INFERTILITY

Almost all the people are having a strong desire to conceive a child at some point during their reproductive lifetime. Understanding what defines normal fertility is crucial to help a person or couple to know when it is time to seek help. Factors like advanced maternal age, weight, diet, smoking, other medical conditions, ovulation disorders, hormonal disturbances, psychological factors, environmental pollutants, medications that hamper the ovulation, positive family history and infections might have an effect on conception in couples.

Infertility by itself does not threaten physical health but has a strong impact on the psychological and social well-being of the couples. Infertility can result in severe emotional stress. Couples often describe the “hope and despair” cycle, as they hope every month that they will finally conceive and then despair when once again it does not happen. Hence, infertility is of public health importance, especially in developing countries because of its high prevalence and its serious social implications.

Infertility/Vandhyatva has been longstanding problem of human community right from the ancient period up to this modern era. If the antiquity of Vandhyatva is looked back, one can see the praise of a fertile woman and slander of a barren woman.

Acc to WHO, Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”

Types of infertility

1. Primary infertility: It denotes those patients who have never conceived.
2. Secondary infertility: It indicates previous pregnancy but failure to conceive subsequently within one or more years of unprotected regular intercourse.

Causes

Conception depends upon on both male & female factor. The male directly responsible in about 30-40 %, the female in about 40-55 % and both are responsible, in about 10% cases. The remaining 10% is unexplained.

Male factors are

1. Defective spermatogenesis
2. Obstruction of the efferent duct system
3. Failure to deposit sperm in high vagina
4. Errors in the seminal fluid

Female factors are

1. Vaginal factors
2. Uterine factors
3. Tubal factors
4. Peritoneal factors
5. Ovarian factors
6. Coital errors
7. Cervical factors

 Ayurvedic view –According to Ayurved, menopausal women and patients with anovulatory cycles are called as “Vandhya”, due to their inability to conceive. There are various opinions cited in different Samhitas which include both male and female factors responsible for Infertility but most relevant reference to this case is from Sushrut Samhita.

Aacharya Sushruta has explained four essential factors for conception namely

• Ritu (ovulatory phase),
• Kshetra (endometrium),
• Ambu (Amniotic fluid),
• Beej (ovum & sperm).

These factors act simultaneously to produce a healthy progeny. Any abnormality of these factors leads to vandhyatva. Because of some aaharatmak/viharatmak dosha any one of these/all of the mentioned factors gets vitiated causing infertility. Praja utpadan being the prime function of Aapanvayu, chikitsa has to be aimed at aapanvayu shaman & beej Prasadan.

Ayurvedic interpretation of the female reproductive system

Ayurveda identifies the female reproductive systems Shroni means the pelvis. Female pelvis is 24 Angulas and is heavier than the pelvis of the male.

There are three Srotas (also called capillaries) in women’s body.

1. Rajovaha srotas: Includes uterus, cervix and vagina along with their blood supply.
2. Artavaha srotas: Includes ovary and fallopian tube along with their blood supply.
3. Stanyavaha srotas: Includes breast tissue along with its blood supply.

Ashaya means any recipient viscus. Garbhashaya means uterine cavity, situated behind the Bhagasthi (symphysis pubis) and a little above the bladder which is surrounded by coils of intestines and is placed between small intestine (Pittashaya) and large intestine (Pakvashaya). Yoni consists of all the female genital organs

Classification:

The Classification of Vandhyatva has not been given separately in any classics except Harita Samhita, Rasa Ratna Sammuchaya and Vandhya Kalpadruma. Harita have described six types of Vandhya with special clinical features.

(1) Kakavandhya: -The woman who has one child but second time she is not conceived.

(2) Anapatya: – The woman who has no child or primary infertility.

(3) Garbhasravi: – The woman who has repeated abortion.

(4) Mritvatsa: – The woman who has repeated still births.

(5) Balakshaya: – Infertility due to loss of Bala (strength).

(6) Unexplained: – Infertility due to idiopathic cause

Causes

• Without Vata, Yoni never gets spoiled, here the word “Yoni” refers to reproductive organs collectively. Vata Dosha is the governing factor of the whole reproductive physiology; ovulation is also under the control of Vata. Therefore any vitiation of Vata will certainly affect the ovulation. An excessive bout of exercise, fear, anxiety or stress, trauma, excessive fasting as is the case in eating disorders or diet including cold, light and dry substances can cause imbalance of Vata. However, infertility rarely involves only one Dosha.
• People with Pitta nature may experience infertility resulting in scarring of the fallopian tube, inhibiting the ascent of the sperm or descent of the ovum. Excess heat may also be responsible for depletion of Shukra Dhatu.
• On the other hand, Kapha people because of the dominant water element in their constitution that supports Shukra Dhatu experience the healthiest and the strongest reproductive system. Infertility in those with Kapha is initiated by a cold, heavy and oily diet along with a sedentary lifestyle. When Kapha Dosha is predominant, fallopian tubes may thicken, uterine fibroids may develop, and often involves Pitta and Vata Scar tissue is due to Pitta pushing Kapha.

Causative factors can be divided into 2 parts:

1. Essential factors
2. Causative factors

ESSENTIAL FACTORS FOR FERTILITY: According to Acharya Charaka

• Matrutah and Pitrutah: The normalcy of Shonita and Shukra.
• Aatmatah and Satvataha: Aatma is always encircled with Satva, which descents in the fertilized egg, and forms Garbha (embryo) without them the formation of Garbha is not possible and established idiopathic infertility.
• Satmyataha and Rasataha: The normalcy of Shonita and Shukra greatly depend upon the use of Satmya Aahar and Vihar. The nourishment of mother and embryo depend upon the Rasa. Without Rasa even mother cannot survive, so there is no question about embryo

CAUSATIVE FACTORS:

• Without Vata the Yoni never gets spoilt, Vandhyatvahas also been described in eighty types of Vatavyadhi. So, Vata is the prime causative factor of Vandhyatva
• MANSIKA ABHITAPA: Normal psychology of the Couple is very important for achievement of pregnancy. Fear of doing sex, marital disharmony and infrequent coitus affect the fertility. Due to Stress, Bhaya, Shoka, Krodha, Lajja, Vata will be vitiated. So, it increases hypothalamic activity of CRH (corticotrophin releasing hormone) and further it inhibits normal GnRH pulsatile secretion and ultimately anovulatory cycles occur.
• BEEJA DUSHTI: When in Ovum, the gene concerned with uterus is damaged, the progeny becomes sterile
• SHUKRA DUSHTI: Quantitative and qualitative abnormalities of sperms along with spermatic fluid cause infertility. Pitruja Bhavas described under six factors are carried to the embryo through sperms
• ARTAVA DUSHTI: The word Artava refers to ovum, menstrual blood, and ovarian hormones abnormality of ovum and ovarian hormones produce infertility.
• AHARADOSHA: Dietetic abnormalities cause infertility in two ways:

1. By producing loss of Dhatus and that of Dhatvagni, thus they influence hormones.
2. By vitiating Doshas which cause various gynecological disorders, leading to infertility. Dietetic abnormalities influence nourishment of the body or cause loss of Dhatus which influences normal secretion of hormones.

• VIHARA DOSHA: Abnormal mode of life and suppression of natural urges aggravate Doshas, which produce various gynecological abnormalities. Other than the supine posture of the women during coitus, discharge of semen on Samirana Nadi or outside the vagina comes under defective practice. In all these conditions probably semen is not properly deposited inside the vaginal canal. Thus sperm fail to enter uterus causing infertility.
• AKALA YOGA: The word “Kala” refers to period of age and Rutukala In adolescent girls and old ladies due to premenarche and menopause stage respectively and before or after Rutukala due to absence and destruction of ovum respectively, the conception does not take place
• BALA KSHAYA: Bala refers to physical strength and capacity to become pregnant. Here, probably Bala refers to infertility due to unknown known cause or premature aging or any systemic disorder.

Management of infertility by Ayurveda

Ayurveda supports health by strengthening body’s own self-healing and balancing mechanisms and doesn’t rely on intervention by any outside or foreign substance to replace or correct the hormones in the body. It focuses on the treatment of infertility holistically with an aim of improving the overall health and quality of life of the individual.

DIET

• Diet plays a vital role in the prevention and cure of diseases and in maintenance of good health. “Annam Brahmam” – Food has been compared to God, in the ancient Indian scriptures since it is the main factor for sustaining and nourishing life.
• As per Ayurveda, food affects the mind also by causing either an increase or decrease in the three qualities of mind, i.e., Satvaguna, Rajoguna and Tamo guna. It is said in ancient Indian literature that if dietetics is followed, medicine is not needed and if dietetics is not observed, even medicines are not useful
• Dietary management involves strict compliance and adherence to foods that increase Ojas (an intersection factor of physical, mental and spiritual health of the body, responsible for overall health, energy and liveliness) and to avoid the substances which diminish the Ojas.
• This is important to regulate ovulation and enhances fertilization. Eating whole foods provides all nutrients for the health of the body in addition to the fibres that influences hormonal levels of the body. Foods such as processed carbohydrates, excess starch, antibiotic and hormone laden meat and milk and canned produce destroy fertility.
• Ojas building food include as milk, ghee, nuts, sesame seeds, dates, pumpkin seeds, honey, saffron and avocados help to replenish and build Ojas. Fresh organic fruits and vegetables, protein from plant sources like beans, and peas, sweet, juicy fruits such as mangoes, peaches, plums, and pears, asparagus, broccoli, whole grains, spices such as ajwain powder, turmeric (improves the interaction between hormones and targeted tissues), cumin (purifies the uterus in women and the genitourinary tract in men) and black cumin boost fertility. Root vegetables, grains, onions, garlic, chives improve circulation and nourish the blood.
• Diet should be free from Trans-fats as they block arteries, threaten fertility and harm the heart and blood vessels and therefore, must be avoided. Foods containing preservatives and other chemicals, like artificial sweeteners, Monosodium Glutamate (MSG), diet high in fat and other artificial flavouring and colouring, excess alcohol and caffeine, tobacco, soda, smoking, red meat, refined carbohydrates, such as pasta, white bread, rice etc can exacerbate the problem of infertility.

Treatment principles of Infertility in Ayurveda

1. Agni deepana and Ama pachana
   Ama formation (toxins created when undigested food forms in the stomach) by the imbalance in Agni (the power of digestion) lead to many diseases. Therefore, the treatment of Ama must always include the treatment of Agni, including the use of digestive and carminative Ayurvedic formulations, eating meals at proper time following an appropriate schedule. Ayurveda Panchakarma treatments help to eliminate Ama thus corrects Agni. Healthy Agni will also contribute to healthy Ojas.
2. Vatanulomana
   The main dosha involved in infertility is Vata. So Vatanulomana (correcting the functions of Vata) is very important in the treatment of infertility. Ayurvedic formulations, following routine exercises and strict diet schedule will help in Vatanulomana.
3. Sodhana
   Suitable sneha–swedas are done prior to sodhana. Then treatment modalities like Vamana (emesis), Virechana (puragation), Vasti (medicated enema) and Utharavasti special enema administered through urethral or vaginal routes) are done as per the condition of the patient. The patient has to follow peyadi krama (strict dietary regimen to be followed after Sodhana). This detoxification therapy helps in the expulsion of the toxins from the body. These therapies help to correct ovarian, tubular and uterine problems causing infertility.
4. Ayurveda treatments help in releasing tension and removing impurities from the body. They nourish the body, revitalize the mind and strengthen the immune system. They are beneficial in reducing stress, nourishing all dhatus of the body and pacifying Vata

Ayurvedic herbs:

• As infertility is not a disease by itself but a manifestation of some disease, the herbs used in the treatment are directed towards eradicating the underlying cause. The most commonly known and used herbs such as Ashwagandha (Withania Somnifera), Shatavari (Asparagus Racemousus), Amlaki (Emblica Officinalis) and herbal formulas such as Mensu and Chyavanprash are extremely useful formulations which help to create the synergistic hormonal balance between the Follicle Stimulating Hormone (FSH) and the Luteinizing Hormone (LH).
• No individual herb alone is considered useful for promoting fertility. Therefore, a combination of herbs is used in the treatment of infertility with the purpose of correcting a organic or functional problem that causes infertility.
• Medicated Ghees and oils such as Satapushpa tailam, Narayana tailam, Phala sarpis, Kalyana ghrita, Kalyanagulam, Dadimadi ghrita are commonly used. The right combination of herbs helps in regulating menstrual cycles, enhancing general health and wellness, invigorating sperm (enhancing a man’s sperm count, morphology and motility), reducing stress, enhancing sleep controlling anxiety and increasing energy level, balancing the endocrine system, increasing the chance of pregnancy for women undergoing in- vitro fertilization (IVF) and improving blood flow in pelvic cavity, thereby promoting fertility.

Panchakarma therapies: Therapies such as Shirodhara, Abhyanga, Marma therapy, Nasya, Basti, chakra balancing Pinda, Visesh and vedana help in releasing tension, impurities and trapped energy within the body. They nourish the body, revitalize the mind and strengthen the immune system. Rejuvenation therapies are beneficial in reducing stress, nourishing all Dhatus of the body and pacifying Vata.  Panchakarma is usually prescribed for infertile couples. Rejuvenative therapies are basically recommended for Vata Dosha, and cooling light therapies for Pitta Dosha. Shodhana chikitsa helps in uterine hostility, and non-ovulatory cycles.

Removal of local disorders: To remove obstructions in passage and to facilitate proper coitus, and to increase receptivity of the genital tract to the entry of the sperm, Basti is recommended. Massaging the body reduces stress, rejuvenates the entire body, and pacifies the underlying Dosha. Female infertility is sometimes caused by blocked tubes, pelvic adhesions or other types of trauma or inflammation in the reproductive organs. While a long believed that surgery procedures were the only way to even partially decrease these problems, Ayurvedic experts have founded a deep tissue work can not only decrease mechanical blockages, but also reduce pelvic pain and improve sexual arousal and orgasm for women.

A sedentary lifestyle results in stagnant lymph flow. If the body is too active, the body may not be able to carry away all the waste that is produced. Therefore, the deep tissue-massage works to stimulate the flow of lymph. This bodily fluid carries wastes and impurities away from tissues and needs muscle contractions to move efficiently throughout the body. The massage can help in increasing the chances of conception by clearing blocked fallopian tubes.  Reflexology, is an effective technique of interrupting stress and returning the body to a state of equilibrium which involves massaging different areas of the hands and feet (to establish the tension level for the rest of the body) corresponding to those internal organs that may cause infertility.

Do’s

1. The women who consume Lasuna never remain infertile
2. Milk is beneficial for Vandhya and also helps to achieve pregnancy.
3. Meat increase Retas and Shukra, and beneficial for Vandhya.
4. Coitus during Rutukala

Don’t: Suran, Kanji, Vidari and Tikshna Ahara.

Infertility is a global problem, so researchers are moving towards this problem. Ayurveda can give a promising hand to over rid this problem. Couple should follow some instructions.

General instructions for couple are-

1. Reduction of weight in overweight or obese persons.
2. Avoidance of Alcohol and heavy smoking.
3. Avoidance of tight and warm undergarments.
4. Avoidance of too frequent intercourse.
5. Counseling for psychosocial evaluation.
6. Discuss – Psychology and coital problem.
7. Advice to intercourse during the time of LH surge (detected by LH test kit, one can LH surge in urine by getting a deep blue colour of dipstick. The test should be performed daily between days 12 to 16 of a regular cycle).

Preventions: Some cases of female infertility may be prevented by taking the following steps:

1. Avoid excessive exercise.
2. Avoid smoking.
3. Control diseases such as diabetes and hypothyroidism.
4. Follow good weight management guidelines
5. Get early treatment for sexually transmitted diseases.
6. Have regular physical examinations to detect early signs of infections or abnormalities.
7. Limit caffeine and alcohol intake