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Introduction

Infertility is defined as failure to conceive within 1 or more years of regular unprotected coitus, though it is not physically disabling disorder but has far reaching psychological and social consequences1. 60 to 80 million of couples suffering from infertility every year worldwide, probably between 15-20millions in India2. Women undergoing invitro fertilization (IVF) with low AMH has less success rate and ultimately have only option of IVF with donor egg. the success rate of IVF depends largely on the ovarian response at the time of oocyte retrieval which eventually reflects on the ovarian reserve 3. Ovarian reserve means the quantity as well as quality of follicles present in the ovary. AMH is produced by Granulosa cells of primordial follicles (<6mm), helps Oocyte maturation and follicular development and recruitment of dominant follicle4. AMH predict the future reproductive lifespan therefore it is considered as the best endocrine marker for assessing age related decline of ovarian pool in healthy women5. Virechana karma is one of the prime purificatory procedures, which will act on Tridhosha. Acharya Kashyapa indicated Virechana in Agarbha and Garbhakama6. The effect produced by Virechana can improve the quality of Beeja i.e., sperm and ovum as mentioned in Kashyapa Samhita7. Niruha basti plays a role in yoniprasadana and Putrada even to infertile women explained by Acharya charaka8. Administration of drugs through Uttaramarga is known as Uttara Basti, it is used after niruha basti and superior in quality9. According to Acharya Charaka Uttara Basti pacifies the Vayu thereby helps the women to conceive10.

Shatavari Ghrita11 is unique combination of drugs like shatavari, goksheera and ghrita which is explained by Vangasena in the Vajikarana adhikara indicated in sukrashodhana and artava dusti. Acharya Kashyapa mentioned that Shatavari12 is having property like Pushpaprajakari, vrishya, Rasayana and Balya which may help in Vandhyatava (low AMH) in increasing AMH value. So, by all the above explanation the procedures like virechana followed by Uttara Basti with Shatavari ghrita is taken in Vandhyatva w.s.r low AMH. Shatapushpa churna is selected as a shamana yoga, as Shatapushapa13 is having property like Balya, Pustivardhana, Yonishukravardhini, Vataprashamani and Putraprada mentioned by acharya Kashayapa in shatapushpa shatavari kalpa. Hence the study carried out to evaluate the combined effect of virechanottara uttarabasti with shatavari ghrita followed by shatapushpa churna orally in vandhyatva w.s.r. to low AMH”.

CASE REPORT:

A female patient of 26 years age consulted the OPD of Department of Prasuti Tantra & Stri Roga, Taranath Govt. Ayurved hospital, Bellary. Patient was anxious to conceive since 5 years of her marital life.  Associated complain were irregular cycles and constipation.

History of Present Illness:

Patient was apparently healthy before 6 years gradually she observed irregular cycle; she was not much worried but after the marriage when it comes to conception, she became anxious. she was consulted modern hospital hypothyroidism diagnosed along with low AMH. Doctor suggested her for IVF but couple was unable to afford it and they don’t want to undergo IVF so for further management she came to our hospital.

History of Past illness- Patient did not have history of major illness.

Past Medical and surgical History- Hypothyroidism on medication

Drug History- she used to take thyroxine 25mcg daily OD

Family History- Not significant

Menstrual History:

Table no.1

Personal history: Table no.2

General examination:

Built- moderate, Weight- 60kg, Height- 152 cm, Pulse rate- 78bpm/min, B.P.- 130/70mmhg, Respiration rate18 times/min, Temp- 98.6 F

Physical Examination:

Ashtavidhapariksha

Nadi- pittakapha

Mutra- Samyak

Mala- Baddhata

Jihva- alipta,

Shabda- Samyak

Sparsha- anushna

Drika- Samanya

Akriti - Madhyam

Dashavidhapariksha

Prakriti- Vatapittaja

Sara- Rasa-raktasaara purusha

Samhanana- Avara

Pramana- Madhyam

Satmya- Madhyam

Satva- Madhyam

Vaya- yuvati

Vyayamshakti- Avara

Aharashakti- Madhyam

Systemic Examination

CVS: Heart sounds (S1S2): Normal

Respiratory system: normal bilateral air entry, no added sounds.

P/A: soft and non-tender

Samprapti Ghatak:

Dosha-                       Vatapradhana tridosha

Dushya-                      Rasa, Rakta, Meda, Artava

Srotas -                       Rasa, Rakta, Artava

Strotodushti-                Sanga, vimargagamana

Agni-                           Jataragni, dhatwagni

Rogmarga-                  Aabhyantara

Udbhava sthan-           Amashaya, Pakvashaya

Sanchara   sthana-       sarva shareera

Adhistana :                 Garbhashaya

Investigations: Refer. figure no 1

AMH (Anti mullerian hormone) – 0.509ng/mL

TSH -2.481µIU/Ml

Treatment protocol:

Table no.3

Table no. 4

First cycle: after completion of menstrual phase, patient been posted for virechana karma.

Time of administration of Basti:

Second cycle:

Niruha basti : Niruha basti as a purva karma given before administration of Uttara basti, morning on empty stomach. Uttara basti : After pratyagama of given Niruha basthi, patient is advised to have laghu bhojana & then Uttara basti was administered  for  5days , after 5days of her menstrual cycle.

Third cycles of uttarabasti done.

Result:

After Virechana, appetite and sleep Improved. constipation relieved

After the 3 cycles of uttarabasti menstrual cycle became regular, quantity of menstrual blood also improved to 2-4 pads/day.

AMH value improved from 0.5ng/ml to 1.40ng/ml

Discussion

Disease discussion:

In present study, observed that most of the nidana's leads to vitiation of tridosha mainly Vata-kapha, Jatharagni Vaishamya ending in Aamotpatti. Aama formed adheres to srotas and causes avarodha to rasa and artavaha srotas end is hampered leading to poor nourishment of rasa dhatu and its upadhatu artava. Dosha's get sthansamsraya in yoni, further due to manasika bhava chinta etc causes vata dusti and rasadhatu dusti which leads to artava dusti all these factors may cause for abeejotsarga(no secretion of AMH from the follicles) which is manifested leading to vandhyatwa.

Probable Tridosha involvement in Vandhyatva (decreased AMH level):

1. Vata stands for proliferation & division of cells (granulosa & theca cells) i.e. "vayu vibhajate". When Vata in the normal state it regularizes the Hypothalamo- pitutary ovarian axis.
2. The main function of Pitta is Paka karma. conversion of Androgens to oestrogen in graffian follicle. Pitta Dosha also makes maturity of follicle by its function of paka karma.
3. Kapha Dosha binds all the cells together and gives nutrition for growth and development of the cells. If follicles are not growing properly, it may be due to Vata and Kapha dushti.

DISCUSSION ON DRUGS:

As per classics, the therapeutic efficacy of the drugs depends upon its properties namely Rasa, Guna, Virya, Vipaka and Prabhava. The activity of the drug may be produced by either one of these or in combination.

1. Trikatu Churna: In this study Trikatu churna is used for Deepana and pachana. It normalizes the Jatharagni and Dhatvagni thereby helping in proper production of Rasa Dhatu and Artava Dhatu.
2. Gritha: Gritha alleviates Pitta & vata. It is beneficial for rasa dhatu, shukra dhatu & ojas. It is sheeta veerya in property & is Mrdukaram, swara varna prasadhanam. vrushya, balya,and yonishodhana property. Ghrita Moorchana: It is done to remove the ama dosha, as almost drugs used for Ghrita Moorchana contains Ushan Veerya.
3. Shatavari ghrita : Shatavari Ghrita is unique combination of drugs like shatavari, goksheera and goghrita indicated artava dusti. Due to Madhura Rasa, Sheeta Virya, Snigdha Guna of shatavari ghrita, and having balya, ojakara, vrishya,rasayana, pushpaprajakari and garbaposhaka properties will help in vandhyatwa. Shatavari is proved to enhance folliculo genesis there by it increases the secretion of AMH. it also improves endometrium thickness.

 MURCHITA TAILA: Murchita tila was used for Abhyanga for 3 days. It primarily pacifies Vata Dosha and associated Pitta Dosha,brimhana, vrishya,sthairya and garbhashaya shodhana.

ERANDA TAILA: Eranda Sneha facilitated the vata anulomana karma, its Sukshma guna makes its entry easy to Sukshma srotas level, by which it removed srotorodha by its teekshna,ushna vyavayi guna and thus allow normal movement of apana vayu and finally leads to yoni vishodhana (cleanses the yonimarga). It is said to be Vata-kaphahara, Srotovishodhana, Yoni vishodhanam, Adhobhaga doshahara.

Shatapushpa choorna Ushna virya of shatapushpa increases the blood circulation in yoni and garbhashaya, due to this garbhashaya gets proper nutrition which helps for conception. Shatapushpa acts on apana vayu and normalize the pathology and helps to increase the size of follicle there by increased secretion of AMH from the antral follicle. As per Modern view, Shatavari and Shatapushpa are having phytoestrogenic property. Phytoestrogen have ability to affect the endogenous production of estrogen. The pituitary gland releases gonadotrophins that stimulate estrogen synthesis in the ovaries and effective by regulating the GnRH pulsatile release, normalize by hypothalamus pituitary ovarian axis, corrects hormones, Follicle development (increasing the size of follicles) and secretion of AMH from pre antral and antral follicles.

Discussion on virechana karma

Selection of virechana karma in vandhyatwa (Low AMH):

1. Acharya Sushruta mentioned that, to achieve conception 4factors are essential those are rutu, kshetra, ambu, beeja. Among this any abnormality /disturbance in the normal qualities of beeja (ovum/ follicle) might result into abeejotsarga. The main reason for abeejotsarga considered to be the aratava dusti due to srotoavarodha and vitiated artava does not possess healthy beeja(follicle) so virechana planned to overcome the srotoshodhana of arava vaha srotas and thus regulating hormonal imbalance.
2. Virechana is major line of treatment for morbid pitta dosha & also it acts on all tridosha. By virechana karma beeja (follicles) becomes Shuddha which is considered for essential factor for conception.
3. Vandhyatwa is a vata dominant vyadhi and mridu samsodhana mentioned in vatadosha chikitsa.
4. virechana is indicated in Agarba and Garbhakama. Virechana is mentioned as Yonivyapada Samanya Chikitsa Siddhanta.
5. Acharya have given a list of the various disease conditions (Virechya Vyadhi) where Virechana Karma is ideal to administer as prior choice of therapy. Effect of virechana karma Correction of rasadhatu, pitta dusti and apanavayu vikruti by virechana which expels out the accumulated vitiated doshas, cleanses the body, regulating the menstrual cycle, improving the health of reproductive cells and enhancing hormonal balance, then artava and garbhashaya shuddhi all of which are crucial factors for fertility and helps in increasing the quality of follicles.

Srotovishuddhi by Virechana Karma increases the bioavailability of drugs and help in better absorption of uttarabasti, vata anulomana karma of virechana which initiates the proper function of vitiated apana vayu and yoni vishodhana (cleanses the yonimarga), agnivardhana particularly dhatwagni which controls hormones and by virechana all the dhatus become stable and normalizes the Jatharagni and Dhatvagni thereby helping in proper production of Rasa Dhatu and Artava Dhatu which responsible for proper growth and development of follicle there by it overcomes vandhyatwa. Virechana is also have effect on mental health (manah Shuddhi), helping to alleviate stress and anxiety which are the causes for low AMH.

UTTARA BASTI PROCEDURE:

Uttara basti is more effective in terms of its superior qualities. In this study Uttara basti is performed after virechana karma,because Uttarabasti procedure targeted at the site of manifestation of the diseses i,e garbhashaya which is the apana vayu kshetra. Uttara basti will normalizes the function of apana vayu and prepare kshetra for Garbha dharana.

Niruha basti as a purva karma for uttarabasti : 2 or 3 nir?ha vasti should be given before the day of uttarabasti before the administration of uttaravasti for basti shodhanarta, yoniprasadana, vatanulomana and increases local circulation and help in absorption (bioavailability) of uttara basti drug.

Effect of Uttara basti in vandhyatva:

1. Sthanika abhyanga and Nadisveda is to be given to the lower abdomen, thighs and yoni Pradesha prior to Utttar Basti make the Anulomana. does Mruduta (relaxation) to reproductive system, so the patient does not suffer from discomfort or pain during and after procedure.
2. When shatavari ghrita enters the intrauterine route, due to sukshmaguna of sneha dravya, it enters the uterine cavity (artavavaha srotas) first appears in the uterine wall with rapid dispersion in to the lymphatic and venous structures.
3. Ghrita impregnated with shatavari, Goksheera having sheeta veerya will facilitates absorption & delivery of the veerya of the drugs used to the target organ and site of action i.e. pre antral & antral follicles, where the beejotsarga i.e secretion of AMH start as Uttaravasti may itself stimulate the organs and also increase the blood supply, shatavari Ghrita having the Sheeta veerya, Madhura rasa as these do Brimhana effect.

Conclusion

Vitiated Vata and Kapha both are mainly responsible for avarana that leads to Artava dusti and Abeejotsarga. In this present study women suffering from Infertility due to issues in Low AMH can be considered under Beeja Dushti. shodhana can be better line of management as it works on correcting the underlined root cause and treat the disease after detoxification of the body. Virechana karma adopted here for shodhana purpose which relieves the avarana and does the beeja Shuddhi. Vata is the main causative factor for Vandhyatva. to treat the apana vata dushti Basti   adopted. Basti remove avarana kapha and might have restored the normal function of vata and regulates functioning of pelvic organs, maintain follicular growth and development. Uttara Basti with shatavari ghrita acts as sthanika chikitsa by doing Brimhana. it stimulates endometrial receptors then stimulation of h-p-o axis to restore the physiological foliculogenesis by correcting artava dusti. Shatapushpa choorna as shamana yoga was planned to correction of Apana vayu vitiation and removing obstruction, thus help in Samprapthi Vighatana of Vandhyatva. Virechanottarauttarabasti with shatavarighrita followed by shatapushpachoorna orally effective in the management of low AMH. Uttarabasti with Sedentary life style can be assessed with valid questionnaire to evaluate effect of the stress factor on vandhyatwa (low AMH).