E-ISSN:2456-3110

Case Report

Hyperprolactinemia

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 12 DECEMBER
Publisherwww.maharshicharaka.in

Role of Ayurveda in management of Ovulatory Factor Infertility Associated with Hyperprolactinemia: A Case Report

Kashyap K1*, Malik N2, Swathi C3
DOI:10.21760/jaims.9.12.38

1* Khushbu Kashyap, Post Graduate Scholar, Department of Prasuti Tantra and Stri Roga and Ayurveda, Sri Jayendra Saraswathi Ayurveda College and Sri Chandrashekhraendra Saraswathi Viswamahavidalaya, Chennai, Tamil Nadu, India.

2 Neha Malik, Post Graduate Scholar, Department of Prasuti Tantra and Stri Roga and Ayurveda, Sri Jayendra Saraswathi Ayurveda College and Sri Chandrashekhraendra Saraswathi Viswamahavidalaya, Chennai, Tamil Nadu, India.

3 Swathi C, Associate Professor, Department of Prasuti Tantra and Stri Roga and Ayurveda, Sri Jayendra Saraswathi Ayurveda College and Sri Chandrashekhraendra Saraswathi Viswamahavidalaya, Chennai, Tamil Nadu, India.

Infertility affects approximately 17.5% of the global adult population, with about 8% of currently married women in India being infertile, most are experiencing 2° infertility (5.8%). Ovulatory abnormalities account 25% of all causes of female infertility. Hyperprolactinemia (HPRL) causes infertility by suppressing the hypothalamic-pituitary-gonadal axis, which reduces ovarian estrogen release, resulting in anovulation and infertility. Infertility develops from oligo-ovulation or anovulation since no oocyte is released, thus there is no chance of fertilization. This can be understood as Artava Dushti from classical Ayurvedic perspective associated with Rasa Dhatva Agni Mandya. The treatment principles lie in regulating the Agni followed by alleviating the Kapha which obstructs the Strotas. A 40-year-old female patient present with complaint of unable to conceive since 7yrs despite regular unprotected intercourse, with additional complaints of bloating, body heaviness, and headaches during menstruation. She was diagnosed with PCOD in 2017 and underwent ovarian drilling and unsuccessful fertility treatments, including IUI and ICSI. Then she approached SJSACH OPD for further treatment where she was diagnosed with HPRL and Hypothyroidism. The patient underwent Vamana as Shodhana Chikitsa followed by Shaman Chikitsa, resulting in a significant reduction in TSH and prolactin levels, leading to normal ovulation. Hence conditions of Anovulation which are associated with endocrinal anomalies like HPRL, Hypothyroidism can be managed with proper Ayurvedic diagnosis and treatment. In the present scenario, patient was treated with an initial round of counseling followed by Shodhana and Shaman Chikitsa which is proper utilization of Satwa-Avachaya Chikitsa followed by Yukti-Vyapasharya Chikitsa.

Keywords: Agnimandya, HPRL, Rasa Dhatu, Strotoshodha

Corresponding Author How to Cite this Article To Browse
Khushbu Kashyap, Post Graduate Scholar, Department of Prasuti Tantra and Stri Roga and Ayurveda, Sri Jayendra Saraswathi Ayurveda College and Sri Chandrashekhraendra Saraswathi Viswamahavidalaya, Chennai, Tamil Nadu, India.
Email: 		Kashyap K, Malik N, Swathi C, Role of Ayurveda in management of Ovulatory Factor Infertility Associated with Hyperprolactinemia: A Case Report. J Ayu Int Med Sci. 2024;9(12):282-287.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-11-07 2024-11-18 2024-11-28 2024-12-09 2024-12-22
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© 2024by Kashyap K, Malik N, Swathi 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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Khushbu K et al. Role of Ayurveda in Ovulatory Factor Infertility Associated

Introduction

HPRL levels have a deleterious effect on the gonadotropic axis in both men and women, at numerous levels and regardless of the reason. The main impact is to reduce pulsatile gonadotropin releasing hormone (GnRH) secretion via hypothalamic kisspeptin neurons and potentially additional GnRH afferent neurons. Prolactin (PRL) also inhibits pituitary LH and FSH secretion, and the positive feedback of estradiol on mid-cycle gonadotropin release, leads to anovulatory cycles and, eventually, infertility.[1] Clinical data also support an inhibitory effect of high prolactin levels on the function of the corpus luteum. Thus, in hyperprolactinemic women with ovulatory cycles, it was shown that hyperprolactinemia leads to luteal phase insufficiency and low progesterone levels.[2]

Elevated PRL levels have been reported under specific physiological conditions (pregnancy or breastfeeding, stress, exercise, and anxiety), pathological conditions (most commonly Prolactinomas) and medicines that are known to interfere with the neuroendocrine regulation of PRL. In addition, hormones involved in stress exert an effect on the hypothalamic-pituitary-gonadal axis (HPG). In the course of the stress reaction, among other occurrences, there is an increased secretion of cortisol (COR) and prolactin.[3]

Thyroid hormones and prolactin share several elements of regulation and inter-related reactions. TRH promotes pituitary prolactin secretion. The smallest TRH doses capable of increasing TSH also increase prolactin levels, indicating a physiologic role for TRH in the regulation of prolactin production. Except in hypothyroidism, normal physiologic changes and aberrant prolactin secretion can be explained by dopaminergic inhibitory.[4]

In Ayurveda, both disorders (HPRL and Hypothyroidism) can be correlated with Agnimandya (Poor metabolism) at any level. The occurrence of anovulatory cycle in this present condition can be linked to the Artava Dushti associated with Rasa Dhatva Agnimandya. Deepan, Pachana, Shodhana, and Shaman Chikitsa are used to treat the underlying reason i.e., Yuktivyapyashraya Chikitsa, while Satwa-Avachaya Chikitsa is used to treat stress or Mansik Vikara or Shok, which can also be the cause of the increase in production of Prolactin.

Case Report

Artava Dushti A 40 years old female patient present with complaint of being unable to conceive with regular unprotected intercourse since 7yrs. She also complaints of heaviness of the body, bloating of abdomen, and headache before one week and during periods.

She was diagnosed with PCOD in 2017 and underwent ovarian drilling. She conceived with the help of ovulation induction in 2018 which was spontaneous abortion.

She also underwent various procedures (IUI, ICSI) and tried different systems of medicine for 7 years, which proved unsuccessful. Then she approached SJSACH OPD on 1/7/2023. She underwent various investigations, which revealed HPRL and Hypothyroidism. She was diagnosed with with Rasa Dhatva Agnimandya. Counseling was done and Vamana Karma was advised to her for effective management.

History of past illness

PCOD - Resolved (2018)
CMV IGG - Positive (2018)
Herpes IGG - Positive (2018)
K/C/O - Migrain / sinusitis - 23 yrs of age.

Personal history - Appetite was normal, bowel was constipated two days prior to menses, and bladder regular with flow.

Habits - Not relevant

Menstrual History - Patient attained menarche at 13yrs of age. Nature of cycle is regular with duration of 28 days.

Number of pads used per day:

Day 1 - 2 pads
Day 2 - 4 pads
Day 3 - 3 pads
Day 4 - 2 pads
Day 5 - spotting
Dysmenorrhea - present, clots - present, White discharge - absent.

Marital History - Got married at the age of 32 yrs. (8yrs of marital life)

Coital History - 2 times per week, Dyspareunia - absent


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Obstetrical History - G1P0A1

G1 - conceived with ovulation induction
A1 - spontaneous abortion within 46 days. (2018)
No any contraceptive history.

Treatment History

Table 1: History of treatment

2017Ovarian drilling (PCOD)
2018
January
February
March
June
August		Ovulation induction (failed)
Conceived
Spontaneous abortion
Ovulation induction
Pseudo Pregnancy
2019IUI (3 Cycles)
2020IVF (implant failed)
2020Siddha treatment

General examination

The patient was moderately nourished female.

Blood pressure: 120/80 mm/hg
Temperature: 98°F
Pulse: 84/min
Respiratory Rate: 19 cycles/min.

On Examination, Pallor, icterus was absent. Central cyanosis, digital clubbing and local lymph adenopathy was absent. General and localized oedema was absent.

Systemic examination

CVS: S1 S2 Normal.
CNS: Well oriented, conscious.
RS: Normal vesicular breathing, no added sounds.

Dashvidha Pariksha

Prakruti - Vata + Pitta
Vikruti - Vk
Sara - Mansa
Samhanana - Madhyama
Pramana - Madhyama
Satmya - Madhyama
Satva- Madhyama
Aahara Shakti - Madhyama
Jarana Shakti - Madhyama
Vyayama Shakti - Madhyama
Vaya - Madhyama

Investigation

USG pelvis (12/6/2023) - no significant findings.

TSH - 7.280mIU/ml (11/6/2023)
Prolactin - 78.62ng/ml
HbA1C - 6.02%

Male Partner - (Age - 41yrs, occupation - IT Engineer)

Semen analysis (23/9/2023)
Sperm count - 60million/cc
Active motility - 45%
Slow Progression - 30%
Non-motile - 10%
Morphology - Normal - 45%
Abnormal - 55%
Fructose - Present
Vitality - 75%

Treatment

Table 2: Internal medicine: (For 7days)

MedicineDose
Mahashankh Vati1 tab thrice a day (B/F)
Panchkola PaniyeWhile having thirst

Procedure

Table 3: Procedure details

DateProcedureDose
8/8/2023Snehapan Day 138ml
9/8/2023Snehapan Day 276ml
10/08/2023Snehapan Day 3114ml
11/08/2023Snehapan Day 4170ml
12/08/2023Snehapan Day 5230ml
13/08/2023Abhyanga and Bashpa SwedanaMahanaryana Taila
14/08/2023Abhyanga and Bashpa SwedanaMahanarayana Taila
14/08/2023Vaman KarmaMadanphala

Table 4: Discharge Medicines

MedicinesDose
Arogya Vardhini Vati1BD (After Food)
Phalasarpi½ tsp (Empty Stomach)
Sukumara Kashyam15ml BD with lukewarm water (Before food)

Observations

Table 5: Comparison Before Treatment and After Treatment

InvestigationsBefore Treatment (11/06/2023)After Treatment (18/08/2023)
Prolactin78.2046.38
TSH7.2805.55

Vamana Karma:

Koshta Assessment was done - Madhyam Koshta.


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Snehapan - Kalyanka Ghrita
Abhyanga - Mahanarayana Taila
Vamana Aushadh - Madanphala

Table 6: Follicular Study (1/9/2023): LMP - 22/08/2023

DayRt ovary
1/9/2023Dominant follicle (8mm)
4/9/2023 (14th day)Dominant follicle (14*14mm)
ET - 12mm
6/9/2023 (16th day)Dominant follicle - 1.7*2cm
ET - 12mm
8/9/2023 (18th day)Dominant follicle ruptured
ET - 12.2mm

Discussion

As stated in Sushruta Samhita, Dosha Dhatu and Mala are the main roots of the body, hence balance must be maintained to achieve a healthy state. All Dhatu are nourished by Jathragni, which generates the Ahara Rasa, which will nourish each Dhatu through the proper channel. Agnimandya may occur at any time as a result of Kaphakara Nidana, which increases Dhatugata Mala Sanchaya (Ama), which causes Srotorodha and impaired Dhatu. If there is Agnimandya of Rasa Dhatwagni, it vitiates its Ashraya (Rasa Dhatu) and Upadhatu (Artava).[5] In this present case, patient is present with the symptoms of Agnimandya along with Artava Dushti. Hence the patient is diagnosed with Artava Dushti with Rasavaha Strotodushti. According to Acharaya Charak, treatment principle for Rasavaha Strotodushti is Langhan Chikitsa[6] and Langhan includes 4 types of Shodhana Karma (Vaman, Virechan, Nasya, Basti), Pipasa, Maruta, Atapa, Pachana, Upavasa and Vyayam (according to the patient).[7] Agnimandya leads to the formation of Ama which is responsible for Strotorodha. So, the line of treatment for Strotoshodhan is Deepan, Pachan, Shodhan and Shaman Chikitsa.

Mahashankh Vati and Panchkola Paniya advised for the Deepana and Pachana before the procedure since assimilation of the drug is essential for it to perform its intended action, which might occur when Agni is optimal. Deepan Dravya given at the beginning of treatments enhances Agni by making the medicine available for it to accomplish the needed action. When the drug is administered after Deepan Dravya, the absorption at the cellular level increases, allowing Dravya to perform adequately.

Although Aama Dosha generates obstructions in physiological channels, Drugcannot reach its site of action; hence, a Pachan Dravya should be given first to release impediment generated by digesting Ama. To improve bioavailability of a medicine, Deepan and Pachana are first necessary.[8] Ghrit has actions of Yogvahi, Agnideepaka, Rasayana, Vrishya, Vata-Pitta Shamaka, and alleviates Kapha Dosha resulting from Samskaranuvartana. In Kalyanaka Ghrita majority of drugs are Kashaya, Katu and Tikta Rasa, Laghu and Ruksha Guna, Katu Vipaka, and Ushana Virya. These properties are Kapha-Vata Shamak, Deepan, Pachana, Vrishya, Rasayana, and Yoni Doshahara. Haridradvaya, Sarivadvaya, Ela, Talisa, Vidanga, Devadaru, Nirgundi, Amalaki, and other plants have Dipana, Pachana, and Amadoshanashak properties, which regulate Jatharagni, Dhatvagni, and Bhutagni, resulting in proper formation of Dhatus and Upadhatus (Artava) and Strotoshodhan by removing Ama.[8] Deepana and Pachana properties of Kalyanaka Ghrita clears channels of Manovahasrotas. The agitated mind can be controlled by pacifying Vata Dosha, thus administration of Kalyanaka Ghrita also helps in psychological factors.[9] Vaman Karma is effective in alleviating Kapha and Vata Doshas. Drugs with Kapha Vatahara, Ushna, Deepan Pachana, Rasayana and Vajikarana characteristics may be used to treat disease. Vamana Karma is having characteristics of Kaphavrit Agnimandya Janya Vyadhi Nashak, hence it may be effective in hypothyroidism and hyperprolactinemia. The prolactin and TSH levels were taken after one month of procedure (Vaman) which shows a remarkable reduction of values. Follicular study shows maturation, rupture of dominant follicle, and Endometrium thickness. Then patient was advised to take some medications for further management and pre-conceptual care.

Conclusion

Ovulatory factor is one of the major causes of anovulation. Endocrine disorders such as HPRL and hypothyroidism are well-known causes of infertility due to their inhibitory influence on gonadotropin production and can be managed by Ayurveda. In this present case, patient was treated with an initial round of counseling followed by Shodhana and Shaman Chikitsa which is proper utilization of Satwa-Avachaya Chikitsa followed by Yukti-Vyapasharya Chikitsa.


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3. Wdowiak A, Raczkiewicz D, Janczyk P, Bojar I, Makara-Studzińska M, Wdowiak-Filip A. Interactions of Cortisol and Prolactin with Other Selected Menstrual Cycle Hormones Affecting the Chances of Conception in Infertile Women. Int J Environ Res Public Health. 2020;17(20):7537. doi:10.3390/ijerph17207537. PMID: 33081268; PMCID: PMC7588978.

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5. Sharma VB, Padhar BC, Meena HM, Mathur SK. Efficacy of Vyoshadi Guggulu and Shadushana Churna in the management of subclinical hypothyroidism: An open labelled randomized comparative pilot clinical trial. AYU. 2022;41:181-7.

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7. Kashinatha Sastri PT. Charaka Samhita of Agnivesha. Sutra Sthana. 1st ed. Varanasi: Chaukhambha Sanskrit Pratishthan; 2011. Ch. 22, Ver. 18. p. 427.

8. Singh Y, Ansari A, Singh V, Parhate S, Sharma RP, Singh TR. Therapeutic potential of Kalyanaka Ghrita (polyherbal-medicated Ghrita) in purview of Alzheimer’s disease: A literary review. J Drug Res Ayurvedic Sci. 2023;8:201-12.

9. Ramana GV, Yadav B, Gupta HK, et al. Clinical Evaluation of Kalyanaka Ghrita in the Management of Cognitive Deficit in Children. J Res Ayurvedic Sci. 2019;3(3):85-91.

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