E-ISSN:2456-3110

Case Report

Management of Artava

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 5 May
Publisherwww.maharshicharaka.in

Management of Artava Kshayajanya Vandyatwa with history of Garbhapaata - A Case Study

Jana P1*, Rashmi C2
DOI:10.21760/jaims.9.5.46

1* Papiya Jana, Professor, Department of Prasuti Tantra and Stree Roga, Sri Kalabyraveshwara Ayurvedic Medical College Hospital and Research Centre, Bengaluru, Karnataka, India.

2 Rashmi C, Post Graduate Scholar, Department of Prasuti tantra and Stree Roga, Sri Kalabyraveshwara Ayurvedic Medical College Hospital and Research Centre, Bengaluru, Karnataka, India.

Artavakshaya is one of the common presentations in day to day practice. Infertility can be one of the complications due to Artava Kshaya. As Artavakshaya can be a cause of anovulatory cycles along with irregular menstruation. Artavakshaya can result in Vandyatwa if left untreated. Infertility is the inability to conceive in one or more years of regular unprotected coitus. In the present case study 36 year old patient who was anxious to conceive with PCO changes and one history of Garbhapaata is treated with Shodhana and Shamana therapy including Vamana Karma, Virechana Karma followed by Matra Basti with Phala Ghrita.

Keywords: Artava Kshaya, Garbhapaata, Phala Ghrita, PCOD

Corresponding Author How to Cite this Article To Browse
Papiya Jana, Professor, Department of Prasuti Tantra and Stree Roga, Sri Kalabyraveshwara Ayurvedic Medical College Hospital and Research Centre, Bengaluru, Karnataka, India.
Email: 		Jana P, Rashmi C, Management of Artava Kshayajanya Vandyatwa with history of Garbhapaata - A Case Study. J Ayu Int Med Sci. 2024;9(5):270-278.
Available From
https://jaims.in/jaims/article/view/3226

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-03-07 2024-03-17 2024-03-27 2024-04-08 2024-04-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 24.85

© 2024by Jana P, Rashmi Cand 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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Introduction

Artavakshaya is defined as Yathochita Kaala Adarsharshana, Alpata and Yonivedana as mentioned by Susrutha Acharya.[1] Artava Kshaya can also lead to Vandyatwa as Acharya Charaka opines Yoni Dosha, Manasika Dosha, Sukra Dosha, Asrig Dosha, Ahara Dosha, Vihara Dosha, Akala Yoga and Bala Sankshaya are the factors influencing fertility or they can be taken as causative factors for infertility.[2] Infertility is not an independent disease, rather a cardinal feature of so many diseases among which anovulation due to Polycystic ovaries is found out to be a major cause. Ovulatory disorders make up 25% of the known causes of female infertility.[3] Oligo-ovulation or anovulation results in infertility because no oocyte will be released timely based on the monthly cycle.

Acharya Vagbhata said that Vata, Pitta and Kapha in combined form are main causative factors for Artava Kshaya (Ksheenartava).[4] Acharya Chakrapani says Shodhana purifies the channels, hence both Vamana and Virechana should be used methodically. Acharya Kashyapa says Artavakshaya is an Anuvasana Yogya Vyadhi.[5] In present case study combined effect of Vamana, Virechana and Matra Basti was found effective in the management of Vandhyatva due to anovulation (PCOS).

Case Report

A 36 year old female patient, who is house wife with marital life of 4 years, reported to Prasuti Tantra & Stri Roga OPD of Shri Kalabyraveshwara Ayurveda Medical College, Hospital and Research Centre Bengaluru who was Anxious to conceive since 1½ years. Patient also complaints of Irregular menstrual cycle with scanty menstrual bleeding since 6 years. Patient also complained of Cough, cold and dyspnoea on and off since 15 years

History of Present illness

Female patient aged 36 years, attained menarche at 12 years of age and had regular menstrual cycle. At the age of 21 years she was diagnosed with tuberculosis of right lung and had taken treatment for the same. The history of treatment is unknown. Since then, the patient suffers from on and off episodes of cough, cold and dyspnea for which she was taking modern medications where she had temporary relief.

Gradually patient noticed change in her pattern of menstrual cycle but it was not given much attention. The patient faced irregularity in menstrual cycle both in terms of duration and flow 6 years ago. Investigations revealed hypothyroidism and she started with modern medicines. However, her menstrual irregularities continued and hence she approached SKAMC for further management. She was advised with Shodhana and Shamana treatment where her thyroid levels came to normalcy and her menstrual irregularity also resolved.

In the meanwhile, she got married 4 years back and was anxious to conceive, for 2 years she tried for natural conception but failed to conceive and in 2021 she again approached SKAMC for further management where detailed history was taken and both the partners were sent for investigations.

The male partner had all normal parameters related to semen analysis. The patient had anovulatory cycles based on investigations. Rests of the parameters were normal. In 2021 she underwent Kramataha Shodhana as a procedure for Garbhadhana followed by Shamanoushadhis and patient conceived at the end of treatment. Patient shifted to her native and she didn’t follow-up for further ANC.

At 6th month of pregnancy, the patient suffered from repeated episodes of cough, cold, dyspnoea and haemoptysis and had premature labour pains where she had still birth. After this the patient tried for natural conception for 1 ½ years which failed and she again visited SKAMCH & RC.

History of Past illness

  • H/O Tuberculosis of right lung at 21 years of age.
  • H/O Hypothyroidism 6 years ago had taken modern medications for 6 months and discontinued. Had taken Ayurvedic treatment for the same from SKAMCH & RC
  • Had taken treatment in SKAMCH & RC for primary infertility 2 years ago

Occupational History: House Wife

Koutumbika Vrittanta: All other family members are said to be healthy.

Shastra Karma Vruttanta: Patient Not Underwent Any Surgery


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Chikitsa Vruttanta

  • H/O tuberculosis of right lung, had taken treatment for 3 months – details unknown and 6 months of ayurvedic treatment – details unknown
  • H/O Hypothyroidism 6 years ago had taken modern medications for 6 months and discontinued. Had taken Ayurvedic treatment for the same from SKAMCH & RC - few treatment details which was available was -
  • Underwent Vamana Karma in 2019
  • Swarnamalini Vasanta Rasa 1-0-1 A/F
  • Gandhaka Rasayana 1-0-1 A/F
  • Katuki Churna for external application
  • On and off symptoms of cold, cough and dyspnoea, patient was taking Montec LC 0-0-1 A/F, Ascoril LS 10 mL TID for 3 days.
  • Had taken treatment from SKAMCH and RC for primary infertility – underwent Kramataha Shodhana followed by Shamanoushadhis where patient shifted to her native and she didn’t follow up for further ANC.

Vaiyaktika Vruttanta

  • Diet - Vegetarian
  • Appetite - Good
  • Bowel - once or twice a day, Regular
  • Micturition - 4-5 times/day
  • Sleep - Sound
  • Habits - nil

Rajo Vruttanta

Age of menarche - 12 years

Menstrual History

  • Nature - Irregular
  • Bleeding duration - 1-2 days
  • Interval - 35-70 days
  • Amount of bleeding - Scanty
  • Dysmenorrhoea - absent
  • Colour - Bright red
  • Clots - absent
  • Foul smell - Absent
  • No Pads used - 1st day : 1-2 pads
  • 2nd Day - 1 Pad
  • LMP - 28/02/2023

Vyavaya Vruttanta

3-4/times week

Dyspareunia - absent

Contraceptive History

No contraceptive history

Prasava Vruttanta - P1D1

D1 At 6th month - still birth

Partner Details

Name - XYZ

Age - 38 years

Occupation - Accountant

Habits - None

Not known case of DM/HTN/Asthma/ Hypothyroidism

Seminal Analysis - Normal study

Ashtavidha Pariksha

Nadi - 76/min

Mutra - 4-5 times a day.

Mala - Once or twice a day

Jihwa - Alipta

Shabda - Prakruta

Sparsha - Anushna Sheeta

Drik - Prakruta

Akruti - Madhyama

Dashavidha Pareeksha

Prakruti- Vata Kapha

Vikruti -

Dosha - Vata Pradhana Tridosha

Dushya - Rasa, Rakta and Artava

Desha - Sadharana

Bala - Madhyama

Saara - Madhyama


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Samhanana - Madhyama

Pramana - Madhyama

Satmya - Madhyama

Satva - Madhyama

Ahara Shakti

Abhyavarana Shakti - Madhyama

Jarana Shakti - Madhyama

Vyayama Shakti – Madhyama

Vaya - Madhyama

General Examination

Built - Moderate

Nourishment - Moderate

Pallor - Absent

Edema - Absent

Clubbing - Absent

Cyanosis - Absent

Icterus - Absent

Lymphadenopathy - Absent

Height - 164cm

Weight - 60kg

BMI - 22.3 kg/m2

Pulse Rate - 76 beats/minute

BP - 110/80 mm Hg

Respiratory Rate - 18 cpm

Heart Rate - 76/minute

Temperature - 97°F

Tongue - Uncoated

Athura Bhoomi Desha Pariksha

Jatataha - Sadharana

Samvrddhataha - Sadharana

Vyadhitaha - Sadharana

Systemic Examination

Respiratory System

Inspection:

Shape of the chest - Bilaterally Symmetrical

Chest movements - Symmetrical

RR- 18/min

Palpation: Trachea - Centrally placed

Percussion: Resonant over the lung field except cardiac dullness.

Auscultation: Bilateral NVBS heard

Cardiovascular system

Inspection - No distended vessels over neck or chest.

Percussion - Cardiac dullness present on left side.

Auscultation - S1 S2 heard, No murmurs heard.

Central Nervous System

Patient is conscious well oriented to time, place and person.

Per Abdomen Examination

  • Inspection Contour - Round Umbilicus, Centrally placed, Inverted
  • Palpation Soft, Tenderness in supra pubic region, No organomegaly observed
  • Percussion NAD
  • Auscultation - Normal Bowel sounds heard

Gynaecological Examination

Breast examination: NAD

Examination of Vulva

Inspection

Pubic Hairs - Normal

Clitoris - Normal

Labia - Normal

Redness - Absent

Swelling - Absent

Palpation

No Palpable mass noted


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Per Speculum Examination

Vagina

Redness - absent

Local lesions - Absent

Discharge - Absent

Cervix

Healthy

Size - Normal.

External Os - Multiparous

Cervicitis and erosion - absent

Per Vaginal Examination

Cervix

Texture - soft

Mobility - Mobile

Cervical motion tenderness - Absent

Bleed on touch - Absent

Fornices - Lateral – Free and Nontender

Posterior - Free and Nontender

Uterus - Bi Manual examination

Position - Ante verted

Direction - Ante flexed

Size - Normal

Mobility - Mobile

Tenderness - Absent

Investigations

SNDateTestResults
1.2/3/23HbA1c4.7%
2.2/3/23AMH4.66ng/mL
3.2/3/23FSH10.07mIU/mL
4.2/3/23LH7.90mIU/mL
5.26/7/23TSH2.93 uIU/mL
6.26/7/23Hb11.2mg/dL
7.26/7/23VDRLNon Reactive
8.26/7/23HIV I & IINegative
9.26/7/23HbsAgNegative

USG - Abdomen and Pelvis Impression

1. Normal Sized Uterus

2. Bilateral Polycystic Ovaries

3. No Dominant Follicles Seen

X-Ray Impression - Normal Study

Follicular study Impression

  • No Dominant follicles seen
  • No sign of ovulation/ Rupture of the follicle

Roga Pareeksha

Nidana

  • Aharaja - Adhyashana, Vishamashana, Akala Bhojana junk foods like pizza, pasta, cakes, panipuri
  • Viharaja - Ratri Jagarana, Diwaswapna
  • Manasika - Chinta and Shoka

Rupa Yathochita Kala Adarshana of Artava (oligomenorrhea), Arthava Alpata (hypomenorrhea), Artavakshaya (anovulation)

Samprapti

Nidana Sevana

↓

Vata Pradhana Tridosha Prakopa

↓

Agni Vaishamya

↓

Rasa Dushti

↓

Arthava Dushti

↓

Stana Samshraya in Garbhashaya and Beejagranti

↓

Yathochita Kala Arthava Adarshana

↓

Artava Alpata

↓

Arthava Kshaya

↓

Vandhyatwa


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Samprapti Ghataka

  • Dosha - Vata Pradhana Tridosha
  • Dushya - Rasa, Rakta, Artava
  • Agni - Jataragni, Dhatwagni
  • Agni Dushti - Jatargni Dusti, Dhatavagni Dusti
  • Srotas - Rasavaha, Artavaha Srotas
  • Srothodushti - Sanga
  • Udbhava Staana - Aamashaya
  • Sanchara Staana - Rasavaha, Artavaha Srotas
  • Vyakta Staana - Garbhashaya
  • Adhishtana - Garbhashaya
  • Vyadhi Marga - Abhyantara
  • Sadya Asadhyatwa - Sadhya

Vyavachedaka Nidana

VyadhiInclusionExclusion
Vandyatwa due to Artavakshayaü Yathochita Kaala Adarshanath
ü Alpata
Pushpagni Jatahariniü Scanty menstruation
ü Vandyatwa		×  Yathakalam Prapashyati
×  Sthula
×  Lomasha Ganda
Vandyatwa due to Putragni Yonivyapadü Vata Prakopa×  गर्भं जातं जातं विनाशयेत् repeated abortions not seen- h/o only stillbirth

Differential diagnosis

DiseaseInclusionExclusion
Hyperprolactinemiaü Irregular Menstrual cycles
ü Infertility		☓  Galactorrhoea
☓  Acne hirsutism
Asherman’s Syndromeü Menstrual Irregularities
ü Infertility		☓  Secondary Amenorrhea
☓  Dysmenorrhoea
☓  No adhesions noted in USG
Infertility PCOD (Anovulation)ü Irregular Menstrual cycles
ü Scanty Menstrual Flow
ü Follicular study shows no large follicles and non-rupture of follicle
ü USG shows polycystic appearance of ovaries		-

Vyadhi Nirnaya

  • Vandyatwa due to Arthavakshaya
  • Infertility due to PCOD and Anovulation

Treatment Given

DateSymptoms PresentTreatment GivenObservation
17/2/2023 - 20/3/2023Cough +
Wheezing +
Tiredness +
Irregular menstrual cycle
Scanty bleeding
LMP - 28/2/2023		1.  Dashamoola Haritaki Rasayana 1tsp BD with Warm water B/F
2.  Elakanadi Kashaya 2tsp BD with 4-6 Tsp of water half an hour before food
3.  M2 Tone tablet 1TID A/F
For 1 Month		Cough, wheezing and tiredness reduced
21/3/2023 - 4/4/2023Scanty menstrual bleeding
Number of days of Bleeding - 1-2 days
No Pads used -
1st Day - 1-2 pads
2nd Day - 1 Pad
LMP - 28/2/2023
Irregular menstruation		Sarvanga Udwartana with Kolakulattadi Churna + Triphala Churna followed by Bhaspa Sweda for 10 days
Snehapana with Varunadi Ghrita for 4 days
Sarvanga Abhyanga with Moorchita Tila Taila followed by Bhaspa Sweda for 1 day
Vamana Karma		Menstruation D1 on 6/4/2023
Number of days of Bleeding - 3 days
No Pads used -
1st Day - 3 pads
2nd Day - 1 Pad
3rd Day - 1 pad
19/4/2023 - 01/5/2023Number of days of Bleeding - 3 days
Nos of Pads used -
1st Day - 3 pads
2nd Day - 1 Pad
3rd Day - 1 pad
LMP - 6/4/2023		Deepana and Pachana with
Agnitundi Vati 1-0-1 A/F
Chitrakadi Vati 1-0-1 B/F
for 5 days
Snehapana with Varunadi Ghrita for 4 days
Sarvanga Abhyanga with Moorchita Tila Taila followed by Bhaspa Sweda for 3 days
Virechana Karma with Trivrit Lehya 90 grams		Menstruation D1 on 8/5/2023
Number of days of Bleeding - 3 days
No Pads used -
1st Day - 3 pads
2nd Day - 1 Pad
3rd Day - 1 pad
12/5/2023 - 21/05/2023No dominant follicle
LMP - 8/5/2023		Matra Basti with Phala Gritha – 75 mL for 10 daysMenstruation D1 on 6/6/2023
Development of dominant follicle but no sign of ovulation
10/6/2023 - 19/6/2023Development of dominant follicle but no sign of ovulation
LMP - 6/6/2023		Matra Basti with Phala Gritha – 75 mL for 10 daysDevelopment of dominant follicle and rupture of follicle
20/6/2023Rupture of follicle seen
LMP - 06/06/2023		1.  Phala Sarpi 2tsp-0-2tsp with milk B/F
2.  Jeevani syrup 2tsp-0-2tsp A/F
For 1 month		UPT positive on 27/7/2023

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Results

  • Follicular study Impression - Dominant follicles seen
  • Rupture of the follicle - sign of ovulation seen
  • UPT positive on 27/7/2023
  • With POG of 5 weeks 2 days

Advice

1. Tab Folvite 0-1-0 A/F

2. Sustain 200mg 0-0-1 A/F

3. Inj Maintain IM weekly once

4. Phala Sarpi 2tsp-0-2tsp with milk B/F

Patient delivered a single live male baby prematurely through LSCS with gestation of 32 weeks in another hospital

Discussion

The main treatment protocol focused on treatment of anovulatory cycle & Vandhyatva at the same time keeping in mind about the previous medical illnesses and treatment taken for the same.

Discussion on mode of action of Vamana Karma

Artava Kshaya can be considered as Agni Vaishamyajanya Vikara in general and Rasagni and Medodhatvagni Mandya deficient in particular with Bahu Dosha Avastha (vitiated Dosha). As Artava Kshaya is a metabolic disorder, Vamana helps to increase body metabolism, specifically acting on liver metabolism, which is the main site of hormone formation. Ushna, Tikshna and Vyavayi Vikasi Guna of Madanaphaladi Yoga normalize Kapha vitiation and Vatavaigunya, reduces excess Meda, removes Srotorodha / Sanga and creates normal functioning of Apana Vata there by regularizing the function of Aartavavaha Srotas as Prakrita Vata is responsible for proper menstrual flow

Discussion on mode of action of Virechana Karma

Virechana Karma is mainly indicated for Pitta predominant Vikaras and Acharya Dalhana says Vamana is indicated for Artava Kshaya. But according to Acharya Chakrapani says Shodhana purifies the channels, hence both Vamana and Virechana

should be used methodically. Hence both Vamana and Virechana use in a proper way can combat Srotorodha in Artava Kshaya and can help in the Samprapti Vighatana of the disease. Virechana is bio-cleansing in nature. It removes the metabolic waste, accumulated toxins and vitiated Dosha from the body. It also helps in regularizing the disturbed hormonal levels in the body as it works on liver metabolism thus correcting disturbed lipid levels.

Mode of action of Matra Basti with Phala Ghrita

Acharya Susruta mentioned Vandhya Yonivyapad in the Vataja type of Yonivyapad. For pacifying Vata, Basti is the Shrestha Chikitsa as per Ayurveda Matra Basti given through Guda (rectal route) normalizes Apana Vayu leading to Vatanulomana and physiological functioning of Vata, which may help in turn for the extrusion of ovum from the follicle and ovulation. Basti Dravya spreads all over the body, pacifies the aggravated Dosha along with Vyana Vayu leads to Samyaka Rasa Raktadi Dhatu Nirmana. Sukshma Bhaga of Rasa reaches the Beejagranthi, which regularizes the Beejotsarga with the help of normal Apana Vayu.

Matra Basti after absorption reaches into systemic circulation and the concept of Central Nervous System (CNS) resembles Enteric Nervous System (ENS) the endogenous opioids in the ENS specially endorphins (β-endorphin) are influenced which will affect GnRH release regularizing HPO axis regulating ovarian cycle and ovulation. Endogenous opioids are a group of peptides, which play an important role in the ovarian cycle through the inhibitory effect on GnRH secretion. Other pituitary hormones are also modulated by opiates. β-endorphin has been best known of the opioid related to the reproductive system regulating variety of pituitary hormones including gonadotrophins. Β-endorphin has a role in the regulation of the normal ovarian cycle.

Basti - stimulates - the ENS - generates the stimulatory signal for CNS - causes stimulation of the hypothalamus for GnRH and the pituitary for Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) with the help of neurotransmitters. Ovaries and the rectum -S2, -S3, and -S4 supply. Parasympathetic activity is mainly responsible for the Apana Vayu activity. Basti given through rectum will stimulate this parasympathetic nervine supply, which in turn helps for the release of ovum from the follicle in the ovary.


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Sharangadhara, Vagabhatta, Yogaratnakar and Bhavaprakash mentioned Phalaghrita in the treatment of Vandhyatva.[6-10] Phala Ghrita mentioned in Bhaishajya Kalpana has Tridosha Shamak, Garbhasthapak, Rasayana etc. property which helps in nourishing the developing follicle to grow as a dominant follicle which lacks in case of anovulatory cycle. Beside this it also helps in proper development of the endometrium which is required for the implantation and nourishment of the zygote. Phala-Ghrita contains mainly Tikta, Madhura and Katu Rasa, Laghu, Snigdha Guna, both Katu and Madhura Vipaka and also Ushna and Sheeta Virya. It also has Dipana, Pachana, Lekhana, Anulomana, Shothahara, Krimighna, Balya, Prajasthapana and Yoni Pradoshanashaka actions.

Conclusion

Aetio-pathology of Artava Kshaya is often associated with one or more combined metabolic disorders like PCOD, Hypothyroidism, and Diabetes. This ends with primary or secondary Infertility which cause emotional stress, social stigma, financial burden and affect dearly with womanhood. This study can be used as alternative treatment in management of infertility due to abnormal development of ovum and ovulation. This study will contribute as alternate treatment for induction of ovulation. This study will also be useful for females having risk factors of ovulation related infertility as a preventive measure.

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3. Walker MH, Tobler KJ. Female Infertility. [Updated 2022 Dec 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556033/

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8. Vagbhata, Astanga Hrdayam with Nirmalahindi Commentary, edited by Dr. Brahmananda Tripathi, Chaukhambha Sanskrit Pratishthan, Delhi, 2012 edition, Pp1295, pg no. 1142.

9. Yogaratakara with Vidyotini Hindi Commentary by Vaidya Laksmipati Sastri, edited by Bhisagratna Brahmasankar Sastri, Chaukhambha Prakashan, Varanasi, edition 2010, Pp 504, pg no. 408.

10. Bhavamisra, Bhavaprakasa, vol. 2, Commentary by Dr. Bulusu Sitaram, Chaukhambha Orientalia, Varanasi, edition 2010, Pp 770, pg no. 696.


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