of main clinical feature.

Actually there is no difference in both these, at one place (in Artava), the causative

factor has been given the importance and at other, the clinical features.

Since all the classics have mentioned that Artava also exhibits similar clinical

features of Sukra disorders of Artava are being given on the basis of description of

disorders of Sukra.

Classification of Artava Dusti:

(1) On the basis of Causative Dosa

(a) Vataja (b) Pittaja (c) Slesmaja (d) Raktaja (e) Vata Pittaja

(f) Pitta Kaphaja (g) Vata Kaphaja (h) Tridosaja

(2) On the basis of specific clinical features

(a) Vataja (b) Pittaja (c) Kaphaja (d) Kunapa Gandhi

(e) Granthi - Bhuta (h) Putipuya (i) Kshina and (j) Mutrapurisa Tulya or

Malatulya



Clinical features21:

(1) Vataja Artava Dusti: The Artava Vitiated by Vata is Red, black or dark violet in

colour. Thin dry, frothy and scattered. It is excreted slowly and with pain specially

perforating or piercing type pain.

(2) Pittaja Artava Dusti:

The Artava vitiated by Pitta is –

Yellowish or bluish in color. It is free from unctuousness, smells like pus, fungus

blood or has putrid smell. At the time of excretion is hot, associated with severe

burning and feeling of heat.

(3) Kaphaja Artava Dusti : The Artava vitiated by Kapha is -

Whitish or slightly yellowish in colour mixed with Majja. It is too much thick,

slippery or lubricous, unctuous and settles down if put in the water.

(4) Kunapa Gandhi Artava Dusti : The Artava vitiated by Rakta -

It smells like a dead body. Artava discharged more and red like fresh blood. It

is also associated with heat and burning etc. features of Pitta.

(5) Granthibhuta Artava Dusti : The Artava vitiated by Vata and Slesma -

It has clotted appearance associated features are of both the dosas (pain due to

Vata and unctuousness due to Kapha etc.

(6) Putipuya or Puya Artava Dusti: The Artava vitiated by Pittakapha-

Putipuya means it is putrid and purulent. It is characterised with other features

of Pitta and Kapha (burning, fever, heat due to Pitta and heaviness etc. due to Kapha).

(7) Ksina Artava Dusti: The Artava vitiated by Pitta and Vayu -

It is scanty, less in quantity and delayed. Associated with pain in Vagina and



also the features of Vata and Pitta Dosas.

(8) Mutra Purisa Gandhi Artava Dusti : The Artava vitiated by Tridosa-

It smells like urine and feces.

Nidana of Artavadusti 22

Authors have not described any specific etiology of these Astartava dusti. But

as it is similar to that of Sukra Dusti. We can correlate Sukradusti Nidana with its

causative factor in some extent.

(1) Viharajanya - Excessive sexual indulgence, untimely sexual congress,

sexual abstinence, sexual congress with an unresponsive woman, supression of the

natural urges.

(2) Aharajanya - Habitual use of unwholesome diet, habitual use of dry bitter,

astringent very saltish, acid or hot articles.

(3) Other - Owing to old age, worry grief or lack of mutual confidence, injury

by weapons, caustics or fire, owing to fear, angry, black magic, emaciation due to

disease, vitiation of body elements. Due to this Nidanasevana, the Dosas get provoked

either sinlgy or collectively and reaching the (Retovaha Sira) Rajovahi sira, soon they

vitiate the (semen) Artava excessively.

In classics Sudhaartava has been told as one of the essential factor for the

conception, complete growth and development of the foetus along with its normal full

term birth. In the quotation as given in the vitiated Artava has been mentioned as one

of the main cause of infertility. This means that if the Artava (Bahipuspa,

menstruating blood) is vitiated by the Dosas then there will be no production of Bija

(Antapuspa, ovum).



In Sushruta Samhita, the Garbhotpatti has been compared with the Ankur

Utpatti and it has been mentioned clearly that the Artava of a woman vitiated by the

deranged Vata, Pitta, Kapha or Rakta either singly or in combination of two or more

Dosas, should be likewise considered as unfit for the purpose of fecundation.

In modern science the menstrual phenomenon and the ovulation are correlated.

In many ovarian dysfunctions the menstrual pattern get disturbed.

In Kasayapa Samhita some Nidanas are given for Artava Dusti.23

(1) Use of Nasya during menstruation.

(2) Consumption of excessive not eatables and drinks.

(3) Use of excessive medicines for Sodhana purpose to the woman of Mrdu Kostha

having received Snehana and Svedana.

Avarana24

In the concept of Artavanasa both Susruta and Vagbhata has described that

both Vata and Kapha when aggravated, obstruct the path, thus Artava is destroyed.

Though Artava is not finished completely however it is not discharged monthly.

Acarya Kasyapa has defined clearly the bad effect of Tiksna Virecana in a

person having Mrdukostha. According to him, due to this, Vata is aggravated and

causes Svasa, Kasa etc. along with Bijopaghata in case of female. Vata mainly Apana

Vata responsible for all type of abnormalities25

Artava Vaha Srotasa Viddhata 26

According to Acarya Susruta the trauma on the Artava Vaha Srotasa cause

anovulation and is the cause of infertility.



Beejadusti 27

During antenatal period if mother takes Vata Prakopaka Ahara and Vihara, the

Vata get aggravated and spoil the Beeja or Beejabhaga or Beejabhagavayava in

female child and that in turn results in the congenital abnormality of female genital

organs which is termed as Vandhya in Caraka Samhita Sarira Sthana and Sandhi Yoni

in Cikistasthana by all acharyas.

Dietic habit23

Due to Ati Usna Annapana, Virya, Artava, Beeja become Upachita. Use of

excess hot water & diet accumulation (maturation / formation) of retas( semen) asrk

(ovum) & egg ( implantation) get vitiated.

Yonivyapada :

Acarya Caraka mentioned that Yoni (reproductive system) of woman when

afflicted with Dosas or diseases, causes, Apatyavighata, does not retain Sukra and

Garbha, i.e. become infertile. Also causes Upadravas like Gulma, Arsa, Pradara and

other Vata disorders, Stambha and Sula28&29

Some specific Yonivyapada related to Vandhyatva. W.S.R. to Anovulation.

Acharana yonivyapada30&31

Dalhana mentioned that in this disease the woman is hyperexcited during

coitus than the man or she feels excessive itching and therefore fertilization also not

occurs.

Madhava Nidana, Bhavaprakasa and Yogaratnakara also mentioned the same

description.



Aticharana 32&33

Susruta explained that Aticharana yonivyapada is cause due to excessive

sexual act and she doesnot retain the Beeja. While commenting Dalhana quotes that is

woman does not achieve conception.

Putraghni / Jatagni 34&35

The aggravated Vata due to predominance of Ruksa property, repeatedly

destroy the foetus. Dusta Sonita is also a causative factor which was given by Susruta

also in different manner as "Raktasansravat".

Suska 36

Only Adhamalla has mentioned Nasta Artava as the onlysymptom of Suska

Yonivyapada.

Vamini 37

All Acharyas mentioned that the disorder, in which Sukra (sperm) only or

admixed with Raja, is expelled with or without pain within six to seven days of its

entry into uterus is termed as Vamini.

Vandhya 9

Susruta defined the Vandhya Yonivyapada with the absence of Artava.

Sandhi yonivyapada :

It is explained in Bijadustijanya Nidana.

Asrja or Apraja38

Acharya Caraka, only explain that due to aggrevation of Rakta and Pitta, there

is bleeding even after achievement of conception. Chakrapani in addition comments

that excessive bleeding leads to abortion, thus the woman remains without progency



(Praja) hence; it is also termed as Apraja.

Summarizing all those references, it can be stated that the Nidana of

Yonivyapada given by Acharyas can be taken as the Nidana of Vandyatva and also

for the anovulation causing Vandhyatva

(1) Aharaja Nidana - Mithyaahara, Dustabhojana

(2) Viharaja Nidana - Mithyavihara Coitus with Ruksa, Durbala, Bala, Excessive

coitus, Use of foreign bodies for sexual organisms

(3) Pradusta Artava -

(4) Beeja Dosa i.e,. Abnormalities of sperm or ovum

(5) Daiva - unknown or idiopathic factor39

Thus etiologies of Vandhyatva can be boldly categorized under 4 headings as

specified by the classics. Though we find number of reasons for Anovulation they go

no,where beyond these four Vyapaka Nidana.

SAMPRAPTI 40

The Vyadhijanaka, Vyapara is called as Samprapti. In detail, the manner in

which the vitiated dosa diffuses in the body to liberate the disease is known as

Samprapti. It is also called Jati and Agati41. Susruta, while explaining Vyadhi

formation specify the "Kha Vaigunya" "Kha" means the Akasa or Avakasa and the

Avakasayukta Bhava (organ) of Sarira are Srotasa42

Srotasas play very important role because no substance in the body can grow

and develop or waste and atrophy independent of Srotasa.

The general causes of Srotodusti given by Charaka are related to Dosa and

Dhatu43. Also the general Srotodusti Laksanas are Atipravrtti Sanga. Siragranthi,



Vimargagamana, among these Sanga may be explained by three ways,

(1) The substance to be produce is less.

(2) The production is normal but the channel is small

3) Or the channel may be obstructed.

Vagbhata stated the importance of Agni in Roganirmana. The Agni and Ama

are interrelated. Also the normal or vitiated state of Dosa depends on Agni. The

Samprapti of Vandhyatva W.S.R. to Anovulation begins with the various factors

explained under Nidana and ends up with Anovulation which is the main cause for the

symptomatology of Vandhyatva.

SAMPRAPTI GHATAKA:

Dosa - Tridosa with predominant Vata

Dhatu - Rasa, Rakta

Upadhatu – Artava

Srotasa - Artavavaha

Srotodusti - Sanga

Udbhavasthana - Pakvasaya (Mulasthana of Vata)

Adhisthana - Yoni & Garbhasaya

Marga - Abhyantara (Garbhasaya as Kosthanga)

The specific etiological factors mentioned previously cause provocation of

vata, pitta and kapha. Vata the main dosa vitiates with its own causative factors also.

vata on account of its quality of subtleness (suksmatvata) is really the impeller of

other two humours. Vitiated vata agitates the other two humors and throw them in the



place having kha vaigunya. Here the khavaigunya is in artavavaha Srotasa specially in

the beejagranthi.

Due to nidana sevana, dosa and agni get vitiated, mandagni is the main cause

of ama formation. The ama formed executes hazardous effects, it adhers to srotasa

and forms avarodhatmaka dusti. Ama spreads throughout the body, propelled by the

vitiated vata along the rasavaha srotasa and in modern physiology, a variety of

transforming and transmitting substances present in the body like enzymes, hormones,

catalyst etc. When these are unable to function properly entirely different metabolites

are formed which the body is not acquainted to process. These accumulated in the

body in different systems affecting the normal mechanism of that particular system.

These may be formed as ama.

Due to hypo functioning of jatharagni, dhatvagni mandya also occurs. Due to

mandagni and nidanasevana, rasa, rakta dhatu get vitiated. Also the dhatvagnimandya

causes the ksayatmaka effect on the artava i.e. the production of artava, upadhatu of

rasadhatu or raktadhatu becomes less. Thus it is the Upadhatvatmaka dusti.

Visvamitra has clarified that hair thin vessels fill the uterus for whole month

to receive bija and due to rasadusti posanatmaka dusti can cause Anovulation.

The vitiated apanavayu and kapha when get mix can cause avaranatmaka dusti

causing Anovulation. The vitiated Vata along with Pitta causes the artavaksaya i.e.

ksayatmaka dusti causing Anovulation.

Line of treatment:

1. Treatment of specific causes responsible for infertility such as treatment of all the

Gynecological disorders including injury to the uterus or its prolapsed, diseases of



shukra & artava & yonyarsha etc to be done. The acharyas have mentioned

unequivocally that pregnancy occurs only in case of healthy reproductive organs.

2. For saking of different etiological factors such as abnormal diet and mode of life,

coitus before or after ritukala, psychological trouble etc.

3. Use of strength producing and brumhana articles to compensate the loss of bala

and dhatus.

4. After using oleation, sudation, emesis, purgation, astapana & anuvasana basti in

consecutive order, the man should be given milk and grita medicated with sweet

drug and oil & masha to the women according to the opinion of some authors.

Kashyapa said that after using cleansing measures ie panchakarma both the

partners should be prescribed congenial diet.

5. Infertile woman should be prescribed with emesis, purgation & astapana basti,

with the help of these procedures the woman conceives positively and delivers

normally.

6. The use of basti in infertility due to diseases of vata is highly beneficial. By the

use of basti the yoni becomes healthy & even a sterile woman would conceive.

The basti is beneficial to the woman having repeated abortions, short lived &

weak children who are delicate & indulge daily in coitus.

7. The drugs prescribed for pumsavana karma can also be used.

Specific treatment:

The drugs prescribed for gynecological disorders to be used to eradicate the

causes of infertility, but there are certain recipes were described by our ancient rishis

which are indicated for achievement of conception by an infertile woman. They were

advocated in various forms. Some of them are used externally& some internally. The



externally applied drugs are in the form of nasya, abhyanga & basti. Whereas

medicines to be taken orally is numerous.

• Nasya(nasal instillation):-

1. Lakshmana triaturated with cow’s milk.

2. Amulet of root of lankakara lakshamana tied round the neck & nasya of

lakshamana triaturated with cow’s ghrita.

3. Narayana taila.

4. Shatapushpa taila.

• Abhyanga (massage)

1. Narayana taila.

2. Shatapushpa taila.

• Basti (enema)

Narayana taila. Shatapushpa taila.

Lasuna taila. Shatapaka taila.

Trivrita sneha. Bala taila.

Shatavaryadi anuvasana. Guduchyadi Rasayana.

Sahacharyadi yapana. Mustadi yapana.

Shatavryadi Rasayana. Jeevantyadi anuvasana.

• Drugs for oral use:

Kalka:

1. Paste of chandana, ushira, manjista,girikarni & sugar candy mixed with cow’s

milks.



2. Paste of sweta-girikarni, sweta-gunja, sweta-punarnava with cow’s milks.

3. Paste of roots of swetarka in milk or Paste of sweta-girikarni or sweta-agrikarni in

milk.

4. Paste of triphala, girikarni, aragvadha, vatsaka, payasa in cow’s milk.

Churnas:

1. Baladhy churna, chandanadya churna, drakshadya churna, khandakadya churna,

& punarnavadya churna.

2. Shatapushpa kalpa

Swarasa or juices:

1. 8 leaf buds of vata, lakshmana & cow’s milk.

2. Bala, sharkara, atibala, madhuka, leaf buds of vata, gajakeshara mixed with

honey, milk & ghee.

3. Root of lakshmana (taken in pushya nakshatra) & pounded with milk by a virgin.

4. Root of kuranta flowers of dhataki leaf buds of vata & neelotpala triturated with

milk.

5. Parswa pippala with jeeraka & white visikha punkha.

Kwath (Decoction)

1. Maharasnadi Kwatha

2. A woman having taken bath after menstruation, if uses milk medicated with

decoction of Ashwagandha in the morning hours, definitely conceives.

Pana

1. Lakshamana with milk



2. Tila taila, milk, phanita, curd and ghee churned and mixed.

3. Entire seeds of one matulunga pounded with milk.

Gutika (Tablets)

1. Yogaraj Guggulu

Taila (Oils)

Narayana Taila Shatavari taila

Baladya taila Satapusphpa taila

Ghritas

Laghuphala ghruta Phala ghruta

Kamadeva ghruta Paniya kalyanaka ghruta

Seetakalyanaka ghruta Brihat shatavari or Shatavari ghruta

Kashmaryadi ghruta Jeevaniya Ghana siddha gruta

Shatavaryadi ghruta Lasuna ghruta

Aristas

1. Dashamoola Arista

Rasa aushaddhi

1. Khandakadya Louha

Paka

1. Puga paka


MODERM REVIEW

FUNCTIONAL ANATOMY OF OVARY

OVARY:

The ovaries are paired sex glands or gonads in female. Each gland is oval in shape

and pinkish grey in colour measuring 4 x 2.5 x 1.5 cm. one on each side near the free

end of the fallopian tube, hanging from the broad ligament by a fold of peritoneum

called mesovarium. They are richly supplied with blood vessels and nerves.

Fig no. 1 Internal Structure of ovary

HISTOLOGY OF OVARY :

There is no organ in the female body which show so much histological variations at

different phases of life i.e. childhood, puberty, pregnancy and menopause. Ovary

consists of the following six elements :

(1) Germinal epithelium: It is outmost covering by a single layer of cuboidal cells,

continuous with the peritoneum, derived from the coelonic epithelium. It is the parent

tissue from which the primitive graffian follicles develop.


24


(2) Tunica albuginia : This layer of eosinophilic collagenous connective tissue of

low cellularity under germinal epithelium.

(3) Stroma: It is a connective tissue network continuous with the tunica albuginia and

containing spindle shaped cells with a few involuntary muscle fibers. It supports the

essential ovarian tissues and carries blood vessels, lymphatics and nerves.

(4) Vesicular follicles or Graffian follicle : Small Islands of cells in various stages of

development are scattered mostly at the peripheral part of the ovary. These immature

ones are called as the primordial follicles. The central cell is the ovum. The remaining

cells surround the ovum in a single layer forming a sort of capsule.

(5) Corpus luteum : When the graffian follicle ruptures corpus luteum develops on

the remnants of the ruptured follicle.

(6) Interstitial cells : Groups of polyhedral cells containing lipid granules

representing stored active principle. They develop the stroma cells or from the cells of

the unruptured follicles.

FUNCTIONS OF OVARY :

The ovaries have two functions, Exocrine function i.e. the production of ova

(ovulation) and Endocrine function i.e. the production of hormones.

The latter is secondary to the former and is present to a limited extent for a

few years before regular ovulation is established and for some time after ovulation.

Both these functions are controlled through the hypothalamic - pituitary

ovarian axis by endocrine, paracrine and autocrine pathways.


25


ESTABLISHMENT OF OVULATION:

The ovary probably first sheds an ovum (ovulation) about the time of the onset

of menstruation, but ovulation is not usually established as a regular phenomenon

until 2-3 years after the menarche. It than continues until the age of 45-50 years,

although it may get less frequent and less regular after the age of 40 years.

Ovulation occasionally precedes the establishment of menstruation and

sometimes occurs even after the cessation of menstrual period. This accounts for the

rare cases of pregnancy reported to have occurred before the menarche and after the

menopause.

'Lipshutz Law of follicular constancy', according to the law the ovulation is

maintained every month even if one ovary is removed.

THE NUMBER OF OVA IN OVARY :

In embryonic life period, in yolk sac, primordial germ cells originate in the

endoderm and ovary is formed by genital ridge.

Oogenesis begins in ovary - 6-8 weeks gestation

Formation of oogonia - 16 to 20 weeks gestation

Transformation of oogonia to oocyte - 11 to 12 weeks gestation. Here the

oocyte enter the 1st meitotic phase and arrest in prophase.

The primary oocyte at birth in both ovary - 2 millions

The primary oocyte in both ovary at puberty - 3,00,000 to 5,00,000 From this

number of primary oocyte, not more than 500 are destined to mature during

the individuals lifetime and the remainder will be lost by some form of

generative process.


26


OVULATION :

Ovulation is the process by which an ovum, in the form of secondary oocyte,

is discharged from the ovary to become a gamete.

PROCESS :

In the ovarian cycle, which occupies approximately 28 days, ovulation takes

place at the midphase, having follicular and luteal phase before and after the

ovulation. The two phases are separated by ovulation.

Changes during follicular phase : In this phase the ovum is prepared for ovulation

by follicle ripening, primordial follicle grows to graffian follicle. The commencement

of ripening of a follicle is heralded by an increase in size of the ovum and of its

nucleus.

The surrounding granulose cells become cuboidal and multiply quickly to

become many layered. At the same time, they begin to secrete liquor follicule, which

form small pools separating groups of cells. These pools later run together to form a

single lake and the system becomes a graffian follicle. This cystic structure is lined by

several layers of granulosa cells which are collectively called the membrane

granulosa. The ovum is surround by a palestaining non-cellular porous area of

glycoproteins the zona pellucida. Between the ovum and zona pellucida is the

periviteline space. The granulosa cells immediately around the ovum constitute the

corona radiata outside the membrane granulosa, the layer of stromal cells, theca

interna and outside this again theca extrena.

27

During the process of ripening, the graffain follicle, by asymmetrical

development seen particularly in the form of a cone shaped theca interna, makes its



way to the surface of the ovary, easily piearcing the tunica albaginea. It thus arranges

itself so that the discuss proligerous with the ovum lies on the side of the follicle

adjacent to the peritoneal cavity. Thus in this stage the ovum is awaiting for release

from ovary in the form of a primary oocyte surrounded by granulosa cells.

Follicular ripening does not take place at an even ratio throughout the earlier

14 days and the major histological changes only appear within the last few hours or

days. An immature follicle is only 0.03 mm in diameter. A ripe follicle is 16-24 mm

diameter immediately before rupture, so it is visible to the necked eye.

Maturation of the ovum :

All the primary occyte in the ovary of a newborn baby are already in the early

stages of the meiotic division. The process becomes arrested in the late prophase stage

and remains dormant until follicular ripening is established.

In the midcycle, due to preovulatory LH surge, meiosis is resumed and is

completed within the 35-45 hours prior to the ovulation. This first maturation

division, during which the number of chromosomes in the nucleus is halved, results in

the formation of a secondary oocyte and a polar body. The latter comes to lie in the

perivitelline space of the oocyte. The second division, which results in the oocyte

casting off another polar body and the 1st polar body dividing into two, only occurs

after the ovum is liberated and probably only after it is fertilized.

During maturation, the ovum increases in a diameter from 0.2 to 0.1 mm and

at the end its nucleus is off centre and displays a prominent nucleolus.

Rupture of the follicle - ovulation :

28

The word rupture implies an explosive or dramatic occurrence, but the

discharge of the ovum from the follicle is a comparatively gradual process occupying



many seconds if not minutes during which the ovum, still surrounded by a corona

radiata of variable thickness, oozes out. The follicular fluid escapes with the ovum

and occasionally slight bleeding takes place from the site of rupture.

Ovulation usually occurs from 13th to 17th day (day 14th) of 28 day menstrual

cycle. It occurs 14 days before onset of next menses irrespective of length of

menstrual cycle (Knaus, 1934).

Life time :

Unless fertilized, the ovum survives only 12-24 hours and then disintegrates in

the tube without leaving any trace. Nevertheless ova have been recovered from the

fimbria and from the lumen of the tube 2-4 days after ovulation, and from the uterus

4-5 days after ovulation. Such if not already fertilized is probably degenerate or

certainly incapable of being fertilized.

Causes of ovulation :

(1) Ovulation occurs as a result of thinning and degeneration of the cyst wall, this

being associated with the production of proteolytic enzymes. The activity is enhanced

by progesterone.

(2) The progesterone induced mid-cycle rise in FSH also serves to free the oocyte

from its follicular attachments.

(3) Plasminogen activators activate plasmin which generates active collagenase

leading to degeneration of the collagen in the cell wall, especially at the follicular

apex or stigma.

29

(4) Exit of the ovum may possible be encouraged by contraction of micromuscle cells

present in the theca externa and the stroma. These being activated by prostaglandins

which are said to be essential to follicle rupture and the ovarian content of which is



increased by the action of LH.

Changes during Luteal phase : Just after the ovulation profound changes takes place

in the wall of follicle. The cyst collapses and the lining cells undergo leuteinization, a

process in which they enlarge by limbering fluid. Their bloatedness causes them to

become closely packed and makes their nuclei look relatively small. Luteinization,

which is brought about by enzyme action, affects both the granulosa layer (granulosa

lutein cells) and the theca interna (theca lutein cells), the latter being more prominent

in the early stages and former in the later stages.

The corpus luteum is 1-2 cm in diameter and projects from the surface of the

ovary. Some of the expansion is taken up by the layers of cells folding into the old

cavity and this gives the corpus luteum its characteristic crehatel shape on section.

The mature structure has a yellow colour on naked eye examination because of the

presence of lipoids. In its early stages, the corpus luteum is grey or greyish yellow.

Within 2-3 days of ovulation, the corpus luteum becomes supplied with blood vessels

which grow down the core of each invagination from the theca interna. During this

process there is often a little bleeding into the cavity where the blood mixes and

makes the appearance red or orange, the corpus haemorrhagicum.

The development is completed in 5 days during which time, it is already

functioning. Its activity is at a maximum during following 3-4 days, but when there

after as degenerative changes commence 4-6 days before the near menstrual period.

30

Degeneration is 1st made evident by the cells becoming vacuolated, there after

they lose their staining capacity, colloid degeneration and fatty changes are described.

But these are followed by hyalinization so that ultimately the corpus luteum is

converted into hyaline tissues, known as a corpus albicans. It is absorbed over the

course of 6-12 months.



Hormonal control :

The cyclical production of FSH and LH in the adult woman is itself largely

controlled by the ovarian cycle. This is by way of a feedback mechanism, which

operates through the hypothalamus and which can be explained in a simplified form

as follows. The discharge of FSH and a little LH from the pituitary, initiated by the

hypothalamus, causes follicle in the ovary to ripen and secrete estrogen. It resulting

high level of estrogen in circulation increases GnRH receptor concentration. A surge

in GnRH accompanies the LH surge. A high level of LH induced ovulation and

corpus luteum formation with a consequent increase in the secretion of progesterone.

Control of ovulation (pituitary ovarian relations) :

The neurohormonal connections are again illustrated by the control of

ovulation in certain animals such as rabit. In those follicular ripening proceeds

spontaneously but ovulation only occurs as a result of coitus. This act by mechanical

stimulation of the cervix. From the cervix, nerve impulses travel through the spinal

cord to the hypothalamic pituitary system which liberates LH to cause ovulation 18

hours after the initial stimulus. In woman, ovulation ordinarily occurs independent of

coitus and is spontaneous but this does not excludes the possibility that it may

sometimes be determined by outside influence.

Correlation of endometrial and ovarian cycles :

By the end of, if not just before the onset of a menstrual period, a new follicle

is beginning to ripen in the ovary; endometrial proliferation therefore occurs during

the follicular phase in the ovary and is the direct result of a mounting estrogen

influence. Ovulation marks the change over from the proliferative to the secretary

phase in the endometrium. Secretary activity and decidual reaction are manifestations


31


of the luteal phase in the ovary and are brought about by progesterone acting in the

absence of estrogens.

The Shrinkage of the endometrium menstrually coincides with commencing

failure of corpus luteum activity and is the direct result of the withdrawal, of the

supporting effect of estrogen and progesterone. For the practical purpose, in mature

women regular menstruation means regular ovulation.

Post menstrually the endometrium is only 1 mm thick where as at the end of

proliferative phase (i.e. 10 days after the end of menstruation the fourteenth day of the

cycle), it measures 2-3 mm. In the periovulatory period it appears sonographically as

a triple layer in the long axis of the uterus and is usually about 10-12 mm in diameter.

In luteal phase endometrium loses both the hyperechogenicity and the triple layered

appearance.

CHANGES DURING OVULATION :

(1) Myometrial changes: The activity of uterine muscle increases with the estrogen

stimulus of approaching ovulation, which is i.e. contractions are small and frequent

and having limited response to oxytocis in the follicular phase.

(2) Tubal changes : The muscles of the fallopian tube behaves like myometrium in

that it shows increased movement about the time of ovulation. This is an estrogen

effect as is the increased cilial activity at that time. These changes are timed to propel

the ovum towards the uterus.

(3) Cervical changes : At the time of ovulation the secretion is so profuse that it may

be noticeable as a vaginal discharge the 'ovulation cascade'. Under the influence of

estrogen, actively secreted mucus shows some characteristic features. The mucus will

stretch into threads measuring more than 6.5 cm, and even 10-15 cm, at the time of


32


ovulation. This property is known us spinnbarkeit. The mucus absorbs water and salts

and when allowed to dry, deposits crystals of sodium chloride and potassium chloride

in a characteristic pattern which suggest the fronds of fern.

All these special characters at this time make for its easy penetration by

spermatozoa. With comparison to luteal phase i.e. after ovulation the position of

cervical spincter which is due to tone of muscles of the isthmus and internal os, is less

tighter and competent during (ovulation) follicular phase which is due to

progesterone.

(4) Vaginal changes : It show histological changes in the vaginal epithelium, but they

are not clearly defined in tissue sections.

DIAGNOSIS OF OVULATION :

The following methods are available for diagnosis.

(A) Analysis of symptoms during ovulation :

(a) Cyclical bleeding : The occurrence of regular normal menstrual losses is strong

presumptive of monthly ovulation.

(b) Ovulation pain (Mittelschmerz) : Many women feel some discomfort in the

hypogastrium or in one or other iliac fossa for 12-24 hours just before or just after

ovulation.

(c) Ovulation bleeding or discharge (Mittelblut) : Some women experience a slight

loss of blood or of mucus tinged with blood at the time of ovulation. This may be

associated with ovulation pain although each can occur independently.

33

(d) Premenstrual mastalgia : Premenstrual pain and tenderness in the breasts is in

some way related to corpus luteum action. So its occurrence is fairly reliable evidence

that ovulation has occurred during that particular cycle.



(B) Temperature changes : The body temperature shows variations during follicular

phase, luteal phase, pregnancy also. For this test to be of value it is essential for the

temperature to be recorded daily under standard conditions, before rising from bed in

the morning and before eating or drinking.

The biphasic curve in the chart is evidence of ovulation as opposed to

anovular menstruation and the thermal shift is a fairly accurate indication of the time

of ovulation.

(C) Endometrial changes : By histological changes in the endometrium can diagnose

evidence of ovulation not the time of ovulation.

(D) Changes in cervical mucus: The different effects of estrogen and progesterone

on the physicochemical properties of cervical mucus are utilized in the fern test. A

failure to demonstrate ferning during the premenstrual week, denote dominant

progesterone influence and suggest that ovulation has occurred. Also the amount and

nature of cervical mucus shows the changes in preovulatory and ovulation stage.

(E) Hormone assay : Ovulation can be reliably confirmed by an estimation of the

mid luteal phase plasma progesterone level i.e. 5-8 days after ovulation. A minimum

of 6.5 ng/ml is taken to indicate ovulation.

(F) Ultrasound : It has been used to describe ovarian and follicular characteristics

throughout the cycle.

(G) Direct observation : Recent ovulation can be diagnosed by the finding of an

active corpus luteum on inspecting the ovary during laparoscopy or laparotomy.

OVULATION DETECTION METHODS


34


Table. No 1: Showing Method Day of cycle Observations

Method Day of cycle Observation

B.B.T Throughout cycle Secretary Endometrium

Cervical mucus

Nature

Spin barkeit

Fern pattern

12-14 & 21-23

12-14days 21-23days

Clear watery, thick viscid

+ -

+ -

Vaginal Cytology 12-14 & 21-23days

12-14 21-23

Discreade cells Folded edges

pyknotic nuclei inclumps.

Background clear Background dirty

Serum progesterone

8 & 21

On 8th < 1 ng/ml 21st > 6 ng/ml

Serial USG

12-14

Follicular measurements

approaching 20 mm

Laparoscopy

Secretary phase

Recent corpus luteum seen


35


ANOVULATION

Anovulation is a very common problem that present in a variety of clinical

manifestations including amenorrhea, irregular menses and hirsutism. serious

consequences of chronic anovulation are infertility & a greater risk for developing

carcinoma of the endometrium and perhaps the breast. The clinician must recognize

the clinical impact of anovulation and undertake therapeutic management of all

anovulatory patients to avoid these unwanted consequences.

Normal ovulation requires co-ordination of the menstrual system at all levels :

a) central hypothalamic – pituitary axis,

b) The feedback signals, and

c) Local responses within the ovary.

The loss of ovulation can be due to any one of assortment of factors operating

at each of these levels. the end result is a dysfunctional state, anovulation and

polycystic ovary.

CENTRAL DEFFECTS

The hypothalamic pituitary axis may be unable to respond, even if given

adequate and appropriately timed feedback signals. Normal pituitary ovulatory

response to the follicles steroid signals requires the presence of gonadotropin

releasing hormone (GnRH) pulsatile secretion within a critical range. Increasing

intensity of GnRH suppression is associated with increasing dysfunction and a

changing clinical presentation.

36

A variety of problems such as stress and anxiety, borderline anorexia nervosa

and acute weight loss after a crash diet, is associated with an inhibition of normal

GnRH pulsatile secretion, the mechanism for this suppression of GnRH is excessive



hypothalamic activity of corticotrophin - releasing hormone(CRH), a response to

stress. these patients present more commonly with amenorrhea. However if GnRH is

only partially suppressed homeostatic pituitary – ovarian function is maintained, and

the patients will be anovulatory.

Anovulation and polycystic ovaries have been reported to be more prevalent

in women with epilepsy. This is another example of how any disruption of normal

ovulation.

Specific clinical syndrome of central anovulatory dysfunction has been

recognized hyper-prolactinemia. Increasing levels of prolactin can cause a woman to

progress through a spectum, beginning with an inadequate luteal phase to anovulation

to the amenorrhea associated with complete GnRH suppression. A search for

galactorrhea and measurement of the prolactin level are important screening

procedures for all women who are not ovulating normally.

ABNORMAL FEEDBACK SIGNALS:

LOSS OF FSH STIMULATION :

In order to achieve recycling a nadir in blood sex steroid level must occur so

that the initial event in the cycle, the rise in FSH, can take place. Sustained estrogen at

such a key movement would not permit FSH stimulation of follicular growth and

maturation and recycling would be threatened.

PERSISTENT ESTROGEN SECRETION :

37

The most common clinical example of anovulation associated with continued

secretion of sex steroids is pregnancy. Persistent and elevated secretion of estrogen

can be encountered rarely with an ovarian or adrenal tumor. In such a case

anovulation or amenorrhea may be present.



ABNORMAL ESTROGEN CLEARANCE AND METABOLISM :

The clearance and metabolism of estrogen can be impaired by other

pathologic condition, such as thyroid or hepatic disease. Both hyper-thyroidism and

hypo-thyroidism can cause persistent anovulation by altering not only metabolic

clearance but also the peripheral conversion rates among the various steroids. When

hypo-thyroidism associated with elevated prolactin levels, demands screening of an

ovulatory and amenorrheic women with a thyroid stimulating hormone(TSH)

measurement.

EXTRAGLANDULAR ESTROGEN PRODUCTION :

Extra glandular contribution to the blood estrogen level can reach significant

proportions. This is accomplished by the extragonadal peripheral conversion of C-19

androgenic precursors, mainly androstenedione to estrogen. Psychological or physical

stress may increase the adrenal contribution of estrogenic precursor. Adipose tissue is

capable of converting andostenedione to estrogen: hence the percent conversion

increases with increasing body weight.

LOSS OF LH STIMULATION:

A failure in gonadal production of estrogen need not be absolute, obviously,

the patient with gonadal dysgenesis and ovarian failure will present with amenorrhea

and infertility because of total lack of estrogen secretion. The failure to achieve a

critical midcycle level of estradiol necessary to trigger the gonadotropin surge may be

due to a relative deficiency in steroid production.


38


LOCAL OVARIAN CONDITIONS :

A follicle can fail to grow and ovulate because of inadequate expression or

impaired function of any of the following local ovarian activities.

1. Selection of the dominant follicle is established during days 5-7 and consequently

peripheral levels of estradiol begins to rise significantly by cycle day 7.

2. Derived from the dominant follicle , etradiol levels increase steadily and through

negative feedback effect, exert a progressively greater suppressive influence on

FSH release.

3. Insulin like growth factor Ⅱ (IGF-II) is produced in theca cells in response to

gonadotropin stimulation, and this response is enhanced by estradiol and growth

hormone. In an autocrine action IGF-II increases LH stimulation of androgen

production in theca cells.

4. IGF-II stimulates granulose cell proliferation aromatizes activity, and

progesterone synthesis.

5. FSH inhibits IGF binding protein synthesis and thus maximizes growth factor

availability.

6. FSH stimulates inhibin and activin production by granulose cells.

7. Activin, augments FSH activities :FSH receptor expression aromatization, inhibin

/activin production, and LH receptor expression.

8. Inhibin enhances LH stimulation of androgen synthesis in the theca to provide

substrate for aromatization to estrogen in the granulose.


39


9. While directing a decline in FSH levels, the mid-follicular rise in estradiol exerts a

positive feedback influence on LH secretion. LH level rises steadily during the

late follicular phase, stimulating androgen production in the theca.

10. The positive action of estrogen also includes modification of the gonadotropin

molecule, increasing the quality (the bioactivity) and the quantity of LH at mid-

cycle.

11. Inhibin and less importantly, follistain, secreted by the granulose cells in response

to FSH : directly suppress pituitary FSH secreation.

12. FSH includes the appearance of LH receptors on granulosa cells, and the final

maturation of the follicle requires LH support.


40


DISEASE REVIEW (MODERN)

INFERTILITY

Infertility:- in + fer + til + i + ti ( lack of ability to reproduce).

Synonym:-

Absolute: - Due to removal of genital organs like hysterectomy, radiation or

oopherectomy, impossible to conceive.

Partially: - Due to ill health conception does not occur till she achieve good health.

Definition: - Infertility is defined as the inability of a couple to achieve conception

after one year of unprotected coitus.

1) Sterility : Implies that inability to conceive. It is an absolute term.

2) Infertility : Implies that failure to conceive. Infertility is again divided into two

types i.e.

a) Primary Infertility : Infertility where conception has not occurred.

b) Secondary Infertility : The conception has failed to occur after a period of

fertility.

Incidence:- 10 to 15% of marriages prove to be childless.

Fertility also varies from time to time in the same individual. In the male these

are not obvious except during childhood and less absolutely in old age, but in the

female physiological infertility is seen.

• Before puberty


41


• After puberty & before maturation. ( fertility is low until the age of 16-17

years) because anovular cycle.

• During pregnancy when ovulation is suppressed.

• During lactation

• Before the menopause

• After the menopause.

Conception rates also depend on many factors such as

• The tendency for smaller families.

• Elderly age at marriage.

• Use of contraceptions for 1 or 2 years for carrier benefit

• Changing life styles like DINK, SINK.

Causes of Infertility

The main etiological factor is found in Female 40%, Male 35%, Combined 10 to

20%, Unexplained --05%.

Female

1) Ovarian factor (5%)

In women menstruating regularly is a cause operating in about 15% of cases of

infertility. Regular anovulation in menstruating women can be a feature of

hypothalamic anovulation, hyperprolactinaemia; other causes of anovulation include

pituitary adenoma or primary hypothyroidism, polycystic ovaries, subclinical adrenal

failure and diabetes mellitus. Luteinized unruptured follicles & luteal phase

deficiency are two other clinical entities where infertility is seen.


42


Generally, failure to ovulate is associated with amenorrhea or

oligomenorrhoea and has the same causes. These include sex chromosome

disturbances premature ovarian failure due to premature menopause or resistant ovary

syndrome is also seen. Anovulation is also a feature of luteal phase deficiency and the

luteinized enraptured follicle.

Luteal phase defect can be short or long, but is more often the latter. There is

decreased hormone production by the corpus luteum as well as decreased levels of

follicle stimulating hormone (FSH) and luteinizing hormone (LH). Some women have

hyperprolactinaemia and hypothyroidism; others have unexplained infertility with

normal cycles, or habitual aborters.

2) Peritoneal Factors:-

1. Pelvic adhesions:-

2. Defective ovum pickup: - May operate by preventing the tube performing its

"octopus" function at the time of ovulation or by creating a mechanical barrier

between the ovary & the tubal ostium. They result from pelvic peritonitis of

any kind but especially that seen in association with appendicitis, and post

abortal or puerperal infections.

3. Endometriosis:- Is seen in at least 15% of women investigated for infertility, if

all grades are Considered.

3) Tubal Factors

Obstruction –

43

(a) Complete - peritoneal & tubal factors may account for up to 35% of all

cases of infertility. Partial or complete bilateral tubal obstruction results from

previous salpingitis. Most commonly this is post abortal, puerperal, gonococcal,



chlamydial or tuberculoses in nature

(b) Partial - loss of cilliary function.

4) Uterine Factors

• Uterine absence, congenital anomalies, septatet uterus, bicorn uterus,

atrophy or hypoplasia at a degree sufficient to bar the ascent of

spermatozoa causes amenorrhea as well as infertility.

• Tubercular endometritis.

• Intrauterine adhesions (Asherman's syndrome) due to previous overzealous

curettage or previous surgery on the uterus

• Submucous polyp, endometrial polyp

• Uterine leiomyomas unresponsive endometrium, hypoplasia, devoid of

secretary gland.

5) Cervical Factors

• Thick-impenetrable cervical mucus or poorly penetrable mucus

• Presence of local sperm antibodies

• To low PH of the mucus at mid cycle.

• Loss of mucus due to amputation of the cervix, cone biopsies or

overenthusiastic cervical diathermy.

• Faculty direction of the cervix such as is found in retroversion or severe

prolapse

• Chronic cervicities.


44


6) Vaginal Factors

Purulent discharge - This is doutful cause of infertility because spermatozoa

can thrive in pus under in vitro conditions.

COITAL ERRORS

Apareunia & dyspareunia

1-2% of couple found not to have consummated their marriage due to fear of

pain during sexual act

Frequency & timing of coitus

Some couple never know the fertile period 72 hrs during ovulation is the

period when conception takes place but due to lack of proper knowledge they missed

to do coitus has to take place every 48 hours during the fertile period to offer the

optimum chance of conception

Lubricants

For easy sex act in dry vagina, or less lubricated vagina many couples use

lubricants without realizing that these have a contraceptive action. [Proprietary jellies

are often acidic & therefore spermicidal]

OTHER FACTORS

Orgasm

It is unnecessary for the woman to experience orgasm in order to conceive if it

were otherwise pregnancy would never result from rape.

Effluvium Seminis

45

Immediately after coitus most of the semen escapes from the vagina is known



as effluvium seminis, which is normal & is never be a cause for infertility but it

accounts a wrong idea about.

Anxiety & Depresion

It is commonly believed that a nervous temperament, particularly extreme

anxiety to conceive lowers fertility.

Occupation & Environment

Fertility rate is higher in rural population because they have no planning.

Diet

• Deficient or unbalanced diet may interfere with ovarian function

• Deficiency of zinc & folate are implicated in decreased

spermatogenesis possibly through defective DNA & RNA synthesis.

• Deficiency of dietary antioxidant micronutrients e.g., beta- carotene,

lycopene, retinol and Alpha-tocopherol may decrease genital tract

secretions in men, leading to infertility especially through

immunological mechanisms.

Contraception

Hormonal contraceptive (oral) may hamper ovulation while intrauterine

devices (IUCD) can cause salpingitis & tubal blockage.

INVESTIGATION

Detailed general & reproductive history has importance in investigating the

infertile couple.

• Age & Occupation

Age over 35 years & sedentary habit favors infertility.


46


• Associated illness

Any other ailments apart from infertility, like menstrual disorders, white

discharge, obesity, dyspareunia urinary trouble to be noted.

Previous illness

Of mumps, gonorrhea, syphilis, hypothyroidism, appendicitis, tuberculosis,

diabetes mellitus any abdominal or vaginal operations to be carefully recorded.

• Family History

Fertility in the family twining, history of tuberculosis, diabetes are to be

enquired.

• Personal History

Mode of life on various aspects like family means domestic work, job stress,

worry , dietary, habit, intake of alcohol, tobacco , smoking habit is to be enquired.

• Menstrual History

This should be interrogated in the routinely

Age at menarche

Duration of cycle

Amount of loss

Dysmenorrhoea

Last menstrual period

Delayed menarche

Scanty and irregular menses


47


Amenorrhea is often associated with infertility.

• Marital & Sexual History

Age at marriage

Marital life duration

Frequency & nature of intercourse

Use of fertile period ,

Dyspareunia,

Contraceptive measures

Period of noncontraceptive intercourse to be enquired.

• Obstetrical History :-This is necessary in secondary infertility.

• Psychological History: - marital disharmony plays a role in it well socially

adjusted couples also takes time for psychosexual coordination,

• General examination:-

Obesity / Extreme lean and thin Special emphasis given to obesity or

marked reduction in weight in recent years.

Hirsuitsm abnormal distribution of hair

Under development of secondary sex characters

• Systemic examination :-

Hypertension

Organic heart disease

Chronic renal lesion

Endocrinopathies


48


Tuberculosis primary & secondary

• Gynecological Examination to be done to note the following

P/V Vaganitis

Chronic cevictits/erosion

Congenital elongated cervix

Hypoplastic uterus

Presence of Adenexal mass

P.I.D

P/S Visible thick & purulent cervical discharge

Pin hole cervix

Cervical erosion

New growth i.e., polyps

Ectropion/Entropion

CLINICAL EVIDENCE OF OVULATION

• Diagnosis of ovulation

1. Indirect 2.Direct 3.Conclusion

• Indirect method

Very regular 28 days menstrual cycle.

Ovulation anticipated by rise of body temperature & mild in pain in abdomen

with in 11th to 13th days

Thin cervical discharge during mid cycle

49

• B B T Method :- The body temperature is recorded in a special chart paper during



whole month at the morning time ovulatory BBT is a biphasic drop of 0.50 F of

temperature followed by sustained rise by 10 F during luteal phase . In anovulatory

cycle Monophasic B B T is seen i.e., no rise during second half of cycle.

• Cervical & vaginal mucus study:-

Fern pattern Test:-

Alteration of the physical chemical properties of the cervical mucus occurs due

to the effect of estrogen & progesterone. Disappearance of fern pattern beyond 22nd

day of the cycle which was present in the midcycle is suggestive of ovulation.

Persistence of fern pattern even beyond 22nd day suggest anovulation. Progesterone

causes dissolution of the sodium chloride crystals.

Spinbarkeit test:-

There is loss of stretchability (spinbarket) which was present in the midcycle

due to high estrogen level during this period.

Sperm cervical mucus contact test:-

Equal quality of semen & mucus is mixed, so there is no interface. In presence

of antibodies more than 25% sperms show jerky or shaky movements by 30 minutes.

The cross check with the donor semen will indicate the source of antibodies. Whether

it is cervical or seminal antibodies.

Post coital test:-

Sperm cervical mucus interaction is detected in this test. mucus is removed

from the cervix with a nasal polyp forceps, a pipette or a tuberculin syringe and


50


examined at various times after coitus with in 8 hr (sim's test huhner's test) to see if

the mucus is invaded by spermatozoa & whether they retain their activity.

The test must be carried out at the time of ovulation because at other times the

cervical mucus is normally unreceptive Examinations are advised within 2-8 hrs of

coitus normally 15 spermatozoa are found in each high power field & that these show

progressive, not rotatory activity. this suggests presence antisperm antibodies in

cervical mucus.

ASSESSMENT OF FEMALE INFERTILITY

Ultrasonography:-

• For follicular growth

• Endometrium thickness

• Luteinized enraptured follicle

USG is commonly used to track follicle development and is better observed

with transvaginal probe than with abdominal ultrasound. The follicle size at ovulation

is very variable but usually the dominated follicle is 14-16mm in diameter. Follicles

are larger in stimulated cycles, being 18-20mm in diameter and larger with

clomiphene than with human menopausal gonadotrophin ( hMG).

The endometrium increases in thickness from a thin broken line in the early

follicular phase to double its size, in the peri-ovulatory period it appears

sonographically as a triple layer in the, long axis of the uterus and is usually about 10-

12 mm in diameter. The luteal endometrium loses both the hyperechogenicity & the

triple layered appearance.

The diagnosis at luteinized unruptured follicle is made on ultrasound when the


51


follicle does not rupture, although serum progesterone raises to follicular study

postovulatory levels.

Hormone Assays:-

• Serum Progesterone

Serum progesterone level measured during the midluteal phase is the most

reliable method of confirming ovulation.The minimum level being 6.5 ng /ml

& preferably over 10 ng / ml. Low progesterone level detected once

insufficient to judge the adequacy at the luteal phase.

• Serum LH

Detection of the preovulatory LH surge has also been used to predict

ovulation. Urinary LH lcits and salivary progesterone also have been used for the

same FHS:LH

• Thyroid hormones

Other hormones which may need to be assessed are free T3, T4 &TSH, Serum

FSH & LH in the immediate post menstrual phase.

• Serum Prolactin- Normal level is 5 -20 ng/ml

Endometrial Biopsy:-

Endometrial aspiration or biopsy taken in the premenstrual phase can be

histological dated. The procedure is still one of the initial outpatient investigations in

developing countries where genital tuberculosis is a significant problem.

Alternatively, it can be carried out in conjunction with laparoscopy under general

anesthesia. If the endometrium in the second half of the menstrual cycle is found to be

in a secretary phase, it can be presumed that during that cycle at least, the woman


52


ovulated.

A diagnosis of luteal phase defect can be made if the endometrium is 2-3 days

out of phase from the day of cycle on repeated biopsy but this is not always accurate.

Curetted material is also sent for bacteriological evaluation for acid fast

bacilli.Polymerase chain reaction (PCR) for m.tuberculosis can be done in selected

cases depending on the clinical profile.

Tubal Patency Test

These are best carried out between the 7th to 10th day of the cycle. At that time

there is practically no risk of disturbing a fertilized ovum. The risk of embolism & of

retrograde dissemination of infection & endometriosis makes it imperative not to

carry out the tests while any uterine bleeding is taking place & for 2 days afterwards.

a) Hystero salpingo graphy(HSG)

b) Hystero contrast sonography ( HyCoSy)

TREATMENT

Couple instruction

• Reassurance

The infertile couple remains psychologically disturbed right from the

beginning more so as the investigation progress. In all cases optimism should be the

keynote, tempered with realism, even when the investigations suggest that the

prospects for pregnancy are poor.

• Correction of coital difficulties

Some couples require instruction on the difficulties of coitus on its timing &

spacing they should not be advised to try to time coitus to coincide with ovulation &


53


to conserve their energies at other times. Conception is most likely between the 10th

to 18th days of a 28 day cycle at which time coitus should be practiced at 48 hour

intervals. Change in coital position can be tried in case of mechanical difficulty.

Immediately after coitus the wife should rest quietly for 10 minutes to ensure that

some semen remains in contact with the cervix.

• Correction of general ill health

Attention to matters such as overwork anxiety, obesity & intemperance in

smoking & drinking. A long care free holiday may sometimes be the answer.

Medical Treatment Of Female Infertility

• The only clear indication for hormone therapy is a proven failure of

ovulation.

• In practice this generally means infertility which is associated with

amenorrhea or Oligomenorrhoea.

• Even in such cases ovulation can never be induced unless the ovaries

contain ova capable of being stimulated.

• To facilitate effective folliculogenesis & ovulation the following drugs may

be helpful.

1) Clomiphene citrate

• ovulation should be induced with clomiphene citrate (CC) with a dose of

50 mg/day starting from day 2 to day 6 of the cycle.

• ovulation is monitored by serial ultrasound monitoring of follicular size

and occurrence of ovulation.


54


2) If C.C fails then FSH & HCG therapy.

3) In hypothalamic disorder: GnRH is given to stimulate the pituitary FSH & LH and

folliculogenesis monitored.

4) Combination of CC+hMG (PCOD). CC 50 to 100 mg/day from 2 to 6 days.

Inj hMG 75 units’ intramuscularly on day 3, 5, 7 & more if so required.

5) Prednisolone: women with anovulation & increased androstenedione. 5.0 mg

prednisolone at night + 2.5 mg every morning until spontaneous

ovulation.

6) Hyperprolactinaemia: bromocriptine 1.25 mg at bedtime daily for 7 days.

7) Laparoscopic ovarian drilling: In PCOD medical line of treatment fails,

laparoscopic ovarian drilling of follicles with monopolar cautery/ laser.

8) Corpus luteal phase defect: Treated with intramuscular progesterone 100mg or

micronized 300-600 mg vaginal tablet daily.

9) For with LUF Luteal phase insufficiency treatment with micronized progesterone

or hCG.

Surgical Treatment:-

1) Wedge resection to induce ovulation in case of failure in response to clomiphene

citrate.

2) Surgery to ovarian tumor

3) Tuboplasty or microsurgery in case of peritubal adhesions, inflammatory

endosalpingeal damage & tubal occlusion by infection. Tuboplasty can be done in the

following methods:-

a) adhesiolysis -- separation or division at adhesion


55


b) Fimbriolysis -- separation of the fimbrae to open up the abdominal ostium.

c) salpingotomy -- to create a new opening in the occluded tube.

d) Tubo tubal anastomosis .

e) Tubo corneal anastomosis.

f) Gilliam's type of operation for retroverted uterus

g) Myomectomy-- specially in sub mucous fibroid.

h) metroplasty

i) Apart from cauterization amputation of the cervix may have to be done for

congenital elongation of the cervix.

j) Enlargement of the vaginal introitus (Fenton’s operation) or removal of

vaginal septum causing dyspareunia.

Assisted Reproductive Technology

ATH -- Artificial insemination Husband

TTH -- Therapeutic, Insemination Husband

AID -- Artificial Insemination of Donor

TID -- Therapeutic Insemination of Donor

IUI -- Intra Uterine Insemination

IVF-ET -- In Vitro Fertilization & Embryo Transfer

GIFT -- Gamete Intra Fallopian Transfer

ZIFT -- Zygote Intra Fallopian Transfer

MIST -- Micro Insemination Sperm Transfer


56


DRUG REVIEW

DHATAKI

Synonyms:

Dhataki, vahnipushpi, tamrapushpi, dahani, parvati, kumuda, guchhapushpa, madani,

pramadani, bahupushpi, vahnijwala, dhatupushpi, kunjara, subhiksa, madhyavasini.

Eng : Downy grislea or fire flame bush. Hindi : dhaya.

Kan : dhataki Marathi :Dhalasa

Lat : woodfordia floribunda kurz (salisb). Family : Lytheraceae.

Kula : Madayantika kula (dhayati kula).

Varga:Chandanadi - (Dha.Ni), Pippalyadi – (Ra.Ni)

Gana : purishasangrhaniya, Mutravirajaneeya, sandhaniya,- (Charaka )

Priyangvadi, Ambashthadi –(Sushruta)

Habitat : all over India , mainly at hilly regions.

Properties :

Guna- Laghu, Ruksha .Rasa – kashaya, katu.

Virya – sheeta. Vipaka – katu.

Karma : grahi, Garbhastapana, vishaghna, krimighna, sandhaniya.

Dosha : kapha-pitta nashaka Dhatu : rakta(hemostat), majja(narcotic).

Botanical description: A shrub with many branches, Leaves – sessile, resemble

pompgranate leaves, 5-10 cm long, stalkless, the leaf is hairy from beneath because at

which it looks wheatish. Flowers – shiny, red coloured,Seed – is grey and slimy, The


57


plant bears flowers in winter and fruits in rainy season, leaves and new branches have

black spots on them.

Parts used : Flowers, Leaves. Dose: 1 -3gm

Chemical composition : Flower contains 2% tannin & glucosidellagic acid, β-

sitosterol, polystachoside, octacosanol, myricetin-3-galactoside, cyanidind-3, 5-

diglucoside, pelargonidin-3, chrysophanol-8-0-B-D-glucopyranoside.

USES :

External uses :Being refrigerant, haemostatic, wound healer, powdered flower is

sprinkled externally over bleeds and wounds, powder flower is rubbed over gums to

prevent teething problems & the juice is used for massage in headache induced by

pitta.

Internal uses :

Reproductive system: useful in per vaginal discharges. In menorrhagia or

leucorrhoea it is given either with rice water or honey.

Therapeutic uses:

1. Swetapradara: Dhathaki powder shall be given with honey

2. Prajasthapana: Nilotpala & dhathaki flower are mixed & taken with honey in the

morning during the rutukala(Ga.Ni)47

Important formulations:

1. Dhatakyadi taila, 4. Dhatakyadi churna,

2. Pushyanuga churna, 5. Aravindasava,

3. Brahat gangadhara churna,


58


DARUHARIDRA

Synonyms – Daru haridra, dravi, pitadra, pitika, kaleyak, peetadaru, sthiraraga,

kamini, katankaderi, pajranya, pitadarunisha, kaliyaka, kamavati, darupita,

pachampcha, karkatakic.

Eng: Indian Berbery Hindi : Daru haldi

Kan : Maradarishina Marathi : Daru haldar

Lat: Berberis aristata. Family: Berberidaceae.

Kula : Daruharidra Kula.

Varga : Pippalyadi , prabhadi, daruharidradi, gudduchadi varga

Gana : Arshogna, kandughna, lekhaniya – (Caraka)

Haridradi, musthadi, lakshadi –( Susrutha)

Habitat : Himalaya from chota Bengal to Nepal.

Properties :

Guna- Laghu , Ruksha Rasa – Tikta Kasay

Virya – Ushna Vipaka –Katu

Karma : Kapha pittahara chedana, sthanya shodhana, sthanya doshahara,dosha

Pachana

Dosha : Reduce kapha Dhatu :Meda, Rasayana, raktagami

Mala – Mutra- purisha , sweda Organs – Eye, liver, spleen and skin.

Botanical description: Evergreen shrub having height 1.25 to 3 meters Leaves – are

strong with fine whorled venation. Strength, but with dentate or corrugated margin,

dark green above pale beneath.


59


Inflorescence – 5 to 8 cms long, with large yellow color flowers. Fruits – Bluish,

purple and small. Flowers – Bloom in the spring and fruits in the winter.

Different varieties:

Berberis aristata Berberis chitra

Berberis lyceum

Part used – Root , stem. Fruit, extract

Chemical composition : karachine (a protoberberine alkaloid), taxilamine, berberine,

palmatine, jatrorrhizine, oxycanthine. Stem & root contain the alkaloid berberine.

Dose : Juice of root 10 – 20ml Kwath – 5-10ml Ghanasatwa- 500mg – 1 gm.

Indications:- Prameha, kustha, netraroga, swetapradara, kamala, varuna, visarpa.

Therapeutic / Internal Uses:

Reproductive system – Useful in uterine inflammations and vaginal discharges.

Sweta pradara – Decoction of daruharidra given with honey

Mutra krccha – Daru haridra kwatha and amalaki with honey

Pradara – Daryadi kwathaa

Important formulations :

1. Ashwagandha arista 4 Bhrangaraja Taila

2. Khadiradi gutika 5 Khadira arista

3. Jatyadi taila 6 Triphala gratha


60


BALA

Synonyms: Bala, odanika, bhadra, samanga, baladhya, vatika, sanasa, maha

samanga, kharayahtika, sheetapaki, veeryabala.

Eng : Country mallow Hindi : Variyara

Kan :Hettuti Marathi :Chikana

Lat : Sida cardifolia linn. Family: malvacea

Kula : karpasa kula.

Varga : Karpasadi varga –( Nighantu adarsha)

Shatavyadhi varga –( Raj Nighantu)

Gana : Balya, Brumhaniya, Prajasthapana

Madhuskandha – (Charaka)

Vatasamshamana –( Susrutha)

Habitat :All over the India

Properties :

Guna- Guru, snigdha, picchila Rasa – Madhur

Virya – Seeta Vipaka –madhura

Dosha : Tridosha Dhatu:Rakta,Mamsa,Shukra,Oja

Karma : Vrishya, balya, tridoshanashaka, oja, vriddikara Mala: -Purisha

Botanical description: A small shrub of height 5-10cm .Root and trunk are stronge

hence it is called as bala. Leaves : -Alternate 2.5 – 5 cm long 5 cm broad,

ciliate,round having 7-9 veins on it and serrated margin.Flowers : -yellow in color

and originate from the angel of the leaf stalk. Flowers have five petals and five


61


sepals.Fruits – like a moonga divided into five partsSeeds: -Small, dusky are called

as beeja bandha.The plants bears flowers and fruits at the end of rainy season.


a. Bala c Atibala

b. Mahabala d Nagbala

Part used:- moola, patra, beeja, panchanga

Chemical composition:- Measures components of seeds are alkaloids mainly

ephedrine. It is also contains fatty acids, musin, potassium nitrate and resin

Dose :Churna 1-3 gm Swarasa 10-20ml

Uses :

External uses: Paste is analgesic alleviates edema it is locally applied over

inflammation and eye disorders.

Internal uses :

1. Being neural tonic and vata shamaka used in paralysis, facial palsy.

2. Emollient, deflatulent and astringent useful in flatulence, sprue

3. Cardiac tonic and alleviates hemorrhagic disorders

Reproductive System: Aphrodisiacs & useful in spermatirrhoea, 46

Diuretic so useful in dysuria being tonic it is helpful in

general debility tuberculosis & undernourishment


1. Baladi kwatha 3. Baladhya ghrita

2. Baladhyaarista 4. Chandana bala lakshadi taila


62


PALASHA

Synonyms – palasha, kimshuka, raktapushpaka, ksharashrestha, brahmavruksha,

samidwara, tripana, vakrapushpa, trivrunta, parna, yagniya, vatahara.

Eng : Downy branch Butea or Bastered peak Hindi : Dak, palasha.tesu

Kan :Muttuga Marathi :Palasa

Lat : Butea monosperma (linn) kuntz Family: Leguminoceae or pappilonaceae

Kula : Simbi kula Upakula – Aparajita kula

Varga : Vatadi varga –(Bha. Ni) Karaviradi varga – (Ra Ni)

Gana :Rodradi , mushakadi, ambasthadi Nyagrodadhi –(Susrutha)

Habitat :Entire India

Properties :

Guna- laghu, snigdha, sara Rasa – Katu, tikta, kasaya

Virya –Seeta Vipaka –Katu

Dosha : kaphavata shamaka

Karma :Agni deepana, saraka, vrsya, sandhaniya, grahi, kusthaghna, rakta stambana

Botanical description: Tree grows 13-16m high stem is crooked with torn bark,

Leaves --10-15 cm long. Flowers – Beautiful red colored, grow in spring. It has pale

yellow trek from which dark saffron color is deribed legume 12-20 cm long 2cm

broad and contains flattened, round, reddish black seeds, gum oozes from the cracked

bark which is known as Butea gum or Bengal kino.Flower bloom in spring and then

tree bears fruits. In summer the blossomed tree is very attractive saffron color of the

is used for ranga panchami which is known as kimshuka.


63



1. Rakta pushpa 3. Peetapushpa

2. Sitapushp 4. Neelapushpa

Part used – bark, flowers, leaf , gum and seeds

Chemical composition: Bark and gum contains kino and tannic acid. 50% gallic acid,

seeds contain 18 %, Stable oil which is called as kino oil.

Dose : Flowers powder 10 – 30gms, Kwatha – 5-10tola, Puspa – 1 – 1 ½ mashi

Uses :

Internal uses : Krimi, raktabhishyanda, raktapitta, jwara, daha, sharkara- Susrutha

Twak roga, arsha, atisara mutrakricha - Caraka

Reproductive system

Gum is aphrodisiac, seed is stimulant and flowers are astringent, Gum is given

orally in sperm debility.

Decoction of flower is useful in vaginal discharges.

For pumsavana karma leaf of palasha is used.(Y.R)45

For garbhinee paricharya in 1st month it has been indicated,


1. Kumkumadi taila 4. Palasha kshara

2. Vanga bhasma 5. Palasha beejadi churna

3. Palsha pushpasava 6. Krimimudga rasa


64


PUTRANJEEVAK

Synonyms: Putranjiva, pavitra, garbhad, sutajivaka, kutajiva, apathyajiva, siddhid,

arthasadhaka, garbhakara, kumarbeeja, akstaphala.

Eng : Child-life tree. Hindi : Jeeyapota, pittojeeya, pitijeeya.

Kan : Putrajiva, Putrajivaka. Marathi : Putrajivaka vruksha.

Lat : Putranjiva roxburghii Roxb. Family : Euphorbeaceae.

Kula : Eranda kula. Gana:Arkadigana

Varga : Prabhadradi varga (Ra.Ni), Vatadi varga ( Bha. Ni), Amalakyadi –( Ni .Ad)

Habitat: Tropical territory of India

Properties:

Guna- Guru, ruksha. Rasa – madhura, lavana, katu.

Virya – sheeta. Vipaka – katu.

Dosha : Vatakapha nashaka Dhatu : Shukra, Artava.

Botanical description: leafy medium sized or large trees up to 15-18 m height.

Leave :obliquely elliptic oblong to ovate, coriacoaus, dark green above, glaucous

Beneath.

Different verities: Putranjiva eylanica, Muell. Arg(In shrilanka).

Parts used: Leaves, fruits, seed.

Chemical composition : seed contains fatty oil those are oleic, linoleic, palmitic,

stearic and arachidic. Fruit pulp contains large proportion of manitol and small

quantities of a saponin glycoside and unidentified alkaloids.

Dose : seeds powder 3-6gm ,leaves juice 10-20 ml


65


Uses :

External uses : Its paste is useful as analgesic in headache, inflammation and abscess

Internal uses : Aphrodisiac and beneficial to foetus.

Decoction of leaves and fruits is given in fever and common cold

Also used for to obtained male child.

Root of putrjiva, visnukanta and shivlingi are recommended for eight days

during pregnancy 44

Specially the seeds of putranjivaka are given in sterility in order to promote

conception and also checks miscarriage

Susrutha – Sleepad Vangasena – Urograha

Bhava prakasha- VIsphota Nighantus – Garbhakara


66


MUSHALI

Synonyms: Muusali, talamilli, sulvaha, talumulika, godapadi,hemapuspi, bhutali,

deerga Kaundika.

Eng : Asparagus. Hindi : Musali .

Kan :Nelatod. Marathi :kali and pandhari musali.

Lat : Asparagus adseenedenus Roxb. Family : Liliaceae.

Gana: Sukrajanana

Varga :Mulakadi varga (R.N),Mulsali kand varga (Ni.Ad), Guduchyadi varga (B.P)

Types:- Sweta and Krishna musali

Habitat: North India

Properties:

Guna-Guru snigdha Rasa –Madhura

Virya –sheeta ,ushna(Bhavamisra) Vipaka –Madhura

Karma : Shukrajana, Vrushya, Bala,Rasayana

Dosha :Vatapitta shamaka,Kapha vardhaka

Botanical description:

A thorny shrub like Asparagus racemosus stem long tall round and oily.

Branches greenish, hallow and ascending it is full of thick and straight throns

measuring 1-1.5 cm Leaves- stalk in long, hairy round, measuring 1.5-4cm and

bearing 6-20 foliates in racemose form. Roots- oblong.

Parts used: Root


67


Chemical composition : Major chemical constituent. Two stigmastoid ,Glucosides,

saponin sars apogenin, Resin, Tanin, mucilar and starch and ash containing oxalate

and calcium.

Dose :3-6 gm powder

Uses: Bitter aromatic, tonic and demulicent, used in general debility in afflictions of

the urino genitor system as importance , also in asthama, piles, dysuriea, diarrhea.

Menorrhoea and gonorrhea. As a tonic it is generally mixed with aromatic

bitters and aphrodsiac, medications (R.N)


68


MISHREYA

Synonyms: Chatra, madhurika, misi, salina, saleya. Talaparni, talapatra, sitashiva,

vanaja, avakapuspi, sanhita puspika, supushpa, suraja nad vanya.

Eng : Fennel seed Hindi : Saunf

Kan : Dodda sampu Marathi :Badi saunf

Lat : Feeniculum vulgarcea Family : Umbelliferacea

Kula : Shatapuspa kula

Varga : Hareethakyadi varga – B.P

Shatavarhadi varga –R.N

Habitat :All over India

Properties :

Guna- laghu, ruksha Rasa – madhura, katu , tikta

Virya –sheeta Vipaka –madhura

Karma :Deepana, hrudya, balya, anulomana, ama dosha hara.

Dosha : Vatapitta shamaka

Botanical description: Perennial plant, but usually of short duration with erect,

branched stem 0.5-1 m height. Leave – 3-4 times pinnate with very narrow Linear

and subulate segments. Flower: in white umbels 15-20 rays more or less glucose

Fruit :6 mm long the vittae very conspiluous .

Parts used : Beeja and mula.

Different varieties: Vanya , Gramya


69


Chemical composition :Ascorbic acid, niacien, riboflavin, tocopherts, choline,

trigonelline, anethols, anisaldehyde, comphene, estrogole, fenchone, foeniculin,

methylchaviol, cynavin, columbianetin, marmesin, ostenenol, B-sitosterol, triterpenes,

umbelliferone. Fennel fruit contain oil. Fruit contains iodine, Vit. A, thiamine, traces

of albumin barium,cithinium, copper, manganese, silicon and titanium have been

reported.

Dose :beeja churna 3-6 gm.

Uses : Artava janana.,Stanya jana.

In kastartava and sutika streeJwara, adhmana, shoola, raktavikara, stanyalpata,

mutrakraccha, pravahika and shukra khsya


1. Misreya arka

2. Mishrakadi churna

3. Dhanyakadi hima

4. Dhanyaka panchaka kasaya


70


SHIVALIGNI

Synonyms: Lingini, Shivaligni, Chitra, phala, Lingini, Pahupatra, Iswanri,

Shaivamallika, Swayambhu, Linga Sambhuta, Lingi, Amrutra, Pandoli, Lingaja devi

chanda, Apastambini, Shivaja & Shivavalli.

Eng:- Bryony Kan:-Shivalingi

Hindi:- Shivaligni, Marathi :Kavale che dole, Analgesic.

Lat : Bryonia lacinosa. Family : Cucurbitaceae

Varga : kushmandadi Varga

Guduchyadi

Habitat :Southern part of Indian in konkar region

Properties :

Guna- laghu, ruksha Rasa – Katu, Ruksa

Virya –Ushna Vipaka –Kata

Karma:- Rasayana vrishya.

71

Botanical description:-Annual slender herbs, glabrous, spreading climbers. Leaves

deeply palmately 5-lobed, 8-12 cm in diameter , 5 cabrous above, smooth, beneath,

margin denticulate undulate. Penduncle(in male flowers ) 5-15mm long, calyxtube

2-4*3-6mm, lobes spreading 1mm long, corolla greenish-yellow, shortly papillose 4-

10mm, broad lobes ovate, acute filaments 1-15mm long, anothers ca 2mm long,

female flower fasciculate, ovary globose. Flowers monoeicious, often male & female

clastered togethers. Calyx companule, lobes Subulate corolla campanulate, 5 partite,

segments often refleved pendicels shorter in male flowers. Fruits berries sphevicle



yellowish green 6 strippe, 12-17mm thick up to 2cm across seeds avoid with

thickened corrugated margins seed cal 5*3 mm grey flowering & furting during the

period from august to December.

Parts used: Seeds

Dose: 3-5 grams.

Internal Use

For pumsavana karma seeds are given with milk 48


72


PERPARATION OF GANASATWA

Indigenous drugs( Putra mjivaka, Shivalingi, Palasha, Dhataki, Daruharidra,

Bala, Mishrey, Musali) are collected from herbal garden under the supervisation of

experts of Dravyaguna Department and dried well in ventilated room. Then Yavakuta

Churna of Indigenous drugs are prepared in udukhala yantra and placed in vessels.

Then added 48 liters of water and subjected to Mandagni. Throughout the procedure,

mandagni is maintained until the quantity is reduced to ¼ (marked on a stick and

dipped into the liquid content). The vessel is removed from gas and kashaya is filtered

in separate vessel. Kashaya obtained by this process is = 11 liters.

b) Preparation of Ghansatwa

Apparatus : Vessel, Gas stove etc.,

Drugs : Kashay of Indigenous drugs.

Quantity : 11 liters.

Procedure

Kashaya of Indigenous drugs is placed in vessels, and subjected to Mandagni

and stirred well. After 10 – 11 hours, the kashaya become semisolid then mild heat is

given and stirred more carefully. After a period of 2 hours, it was dried and then

removed from the gas stove. Then it is dried in to shade and the obtained churna

(dried powder of decoction) and it is about 1.75 kg. It is filled into capsule sheath of

500mg.


73


Fig No. 2 Musali Fig no. 3 Daruharidra

Fig. no. 4 Bala Fig No. 5 Palasha


74


Fig No. 6 Dhataki Fig No. 7 Shivalingi

Fig No. 8 Misreya Fig. No. 9 Putranjeevaka


75


Fig No. 10 PREPARED TRIAL DRUG GHANASATWA

Fig No. 11 Capsules of Ghanasatwa


76

Materials & Methods

A Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction 77

MATERIALS AND METHODS

The present “Clinical study on Apraja vandhya (primary infertility) by an

indigenous compound WSR to ovulatory dysfunction” was carried out on 30 infertile

women attending the OPD of prasooti tantra and stree roga department, N.K.J.

Ayurvedic Medical College and P.G Centre attached Sri Siddharoodha charitable

hospitals. The study included primary infertility cases of varying age and duration of

infertility.

Criteria for selection of cases

Inclusion criteria

1. Married women of age group between 20-35 yrs.

2. Patients having symptoms of Apraja vandhya ( Primary infertility)

3. Scanty, Irregular period with anovulation

Exclusion Criteria

1. Patient suffering from STD,HIV, and Hepatitis B

2. Patient suffering from any systemic diseases like DM,TB

3. Hyper and Hypothyroidism

4. Patients with severe anemia

5. Secondary infertility

6. Nephritis

Subjective Parameters

1. Irregular and scanty menstrual history

2. Primary infertility

Materials & Methods


Objective Parameters

1. B.B.T

2. Cervical mucus study

3. Sonography (Follicular study)

A detailed history of all the cases was recorded in a specially prepared

proforma. The general examination and pelvic examination including per speculum

and bimanual examination were performed and noted in the case paper.Labrotary

investigations were carried out as per necessity

1. Blood – Hb %

W.B.C (TLC and DLC)

E.S.R

2. Urine - Albumin

Sugar

Microscopic

3 Cervical mucus study (on 14th day) to check the

Nature

Viscosity

Fern pattern

Thread ability or Spin barkiet

MATERIAL

Materials & Methods


Individual drugs Viz. (Putramjivaka,Shivlingi, Palasha, Dhataki, Daruharidra,

Bala, Mishrey, Musali) are collected from market under the supervision of dravya

guna specialist. Ghana satva of these drugs are prepared at Rasa shala according to

standard method mentioned in the Ayurvedic text under the supervision of Rasa

shastra department.

This Ghanasatwa (capsules) is administered orally in the dose of two capsules

TID with warm milk as anupana for 20 days (from 5th day of menses up to 25th day)

for 3 consecutive cycles, assessment done after each cycle.

METHODS

Patients fulfilling above criteria were assigned into two groups.

GROUP A – 15 patients will be given trial drug Ghanasatva in a capsule form

GROUP B – 15 patients will be given placebo.

Follow up – Evaluation of symptoms will be done before treatment after 1st

cycle, 2nd cycle and 3rd cycle.

ASSESMENT CRITERIA

The clinical assessment was made depending upon the changes in the

subjective and objective features as mentioned in assessment scale.

1. Fertility or Amenorrhea along with positive response in velocit kit.

2. Ovulation positive by follicular study ( ovulatory study)

3. Regulation and relief of associated symptoms of menstruation

4. Relief from sexual problems

5. Relief from other associated symptoms

ASSESSMENT SCALE

Materials & Methods


Fertility will be assessed by absence of menstruation or amenorrhea followed

by positive U.P.T

Ovulation will be assessed by follicular study.

a. Ovulated G0 0

b. > 20 mm ( non ovulation ) G1 1

c. 12 – 20 mm follicular size G2 2

d. < 12 mm follicular size G3 3

Dysmenorrhoea

a. No dysmenorrhoea G0 0

b. Mild dysmenorrhoea G1 1

c. Moderate – dysmenorrhoea G2 2

d. Severe dysmenorrhoea G3 3

Oligomenorrhoea

a. 3 days G0 0

25 – 30 days

b. 2 days G1 1

30 – 35 days

c. 1 day G2 2

35 – 40 days

d. 1 day G3 3

40 -45 days

Bleeding Duration

Materials & Methods


a. 4-5 days – G0 0

b. 3-4 days – G1 1

c. 2-3 days – G2 2

d. 1-2 days - G3 3

Interval duration

a. 28-30 days G0 0

b. 30-35 days G1 1

c. 35- 40 days G2 2

d. more than 40 G3 3

Cervical mucus Viscosity

a. Thin viscous (Normal) G0 0

b. Mildly viscous G1 1

c. Intermediate G2 2

d. Thick viscous G3 3

Ferning

a. Tertiary Ferning G0 0

b. Primary /secondary G1 1

c. Atypical Ferning G2 2

d. No fern G3 3

Spin Barkeit

a. > 9 cm G0 0

Materials & Methods


b. 5 to 8 cm G1 1

c. 1 to 4 cm G2 2

d. < 1 cm G3 3

Discussion


DISCUSSION

It is a clinical study to evaluate the efficiency of indigenous compound in

vandhyatva.

Vandhyatva has been a long standing problem of human community right

from ancient period up to this modern era.

If we think the antiquity of the vandhyatva, we can see the praise of the

women having children & slander of the barren women & the solutions to her

barrenness are also mentioned in the Vedas, Upanishadas & Puranas.

In samhita kala charaka has explained types of vandhyatva as apraja, sapraja

& vandhyatva.Harita has described vandhyatva as a disease, in eighty vataja vyadhi.

He has defined vandhyatva as a failure to achieve a child rather than pregnancy

because he has included Garbhasravi, Mritavasta, Garbhakostha Bhanga, Balaksaya,

Kakavandhya, Anapatya.

Sashruta described the causative factor for vandhya is artavavaha srotovighata.

Vandhyatva is described by our Acharyas in a very wide sense including the

nidana & chikista, but the etiological factors held responsible for infertility according

to modern science can not be correlated with nidana mentioned in ayurveda, similarly

is the case with treatment so many formulations has been given in our texts for

achieving a conception, but at which type of infertility or on which factors like Ritu,

Kshetra, Beeja, Ambu it will act it is not mentioned clearly.

Now in these days of research in Ayurveda in modern era of science it is the

need of time that we should evaluate all these things separately.

Discussion


30 patients were taken for the present study after proper clinical & laboratory

investigations according to inclusion criteria are divided in two groups.

Group A:-15 patients treated by trial drug i.e.,indigeneous compound of

(Putramjivaka,Shivalingi,Palasha,Dhataki,Daruharidra,Bala,Mishery,Musali)ghanasat

wa filled in capsule at a dose of 500mg trice with milk for 3 cycles.

Group B: - 15 patients treated by placebo at a dose 3 gm BD with milk for 3

cycles.

After each cycles assessment was done using selected parameters to know the

improvement.

Probable mode of Action of the Drugs

In this compound eight drugs mainly Putramjeevaka, Shivalingi, Palasha,

Dhataki, Daruharidra, Bala, Mishery, Musali are prepared,

1. Putramjeevaka (Putramjiva roxburghii)-Having the properties of guru, ruksha

guna, madhur, katu, lavana rasa katu vipak & sheeta veerya having the action

of vata kapha shamak & it has specific impact on the Garbha to form the male

in the contemporary science. But in modern science it has anti-inflammatory

& analagesic action.

2. Shivalingi (Bryonia Lacinios): Having the properties of guru, ruksha guna,

katu, tikta rasa ushana virya katu vipak & action has Rejuvenator,

Aphrodisiac, & promotes the body constituents, Since Medieval period it has

been used treat the infertile women’s to achieve conception. Where the recent

research shows it has Anti-tumor, Antioxidant action & also acts as a uterine

tonic with non-hormonal, Anti-inflammatory, Antispasmodic & Analgesic

action are used to treat DUB & PCOD.

Discussion


3. Palasha (Butea monosperma): Having the properties of laghu, snigdha, Sara

guna, katu, tikta, kasaya rasa, katu vipak & sheeta veerya acts as katha vata

shamak it has actions to increase the Agni, Binds the body tissue works as

Haemostatic agent, Purifies blood & acts as Aphrodisiac. The specific action

for to achieve the conception & in first month Grabhinee Parcharya has been

given imphasiase in the ancient text, as per the recent research it has non-

hormonal Anti inflammatory action.

4. Dhataki (Woodfordia fruticosa): Having the properties of guru, ruksha guna,

kashaya, katu rasa, katu vipak, sheeta veerya action as Kapha Pitta Shamak &

special action as haemostatic, body tissue binding & helps for fertilization &

fetal growth as per the recent research Anti-inflammatory action.

5. Daruharidra (Berberis aristata D C): Having the properties of laghu, ruksha

guna, tikta, kasaya rasa ushana virya, katu vipaka& action as kapha nashaka &

it works as Rejuvenator, Aphrodisiac, blood purifies & special used in uterine

inflammation & vaginal discharges & in the urinary tract infection it is used as

diuretic as per the modern science it is used as Antispasmodic &

Immenagogue action.

6. Bala (Sida cardifolia): Having the properties of guru, snigdha, pichila, guna

madhura rasa, madhura vipak, and sheeta veerya & tridosha nashaka. Special

action as Rejuvenator, Aphrodisiac, nutritive & increases the oja. Where the

recent research it has Antioxidant action & having progesterone like substance

which helps for proper conception & normal growth of fetus.

7. Mishreya ( Feeniculum vulgare, apiacae) : Having the properties of guru,

ruksha guna, madhura, katu, tikta rasa ,sheeta veerya, madhura vipak, action

Discussion


as kapha, vata nashaka, increases agni, Immenagogue, Galactogogue, purifies

blood as per the recent research act as Estrogenic action, Antioxidant, Anti-

inflammatory & Analgesic action.

8. Musali (Asparagus adscendens Roxb); Having the properties of guru,

snigdha,guna madhura rasa, sheeeta veerya, vata, pitta, shamaka & has a

action of Rejuvenator, Aphrodisiac, mainly used in UTI, & as per the modern

research it’s action is Stimulate Insulin, increase sexual desire, prostaglandin

release & Antispasmodic action.

OBSERVATIONS

Age: - For assessment of infertility we have selected the patients among age

group of 20-35 yrs .which is divided in to 3 groups. In that 20-25yrs age group are

40% and 26-30yrs having 46.66%, and 31-35yrs having 13.33%. In the 26-30yrs, age

group fertility problems detected and now a day the marriage age is increased. So we

get more number of patients in this age group.

Marital Life:-In present clinical trial patients belonging to 1-5yrs period of

marital life are 46.66% and 6-10yrs having 50% and 11-15yrs No patients and 15-

20yrs 3.33%. In the modern era life style has been changed. Couples don’t want child

very fast. The carrier conscion couple postpones the fertility for 2to3yrs. Then they

think about & so delayed fertility is turned in to problematic fertility.

Socio –Economic Status:-In this clinical study majority of patients are taken

from lower middle class i.e., 46.66% & upper middle class 36.66% & poor are

16.66%. Because of deficient nutritive diet and neglected irregular periods became

troublesome after marriage and contributes to infertility.

Discussion


Education Status:-In this clinical trial patients belongs into primary school

33.33% and high school women are 33.33% and graduates are 30% and uneducated

women are 3.33%.

Infertility Duration :-In present clinical trial patient belonging to 1-5yrs

periods infertility duration are 60.00% and 6-10yrs period 36.66% and 11-15yrs

period 3.33%.

Occupation: - In present clinical trial patient belonging to 53.33% house wife,

10.00% Government job, 26.66% Private Job & 10.00% are labors.

Menstrual History:-In this study majority of patient belong to irregular

menstrual cycles are 53.33% and 46.66% are having regular cycles.

Bleeding Duration:-In present clinical trial patient from 1-2 days, which is

having 16.66% and 2-3days are 23.33% and 3-4 days are 36.66% and 4-5 days are

23.33%.

Interval Period:-In this clinical trial 28-30 days period are 46.66% and 30-35

days period are 13.33% 35-40 days period are 33.33% and more than 40 days are

10.00%

Character of Menstrual Bleeding:-In this clinical trial character of menstrual

bleeding with normal flow are 66.66%, with cloth are 30.00% and with heavy

bleeding are 3.33%.

Uterine Position: The above study shows that 83.33% of patients are having

normal AV/AF uterus and 16.66% of patients are having RV/RT uterus.

Vaginal Discharge:-The above clinical study shows that the normal vaginal

discharge is present i.e., 46.66% and vaginal discharge is absent i.e.,53.33% out of 30

Discussion


cases.Becouse vaginal discharge decreases the cervical hostility which results the

ifflusium semenis and infertility.

B.B.T:-BBT chart was given to all patients to mark the temperature at

morning time, but some patients did not follow the instruction. Due to inconvenience

we exclude this observation .We had another parameters for detection of ovulation

like follicular study and cervical mucous study for confirmation of ovulation.

Effect of Treatment:-

Effect of treatment was accessed both clinically as well as by lab investigation

included. Cx-mucus study & ultrasonography for follicular study in very cycle.

Observation of 30 patients have been presented with the data are recorded in

previous pages. The critical & descriptive note on the data as follows.

Effect on Dysmenorrhoea: -

When the Dysmenorrhoea is considered then 80.00% got cured in group-A

and 45.16% got cured in group-B. This shows group-A is more effective than

group-B.

Oligomenorrhoea: -

When the Oligomenorrhoea is considered then 80.00% got cured in group-A

and 46.88% got cured in group-B. This shows group-A is more effective than

group-B.

Bleeding Duration: -

When the bleeding duration is considered then 83.87% got cured in group-A

and 52.78% got cured in group-B. This shows that group-A is more effective than

group-B.

Discussion


Interval of Bleeding: -

When the bleeding duration is considered then 84.85% got cured in group-A

and 52.78% got cured in group-B. This shows that group-A is more effective than

group-B.

Cervical Mucus Study:-

Viscosity: -

When the viscosity considered than 81.82% got cured in group-A and 35.48%

got cured in group-B. This shows that group-A is more effective than group-B.

Ferning: -

When the Ferning considered than 80.65% got cured in group-A and 34.38%

got cured in group-B. This shows that group-A drug is more effective than group-B

drug.

Spin Barkeit: -

When the Spin Barkeit considered than 80.65% got cured in group-A and

34.48% got cured in group-B. This shows that group-A is more effective than

group-B.

Follicular Study: -

When the Follicular Study considered than 82.86% got cured in group-A and

57.14% got cured in group-B. This shows that group-A drug is more effective than

group-B drug.

Special Observations: -

During the clinical study in Group-A out of 15 patients only 3 patients

conceived and Group-B out of 15 patients No patients are conceived.

Conclusion


CONCLUSION

1) Primary Infertility is a condition where the couple never conceives after one

or more years of regular & unprotected intercourse.

2) Though the defect in process of fertilization lies in both partners the female is

responsible to 40-60% of cases.

3) Commonly the lacuna in female reflects as irregular & scanty menstruation

which suggestive of defective ovulation, thus contributes 20% cases.

4) Primary Infertility correlated with Apraja vandhya or Adi vandhya, Anapathya

advised to be treated with a fruitful result by herbal medicines.

5) Patients with ovulatory dysfunction charecterised by menstrual abnormalities

were selected & treated with indigenous compound ghanasatwa.

6) The idigenous medicine(ghanasatwa) was prepared (Shivalingi, Putramjivaka,

Palasha, Dhataki, Daruharidra, Bala, Mishery, Musali) as per classical

preparation method.

7) Based on their individual action like Anti-inflammatory, Analgesic,

Antioxidant, Estrogenic, Progesteranic on female reproductive system, they

were found to be effective & normalizing & regularizing the menstrual

abnormalities & ovarian dysfunction.

8) However the present clinical study shows effectiveness of Shivalingi,

Putramjivaka, Palasha, Dhataki, Daruharidra, Bala, Mishery, Musali upon

ovarian dysfunction & menstrual problems. Probable action of drug may fully

established with a large sample size in further research.

Summary


SUMMARY

This study entitled ‘A Clinical study on Apraja Vandhya(Primary Infertility) by an

indigenous compound W.S.R to ovulatory dysfunction was designed under 5 parts.

Part - I : Conceptual study

Part - II : Drug review

Part - III : Clinical study

Part - IV : Discussion

Part - V : Conclusion

Part - I : Conceptual study

It comprises the following sections.

Section -1

Historical Review:

This section comprises historical aspect, which is related to disease.

Section -2

Ayurvedic Review:

The general description of vandhyatva like vyutpatti, nirukti, paribhasha, synonyms,

samanya nidana, bheda, samprapti and chikitsa is explained.

Section -3

Modern Review :

In this functional anatomy of ovary, An ovulation & Infertility definition, incidence,

synonyms,causes,clinical,manifestation,pathogenesis,pathology,pathophysiology,

classification, symptoms, investigations, and principle of management.

Summary


Part – 2 : Drug Review

A general introduction regarding the importance of drug and treatment approach.

The description of trial drug regarding its guna, karma, etc & preparation of drug.

Part – 3 : Clinical Study

In this part aim and objectives, material and methods, selection criteria of patients,

drug dose duration, criteria for assessment of result, scoring pattern, general observation and

effect of therapy in different headings along with total effect of therapy.

Part – 4 : Discussion

Here total report of descriptive discussion based on conceptual study and clinical

study are included. Mode of action of drug is also focused here.

Part – 5 : Conclusion

Conclusion drawn at the end of study.

Bibliography


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RESEARCH PROFORMA

N.K.J.AYURVEDIC MEDICAL COLLEGE AND PG CENTRE.

Post-Graduate Dept of Prasooti-tantra & Stri-roga

2007-2010.

“CLINICAL STUDY ON APRAJA VANDHYA (PRIMARY INFERTILITY) BY AN

INDIGENOUS COMPOUND W.S.R. TO OVULATORY DYSFUNCTION.” Guide Name: Dr. Susmita Priyadarshinee Otta PG Scholar :Dr. Smt. Bagali.C.S

Name of the Patient: Case No. :

Address: OPD No. :

Age; IPD No.:

Sex: Diagnosis:

Occupation: Duration:

Socio Economic status: Date:

Married since:

SOCIAL HISTORY: a) Marital History

1) Married for Yrs.

2) Staying with the husband for Yrs.

b) Education

1) Wife

2) Husband

c) Occupation

1) Wife

2) Husband

d) Monthly Family Income

e) Socio Economic Status-Poor/Lower middle class/ Upper middle class/Rich

CHIEF COMPLAINTS :

1) Duration of Vandhyatwa / Infertility (Primary) for Yrs.

ASSOCIATED COMLAINTS :

1) Sexual Dysfunction

a)Dyspareunia : Yes / No

b) Apareunia :

c) Orgasmic Failure :

2) Purulent Vaginal Discharge : Yes / No

3) Burning Micturation : Yes / No

4) Pain in Lower abdomen : Yes / No

5) Tenderness in Lower Abdomen: Yes / No

6) Backache : Yes / No

HISTORY OF PRESENT ILLNESS ;

Medical History (Past and Present)

a) Record of any previous illness.

b) Use of prolonged cortico-steroid therapy

c) H/o Trauma to lower abdomen

d) Gynecological infection (P.I.D)

MENSTRUAL HISTORY:

a) Age of menarche :

b) Duration of menstrual period : Regular / Irregular

c) Interval of menstruation :

d) Amount of bleeding : Scanty / Average / Heavy

e) Character of bleeding : Normal / With clots / Foul smelling

f) Inter-menstrual bleeding : Yes / No

g) Pain during menses : Yes / No

Site Character

h) Date of L.M.P :

CONTRACAPTIVE HISTORY:

O.C.P / IUCD / Injective / Barrier method

PAST SURGICAL HISTORY;

Abdominal / Pelvic surgery: Yes / No

PERSONAL HISTORY:

1) Appetite

2) Diet

3) Change of weight

4) Mala pravritti

5) Mutra pravritti

6) Sleep

7) Addiction :Alcohol / Tobacco / Tea / Others

8) Avasa : Hygienic / Unhygienic

9) Sexual history ;

a) Coital frequency: Weak

b) Pruritis : Yes / No

c) Use of lubricants during coitus: Yes / No

d) Loss of Libido

FAMILY HISTORY :

DM, TB, Ca, HTN, HIV.

GENERAL EXAMINATIONS :

1) Physical ;

a) Height :

b) Weight :

c) Abnormal distribution of hair

d) Height / Weight relation – Thin / Average / Over weight

2) Head & Neck ;

a) Pallor (Anaemia)

b) Irctus (Jaundice)

c) Teeth & Gum

3) Throats ;

a) Thyroid

b) Cervical Lymph glands

4) Superior Extremity ;

a) Pulse

b) Blood pressure

5) Chest ;

a) Under development of secondary sexual characters : Yes / No

Breast : Well developed / Ill developed

Nipple : Retracted / Normal

Development of axillary hairs: Absent / Normal / Abnormal

Galactorrohea : Yes / No

6) Heart (CVS)

7) Lungs (RS)

8) Abdomen

Liver

Spleen

Kidneys

9) Inferior extremity

Oedema of feet / Legs

Vericose veins

SYSTEMIC EXAMINATION (Yoni Pareeksha) :

Darshana Pareeksha ;

1) Distribution of pubic hairs.

2) Any visible growth.

Per speculum Examination ;

1) Vaginal discharge

2) Vaginal introitus – Narrow / pinhole / Normal

3) Evidence of cervical & / or Vaginal infection (Vaginitis) ; Yes / No

4) Undue elongation of the cervix.

5) Cervical discharge : Yes / No

Character: Watery / Thick / Foul smelling

6) Cervical polyp.

7) Cervical score (Insler’s) & whether the value is compatible with the day of

the menstrual cycle.

8) Cervical erosions.

Sparshana Pareeksha:

Baimanual Pelvic Examination (P/v)

1) Pelvic tenderness : Present / Absent

2) Undue elongation of cervix.

3) Uterus ;

Size : Normal / Abnormal

Position: Rv / Rf/Av/Af.

Mobility: Mobile / Fix.

4) Presence of adnexal masses : Fixed / Mobile / With or without

Tenderness.

5) Tender & fullness in the pouch of Douglas.

INVESTIGATIONS :

Husband’s seminogram: Normal / Abnormal

For female partner;

a) Urine : Albumin

Sugar

Microscopic

b) Blood : Hb%

R.B.S

V.D.R.L

c) Ultrasonography (USG).

d) Follicular study chart:

e) Hysterosalpingography (HSG).

Management :

1) Drug administration:

2) Date of visit:

3) Dosage:

4) Duration of treatment:

OBSERVATION TABLE

Before

treatment

(B.T)

After

treatment

(1st Cycle)

After

treatment

(2nd Cycle)

After

treatment

(3rd Cycle)

Infertility duration

Menstrual History

(a) Interval

(b) Duration

(c)Oligomenorrhoea

(d) Dysmenorrhoea

Sexual problems

(a) Dyspareunia

(b) Fluor semanis

(c) Loss of libido

(d) Pruritis

(e) Purulent vaginal

discharge

(f) Burning

micturation

Ovulation study :

Before treatment:

After treatment:

RESULT :

1) Conceived during treatment.

2) Relieved some symptoms.

3) Symptoms unchanged.

CONCLUSION :

Signature of Guide: Signature of PG Scholar:

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