E-ISSN:2456-3110

Case Report

Infertility

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 4 April
Publisherwww.maharshicharaka.in

Effective Ayurvedic management of Infertility due to low AMH in Elderly Women - Case Study

Danappagoudar M.1*, S. Patil S.2
DOI: http://dx.doi.org/10.21760/jaims.8.4.35

1* Maheshwari Danappagoudar, Post Graduate Scholar, Department of Prasuti Tantra and Stree Roga, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India.

2 Savita S. Patil, Professor and HOD, Department of Prasuti Tantra and Stree Roga, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India.

Pregnancy or the motherhood beyond the edge of reproductive age is referred as Pregnancy in “Elder gravida”. In the developing and developed countries age of marriage and there by child bearing are relatively late in life. Chances of pregnancy for healthy couples in their 20s and early 30s are around 1 in 4 women, 40s around 1 in 10women. Generally reproductive potential decreases as women get older, one of the common reasons is due to low AMH. Age is the single biggest factor affecting a women’s chance to conceive and to have a healthy baby and fertility can be expected to end 5 to 10 years before menopause. Risk of pregnancy complications increases with age. The risk of miscarriage and chromosomal abnormalities in the fetus increases from the age of 35years. Complications such as GDM, Placenta previa, Caesarian section and still birth are common among older women than younger women. According to Ayurveda, Infertility primarily refers to the biological inability of women to contribute to conception and also who is unable to carry pregnancy to full term. Ayurvedic management gives a new hope in women by strengthening body’s own self-healing and balancing mechanism without any intervention by outside or foreign substance to replace or correct the hormones in the body. Case Study: A female patient aged 38 years diagnosed as Primary Infertility due to low AMH treated with Virechana followed by Matrabasti and Shaman Chikitsa, after 3 months of treatment her AMH level increased and also patient got Conceived.

Keywords: Infertility, AMH, Virechana, Matrabasti

Corresponding Author How to Cite this Article To Browse
Maheshwari Danappagoudar, Post Graduate Scholar, Department of Prasuti Tantra and Stree Roga, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India.
Email: 		Maheshwari Danappagoudar, Savita S. Patil, Effective Ayurvedic management of Infertility due to low AMH in Elderly Women - Case Study. J Ayu Int Med Sci. 2023;8(4):211-215.
Available From
https://jaims.in/jaims/article/view/2417

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-02-25 2023-02-28 2023-03-07 2023-03-14 2023-03-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2023by Maheshwari Danappagoudar, Savita S. Patiland Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Danappagoudar M et al: Effective Ayurvedic management of Infertility due to low AMH

Introduction

AMH is best known as a serum marker for ovarian function especially ovarian reserve. In the ovary AMH is secreted from the granulosa cells of pre antral and small antral follicles. Since AMH is expressed by growing follicles prior to FSH- dependent selection and has shown to be detectable in circulation. Serum AMH has taken momentum as a marker for ovarian function, in particular the assessment of the ovarian reserve, ovarian reserve is constituted by the quality and quantity of the primordial follicle, which both decline with increasing age. In younger women AMH level does not correlate, while in the women of late reproductive age, a significant correlation was observed with primordial follicle density. From 25years onwards AMH level starts to decline.

Influencing Factors of Serum AMH:

Hormonal Contraceptive: Serum AMH level in normal ovulatory women decreased when Hormonal contraceptive was used for at least a year and the effect is reversible after discontinuation of tablets. The serum AMH levels 30%-40% lower in women using the oral contraceptive or the progesterone only pill, while in women using an intrauterine device, only a decrease of 17% was observed.

BMI: BMI negatively influence the AMH level.

Vitamin D: Vit D level exhibit seasonal variation with higher level in summer compared with winter. AMH level in women’s of reproductive age also exhibit this seasonal variation, with the level of 18% lower in winter than in summer.

Unhealthy Lifestyle: In last two decades the lifestyle of people has had a tremendous change from eating junk foods, exposure to pollutants,

chemicals, cosmetics, pesticides and working in night shifts is increased. These factors lead to hormonal imbalance and decreases the quality of egg.

Autoimmune Disease: Approximately 20% of patients with low AMH have previously diagnosed with Thyroid autoimmunity (most commonly Hashimoto’s thyroiditis) is the most prevalently 25-60% associated endocrine autoimmune abnormality reported in patient with low AMH.

Case Report

The reported case is 38 years old married, non smoker, non alcoholic came to OPD of Prasuti Tantra Stree Roga, SSCASR with complaints of anxious to conceive since 3 years with low AMH and USG showed endometrial thickness of 7mm. And male factor with normal seminal parameters, they were having adequate vaginal intercourse (3-4 /week). After 2 year she received two IUI treatments and one IVF which were unsuccessful. Her family history was negative for any premature ovarian Insufficiency.

Personal History: Her personal history reveled regular bowel habit and sound sleep. Her appetite was reduced and the Tongue was mildly coated. Her blood pressure: 110/70 mmhg, pulse rate: 86 bpm and BMI: 22kg/m2. She is Pitta Kaphaprakruti with Madyamasatwa and Madyamakosta. In view of symptoms of irregular menstruation with reduced quantity of bleeding and low AMH diagnosed as Dhatu Kshayajanyavandyatwa.

Menstrual history:

Menarche: At 14 years of age

LMP: 19/7/2021

Menstrual cycle: 2-3days/28-40 days.

Day1: 2pads with 40% soakage

Day2: 2pads with 80% soakage

Day3: Spotting

Pain: Present on 1st day

Clots: 1-2cms

Color: Brownish red

Obstetric History: G0P0A0L0



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Ashtasthanapareeksha

Nadi Pitta-Kapha
Mutra Prakruta
Mala Prakruta
Jihva Ishatlipta
Shabdha Utpatti&Grahana-Prakruta
Sparsha Anushnasheeta
Druk Prakruta
Akruti Madhyama

Dashavidhapareeksha

Prakriti Pitta-Kapha
Vikruti Pitta
Sara Rakta sara
Satwa Madhyama
Samhanana Madhyama
Pramana Madhyama
Satmya Mishrarasa Satmya (Katu, Amla Pradhana)
Satwa Madhyama
Ahara Shakti Madhyama
Vyayama Shakti Avara
Vaya Madhyama (Adhiruda)

Diagnostic assessment

Blood routine investigation was done and found to be normal

TSH - 2.7 ng/ml and serum prolactin was 15ng /ml

USG - showed normal anteverted uterus with Endometrial thickness of 7mm and both ovaries appear to be normal

AFC - Rt side (2 follicles) and left side 3 follicles on 2nd day on menstrual cycle.

AMH - 0.9 ng/ml

Treatment

Name of Treatment   Medicine Days
Classical Virechana Purvakarma  
1.Deepana Pachana Tab. Agnitundi Vati 2 BD 3 days
Avipattikara Churna 2tsf HS
2. Snehapaana Phala Ghrita - 40, 80 & 120ml 3 days
3. Sarvabga Abhyanga & Bhashpa Sweda Sahacharadi Taila 2 days
Pradhana Karma Trivrut Lehya 60gms & Triphala Kashaya 100ml (16 vegas)  
Paschat Karma Samsarjana Krama 5 days
Matra Basti Sahacharadi Taila - 60ml 7days
Uttara Basti Phalasarpi 3days


Follow-up:

1st follow-up

  • Phalasarpi 1tsp-0 -0 with warm water
  • Saptasaramkashayam
  • 4tsp-0-4tsp with 20ml of water, before food
  • Hingvastaka tab 1-0-1, Before food
  • Aloes compound 2-0-2, After food
  • Pathya Ahara-Vihara with meditation.

For 2 months

2nd Follow-up

  • Pushpadhanva Rasa 1-0-1, After food
  • Saptasra Kashyam 4tsp o- 4tsp with 20ml of water, before food
  • Phalaghrita Nasya 2drops, Once a day (Morning)
  • Amalaki Rasayana 1tsp-0-1tsp with Warm water

3rd Follow-up and Outcome

After three months of follow-up done in the OPD with reassessment AMH value showed significant improvement.

Discussion

Over the past few decades in modern medical field, Hormonal therapy, IUI, IVF, embryo transfer, gametes intra fallopian transfer are developed but with high expensive & minimal success rate.

The psychosocial stigma related to infertility has provoked the need for an ART in spite of the time-consuming, expensive, and stressful strategies. The value of AMH in detecting the ovarian reserve for an IVF cycle has begun to be better understood in the recent years. It is so unfortunate that donor egg IVF would be the last option of them who have a low AMH value with poor ovarian reserve. Lack of awareness regarding the efficacy of an integrated approach to medical intervention in such cases to proceed with a donor egg IVF technique has grown up as a great challenge to the physicians as well as patients. Ayurvedic approach to Dhatukshayajanya Vandhyata in terms of low level of AMH is having good outcome. The present disease entity can be corelated to Dhatu kshayajanya Vandhyata. The case presents with a Vata-Pitta Dosha Vikriti progressing toward a Dhatu Kṣhaya, thereby


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affecting Artava Upadhatu which was evident from the Artavakshaya Lakshana of the patient. The treatment protocol was mainly for detoxification and it also does Agni Deepana, there by proper formation of Rasa Dhatu and its Upadhatu that is Artava, followed by Matra Basti and Shamanoushada aims for Dhatu Poshana along with Upadhatu (Artava) Poshana.

Ayurvedic approach and its mode of action

Virechana: Virechana is the second most therapy in the sequence of Panchakarma. It is most widely used because of its simplicity and elimination of Dosha in more quantity with less stress to the body.

Mechanism of Virechana

Peristaltic movements push the intestinal material to sigmoid colon and Rectum, The Defecation reflex occurs in response to stimulation of Sensory nerve impulse to sacral spinal card and parasympathetic stimulation, opens the internal anal sphincter. Shodana Karma are Physician induced mild inflammation, mainly Vamana and Virechana drugs are quite irritant to the mucosa membrane leads to inflammation, because of inflammation, permeability of membrane changes and allow the toxins to come out. Chemical changes which are responsible for the permeability are Mast cells (Histamine), Serotonin, prostaglandins and Globulin permeability factor.

Nasya: The drug administered through the nose may act on the Shiras. Drug delivery from nasal route through olfactory nerve to pituitary gland there by helps for secretion of gonadotropins.

Pathogenesis of gynecological disorders always involves Vata Dosha. Hence, Basti Karma, which is the best therapy for Vata Shamana, was administered after Shodhana. Basti Dravya enters enteric nervous system. These signals stimulate endogenous opoids present in Gastro Intestinal Tract mainly by endorphins, regulates hormone. Uttara Basti is indicated for all gynecological disorders, especially in Puspanasa and to get healthy progeny. Notable improvement in the symptoms of Artavaksaya was observed. The value of AMH after the treatment was considerably improved to 1.8ng/ml. In 3rd follow-up she came with missed periods, UPT result was positive and pregnancy confirmed with USG, single intra uterine gestational sac was seen.

Conclusion

Ayurveda supports the body by strengthening body’s own self-healing mechanism. It doesn’t rely on outside substance to fulfil the hormone level. Infertility itself doesn’t stand alone. It is the result of some other disease so understanding the root cause of the disease helps to treat effectively. Rutu, Kshetra, Ambu and Beeja are the prime requisites for Garbha. Beeja is most essential among them. Ayurvedic treatment gives a new hope in elderly women with depleted ovarian reserve. In Charaka Samhita, there is a effective, holistic and wide range of treatment modality for infertility based on Ayurvedic principles. The treatment of Infertility comprises of administration of Panchakarma therapies for detoxification followed by Shamnoushadhas which does Dhatuposhana, stimulate ovaries for Folliculogenesis and producing healthy oocytes. Phalasarpi and Pushpadhanwa Rasa are the best herbal preparations for low AMH and Infertility. Apart from this following Pathya plays a vital role in the prevention and cure of disease Lolimbaraja’s famous quote says “Pathyam Sati Gadarthasya Kim Aushadam Nishevanam”. Dietary management involves strict compliance and adherence to foods that increase Oja. This is important to regulate the ovulation and enhances fertilization.

Patient perspective: The patient was satisfied with the treatment as she had considerable improvement in the AMH value that gives her hopes for undergoing other Artificial reproductive techniques.

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