“ CLINICAL STUDY ON APRAJA VANDHYA (PRIMARYINFERTILITY) BY AN INDIGENOUS COMPOUND W.S.R TO           OVULATORY DYSFUNCTION...
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,                        BANGALORE         NKJ AYURVEDIC MEDICAL COLL...
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,                         BANGALORE.           NKJ AYURVEDIC MEDICAL ...
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,                        BANGALORE        NKJ AYURVEDIC MEDICAL COLLE...
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,                        BANGALORE        N.K.J. AYURVEDIC MEDICAL CO...
DEDICATED TO  My Father and MotherLate   Shri. Siddappa.B.Bagali               and   Smt. Gurubai.S.Bagali
ACKNOWLEDGEMENT        With The blessing of Shri Siddharoodha Mahaswamiji. I wish to record mygratitude towards the revere...
I am thankful to Dr. Bandeppa.S Head of the Department, Dr. PraveenSimpi & Asst Mohan Reddy, Channappa of Rasa shastra & B...
I offer my sincere thanks to all the staff member of N.K.J AMC College SriBagali, Sri Ramesh, Sri Kaddi, Sri Chandrakant, ...
LIST OF ABBREVIATIONSRV            -   RigvedaAV            -   AtharvavedaAH            -   Ashtang HrudayaAS            ...
LIST OF ABBREVIATIONSFSH      =   Follicular Stimulating HormoneLH       =   Luteinizing HormoneGnRH     =   Gonadotropin ...
ABSTRACT       Primary Infertility with a correlation to Apraja vandhya is one of the commongynecological problem faced in...
TABLE OF CONTENTS                                                                 PAGE No.1)              INTRODUCTION    ...
LIST OF TABELS                                                                        Page Table No.                      ...
Page Table No.                         Name of the Table                                                                  ...
Page Table No.                         Name of the Table                                                                  ...
LIST OF FIGURES Figure No.                     Name of the Figures   Page No.Figure No. 1   Internal Structure of ovary   ...
LIST OF GRAPHS Graph No.                         Name of the Graphs                       Page No.Graph No. 1   Distributi...
Graph No.                 Name of the Graphs   Page No.Graph No 17 Over all Result of Group B               110 
Introduction                                              INTRODUCTION          Existence of the human race revolves aroun...
Introduction  problem of female infertility is more serious than the problem male infertility in themale dominating societ...
Objective of the study                                 OBJECTIVE OF THE STUDY     1. To assess the efficacy of Ayurvedic r...
Review of Literature                                       AYURVEDIC REVIEWHISTORICAL REVIEW :         History of any part...
Review of Literature  PURANA KALA.          In Padma Purana it is mentioned that a woman having one child is called as"Kak...
Review of Literature  VANDHYATVA AS A DISEASE :          We does not find unequivocal description of Vandhyatva in any of ...
Review of Literature                                 DISEASE REVIEW(AYURVEDIC)VYUTPATTI:Vandhya:          The word "Vandhy...
Review of Literature  (1) Vandhya - Vandhya refers to incurable congenital or acquired abnormalitiesresulting into absolut...
Review of Literature  (3) Vataja                                                  (4) Pitaja(5) Kaphaja                   ...
Review of Literature  functioning Vayu and normal psychological status (happy mood) are also essential.     Summarizing th...
Review of Literature  (2) Astartava Dusti:      Acharyas have mentioned that Astartava Dusti if remains untreated or notpr...
Review of Literature  Clinical features21:(1) Vataja Artava Dusti: The Artava Vitiated by Vata is Red, black or dark viole...
Review of Literature  also the features of Vata and Pitta Dosas.(8) Mutra Purisa Gandhi Artava Dusti : The Artava vitiated...
Review of Literature            In Sushruta Samhita, the Garbhotpatti has been compared with the AnkurUtpatti and it has b...
Review of Literature  Beejadusti 27          During antenatal period if mother takes Vata Prakopaka Ahara and Vihara, theV...
Review of Literature  Aticharana 32&33          Susruta explained that Aticharana yonivyapada is cause due to excessivesex...
Review of Literature  (Praja) hence; it is also termed as Apraja.          Summarizing all those references, it can be sta...
Review of Literature  Vimargagamana, among these Sanga may be explained by three ways,(1) The substance to be produce is l...
Review of Literature  place having kha vaigunya. Here the khavaigunya is in artavavaha Srotasa specially inthe beejagranth...
Review of Literature       shukra & artava & yonyarsha etc                   to be done. The acharyas have mentioned     u...
Review of Literature  externally applied drugs are in the form of nasya, abhyanga & basti. Whereasmedicines to be taken or...
Review of Literature  2. Paste of sweta-girikarni, sweta-gunja, sweta-punarnava with cow’s milks.3. Paste of roots of swet...
Review of Literature  2. Tila taila, milk, phanita, curd and ghee churned and mixed.3. Entire seeds of one matulunga pound...
Review of Literature                                         MODERM REVIEW                      FUNCTIONAL ANATOMY OF OVAR...
Review of Literature  (2) Tunica albuginia : This layer of eosinophilic collagenous connective tissue oflow cellularity un...
Review of Literature  ESTABLISHMENT OF OVULATION:         The ovary probably first sheds an ovum (ovulation) about the tim...
Review of Literature  OVULATION :         Ovulation is the process by which an ovum, in the form of secondary oocyte,is di...
Review of Literature  way to the surface of the ovary, easily piearcing the tunica albaginea. It thus arrangesitself so th...
Review of Literature  many seconds if not minutes during which the ovum, still surrounded by a coronaradiata of variable t...
Review of Literature  increased by the action of LH.Changes during Luteal phase : Just after the ovulation profound change...
Review of Literature  Hormonal control :         The cyclical production of FSH and LH in the adult woman is itself largel...
Review of Literature  of the luteal phase in the ovary and are brought about by progesterone acting in theabsence of estro...
Review of Literature  ovulation. This property is known us spinnbarkeit. The mucus absorbs water and saltsand when allowed...
Review of Literature  (B) Temperature changes : The body temperature shows variations during follicularphase, luteal phase...
Review of Literature  Table. No 1: Showing Method Day of cycle Observations         Method                     Day of cycl...
Review of Literature  ANOVULATION         Anovulation is a very common problem that present in a variety of clinicalmanife...
Review of Literature  hypothalamic activity of corticotrophin - releasing hormone(CRH), a response tostress. these patient...
Review of Literature  ABNORMAL ESTROGEN CLEARANCE AND METABOLISM :         The clearance and metabolism of estrogen can be...
Review of Literature  LOCAL OVARIAN CONDITIONS :         A follicle can fail to grow and ovulate because of inadequate exp...
Review of Literature  9. While directing a decline in FSH levels, the mid-follicular rise in estradiol exerts a    positiv...
Review of Literature                               DISEASE REVIEW (MODERN)                                            INFE...
Review of Literature       •   After puberty & before maturation. ( fertility is low until the age of 16-17         years)...
Review of Literature           Generally,        failure     to     ovulate      is    associated       with      amenorrh...
Review of Literature      chlamydial or tuberculoses in nature        (b) Partial - loss of cilliary function.4) Uterine F...
Review of Literature  6) Vaginal Factors         Purulent discharge - This is doutful cause of infertility because spermat...
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Clinical Study On Apraja Vandhya (Primary Infertility) By An Indigenous Compound W.S.R To Ovulatory Dysfunction, Bagali, C S, POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA, N.K.J. AYURVEDIC MEDICAL COLLEGE & PG CENTRE, BIDAR. 2009

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  1. 1. “ CLINICAL STUDY ON APRAJA VANDHYA (PRIMARYINFERTILITY) BY AN INDIGENOUS COMPOUND W.S.R TO OVULATORY DYSFUNCTION” By Dr.Smt.BAGALI.C.S A dissertation submitted to theRajiv Gandhi University of Health Sciences, Karnataka, Bangalore . In partial fulfillment of the requirements for the degree of AYURVEDA DHANVANTARI- M.S. (AYURVEDA) In PRASUTI TANTRA & STREE ROGA Under the guidance of Dr. Susmita Priyadarshinee Otta M.S (P.T.S.R) POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA N.K.J. AYURVEDIC MEDICAL COLLEGE & PG CENTRE, BIDAR. 2009
  2. 2. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA Certificate by the guide This is to certify that the dissertation entitled “ Clinical Study on AprajaVandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatorydysfunction” is a bonafide clinical research work done by Dr. Smt Bagali C.S.in partial fulfillment of the requirement for the degree of M.S. (Ayurveda) inPrasuti Tantra & Stree Roga. Signature of the Guide Date : ________ Dr. Susmita Priyadarshinee Otta MS(P.T.S.R.) Asst.Prof. Dept.of Prasuti Tantra & Stree Roga Place : BIDAR NKJ Ayurvedic Medical College & PG Centre Bidar – 585403 Karnataka.
  3. 3. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE. NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR. POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA Endorsement by the HOD, Principal/Head of the institution This is to certify that the dissertation entitled “Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction”” is a bonafide clinical research work done by Dr. Smt Bagali C.S. under the guidance of Dr. Susmita Priyadrashinee Otta, Asst. Professor, Post Graduate Department of Prasuti Tantra & Stree Roga, N.K.J Ayurvedic Medical College & P.G. Centre, Bidar. Seal and signature of the HOD Seal and signature of the Principal/Dean Prof.Dr.L.V.RATHNAKAR.A Prof. Dr.K.V.L.N. ACHARYULU M.D,(K.B)(B.H.U) M.D (SIDDNTA)NKJ Ayurvedic Medical College & PG Centre NKJ Ayurvedic Medical College & PG Centre Bidar – 585403 Bidar – 585403 Karnataka Karnataka Date : _________ Date : _________ Place : BIDAR . Place :BIDAR .
  4. 4. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE NKJ AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA Declaration by the candidate I here by declare that this dissertation/ thesis entitled “Clinical Study onApraja Vandhya (Primary Infertility) By an indigenous compound W.S.R toOvulatory dysfunction”is a bonafide and genuine research work carried out by meunder the guidance of Dr.Susmita Priyadarshinee Otta, M.S. (P.T.S.R) Asst. Prof.PG Department of Prasuti Tantra & Stree Roga.Date : _________ Signature of the candidate Dr. Smt.Bagali C.S.Place : BIDAR
  5. 5. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE N.K.J. AYURVEDIC MEDICAL COLLEGE AND PG CENTRE, BIDAR POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA Copyright Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall declare the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/ research purpose. Date : __________ Signature of the candidate Dr. Smt. Bagali C.S. Place : BIDAR
  6. 6. DEDICATED TO My Father and MotherLate Shri. Siddappa.B.Bagali and Smt. Gurubai.S.Bagali
  7. 7. ACKNOWLEDGEMENT With The blessing of Shri Siddharoodha Mahaswamiji. I wish to record mygratitude towards the revered President. His Holiness Sri Shivakumar Swamiji forhis mangnanimous support. I owe a special debt of gratitude to my guide Dr.Susmita PriyadarshineeOtta M.S (PTSR) Assistant Professor, Post Graduate studies in Prasooti Tantra forher scientific advice, constructive suggestions, constant encouragement & kindcooperation throughout my period of research work. “A good suggestion says the first word of everything.” I will feel short of my duties if I fail to acknowledge Prof. Dr PrabhaSharma,M.D,PhD( B.H.U)former H.O.D Dept of Prasooti Tantra ,who helped me inselecting the topic guided me in clinical work . I am extremely grateful to my teacher Dr. L.V Rathnakara Professor & Headof Department of P.G studies in Prasooti & Streerooga & Koumara Bhritya N.K.JA.M.C. P.G Center Bidar for his timely help. I wish to external my heartiest thanks to the Principal Prof Dr.K.V.L.N.Acharyulu & vice Principal Dr. P.V.Savanur N.K.J.Ayurvedic medicalCollege & P.G Center for providing the necessary facilities in the college forconducting research work. I express my thank to Dr. V.S Patil Medical Director of N.K.J.Ayurvedicmedical College & P.G Center for his advise and momentary support. I humbly express my indebtedness to Dr. Shankar Deputy MedicalSuperintendent & staff of Shri Siddharoodha Charitable Hospital for their help.
  8. 8. I am thankful to Dr. Bandeppa.S Head of the Department, Dr. PraveenSimpi & Asst Mohan Reddy, Channappa of Rasa shastra & Bhaisajya kalpana DeptN.K.J A.M.C Bidar for their constant guidance in the preparation of medicine for theclinical study. Any amount of thankfulness will be in adequate for all the faculty members &of my Department namely Dr.Sridevi Swamy, Dr.Sheela Halli, & Dr.ManishaBhandari for providing all possible guidance & support. I am very thankful to Dr. T.P.Sahu M.D (Dravya Guna) for his expertguidance in identifying the plant Shivalingi. I express my gratitude & regards to Dr. Y.P.Shamarao, Dr.Murthy,Dr.Kotur, Dr.Mulimani, Dr.Tripathy, Parmeshwar Bhat & Dr.Halli. For theirtimely advice. I am deeply indebted to Sri M.Suranagi Ph.D(Statistics) Asst ProfVeterinary College Bidar for his valuable help, co-operation & guidance in dataprocessing. In addition to this I am also very grateful to my batch mates or Dr.Vivek,Dr.Pradeep, Dr.Mahesh, Dr.Gourish & Junior Dr.Joyti. H& Departmental Seniors& Juniors for their mental support which enabled me to complete the dissertation. My special thanks to my friends Dr.Jayasheela Goni, Dr.VandanaGaliyawar & Dr.Anita Murki for their support. I extend my gratefulness to library staff of N.K.J AMC Mr. Kadam,Mr. Rajkumar &Smt. Saku Bai for their help & co-opration during my researchwork.
  9. 9. I offer my sincere thanks to all the staff member of N.K.J AMC College SriBagali, Sri Ramesh, Sri Kaddi, Sri Chandrakant, Sri Reddy, and Sri Gururaj.For their help & co-operation on during my study. I cannot forget my brother Sri Bhimashankar Bagali & Nephew Kr.Sagar& Sri Ravikant Bagali and sisters Smt. Sharada, Smt Shobha, Smt Manjula fortheir incessant love and who always act & a source of energy to me in this world ofuncertainty. I express my deep sense of love & gratitude to my husband Dr. Anil. KBagalkoti & my beloved son Chi. Prateek & others family members who efficientlyshouldered my responsibilities for fulfilling the dissertation work. Last but not least. I express all sense of gratitude to my well wishers andpatients who helped me directly or indirectly throughout the study. Place :- BIDAR.Date: - Dr.Smt. Bagali.C.S
  10. 10. LIST OF ABBREVIATIONSRV - RigvedaAV - AtharvavedaAH - Ashtang HrudayaAS - Ashtang SangrahaBP - Bhava PrakashB.R - Bhaishajya RatnavaliBRN - Bhava Prakash NighantuCha. S. - Charaka Shareer sthanaCha.Chi - Charaka Chikitsa sthanaD.N. - Dhanvantri NighantuHa.S - Harita SamhitaKas.S - Kashyapa Samhitakalp kalpasthanKas.S - Kashyapa SamhitaSiddhi SiddhisthanaM.N. - Madhava NidhanaN.A - Nighantu AdarshaRN - Raja NighantuSha. S. - Sharangdhar SamhitaSu. S . - Sushruta SamhitaSu.Sha - Sushruta SharisrsthanaSu.Su - Sushruta SutrasthanaSu.Utt - Sushruta UttarsthanaYR. - Yoga Ratnakara
  11. 11. LIST OF ABBREVIATIONSFSH = Follicular Stimulating HormoneLH = Luteinizing HormoneGnRH = Gonadotropin Releasing HormoneCRH = Corticotrophin Releasing HormoneTSH = Thyroid Stimulating HormoneIGF-II = Insulin like Growth Factor-IIIUCD = Intra Uterine Contraceptive DevicesPID = Pelvic Inflammatory DiseaseSCMCT = Sperm Cervical Mucus Contact TesthMG = Human Menopausal GonadotrophinPCR = Polymerase Chain ReactionUSG = Ultra SonographyHSG = Hystero Salpingo GraphyHCG = Human Chorionic GonadotrophinLUF = Luteal Unrupturad FollicleMg = MilligramMm = MillimeterNg = Nanogram 
  12. 12. ABSTRACT Primary Infertility with a correlation to Apraja vandhya is one of the commongynecological problem faced in daily practice. The most common cause of infertility is ovulatory disorder characterized byanovulation or by infrequent & / or irregular ovulation. Menstrual disorder likeoligomenorrhoea or complete amenorrhoea usually indicates ovulatory disorders. 30 patients being diagnosed as primary Infertility according to inclusion &exclusion criteria where divided in to two groups of 15 each. Group A where treated with Indigenous Compound Ghanasatwa. Group B where treated with placebo drug. The entire patients were assessed clinically, pathologically & sonographicallyat the end of each cycle & finally the results were analyzed statistically beforetreatment & after each cycle & at the end of three cycles. Finally the effectiveness of the trial drug was assessed 84.85% in theInfertility. During the treatment no side effect was observed.KEY WORDS Infertility, anovulation, apraja vandhya, shivalingi, putramjivaka. 
  13. 13. TABLE OF CONTENTS                        PAGE No.1) INTRODUCTION 1-32) OBJECTIVES 33) REVIEW OF LITERATUREa. Historical Review 4-6b. Ayurvedic Review 7-23c. Modern Review 24- 56d. Drug Review 57-764) CLINICAL STUDYa. Material & Method 77-81b. Observation 82-1105) DISCUSSION 111-1176) CONCLUSION 1187) SUMMARY 119-1208) BIBLIOGRAPHY 121-1239) REFERENCES 124-12810) ANNEXUREa. Research Case Performa
  14. 14. LIST OF TABELS Page Table No. Name of the Table No.Table No. 1 Showing method day of cycle observation 35Table No. 2 Showing 30 Patients According to Age. 83Table No. 3 Showing 30 Patients According to Marital Status. 84Table No. 4 Showing 30 Patients According to Occupation. 85Table No. 5 Showing 30 Patients According to Socio Economic Status. 86Table No. 6 Showing 30 Patients According to Educational Status. 87Table No. 7 Showing 30 Patients According to Infertility Duration. 88Table No. 8 Showing 30 Patients According to Menstrual History. 89Table No. 9 Showing 30 Patients According to Bleeding Duration 90Table No.10 Showing 30 Patients According to Interval Period. 91Table No.11 Showing 30 Patients According to Character of Bleeding. 92Table No.12 Showing 30 Patients According to Dysmenorrhoea. 93Table No.13 Showing 30 Patients According to Oligomenorrhoea. 94Table No.14 Showing 30 Patients According to Uterurine Position 95Table No.15 Showing 30 Patients According to Fornix 96
  15. 15. Page Table No. Name of the Table No.Table No.16 Showing 30 Patients According to Vaginal Discharge 97Table No.17 Statistical Analysis of Dysmenorrhoea in Group-A 98Table No.18 Statistical Analysis of Dysmenorrhoea in Group-B 98Table No.19 Comparison between Dysmenorrhoea of two groups. 99Table No.20 Statistical Analysis of Oligomenorrhoea in Group-A 99Table No.21 Statistical Analysis of Oligomenorrhoea in Group-B 100Table No.22 Comparison between Oligomenorrhoea of two groups 100Table No.23 Statistical Analysis of Bleeding Duration in Group-A 101Table No.24 Statistical Analysis of Bleeding Duration in Group-B 101Table No.25 Comparison between Bleeding Duration of two groups 102Table No.26 Statistical Analysis of Interval duration in Group-A 102Table No.27 Statistical Analysis of Interval duration in Group-B 103Table No.28 Comparison between Interval Duration of two groups. 103Table No.29 Statistical Analysis of Cervical mucus Viscosity in Group-A 104Table No.30 Statistical Analysis of Cervical mucus Viscosity in Group B 104
  16. 16. Page Table No. Name of the Table No. Comparisons between Cervical mucus viscosity Duration of 105Table No.31 two groupsTable No.32 Statistical Analysis of Cervical mucus Ferning in Group-A 105Table No.33 Statistical Analysis of Cervical mucus Ferning in Group-B 106 Comparisons between Cervical mucus Ferning of two 106Table No.34 groups. Statistical Analysis of Cervical mucus Spin Barkeit in 107Table No.35 Group-A Statistical Analysis of Cervical mucus Spin Barkeit in 107Table No.36 Group-B Comparisons between Cervical mucus Spin Barkeit of two 108Table No.37 groupsTable No.38 Statistical Analysis of Follicular study in Group-A 108Table No.39 Statistical Analysis of Follicular study in Group-B 109Table No.40 Comparisons between Follicular study of two groups. 109Table No 41 Overall Effect of Result 110
  17. 17. LIST OF FIGURES Figure No. Name of the Figures Page No.Figure No. 1 Internal Structure of ovary 24Figure No. 2 Musali 74Figure No. 3 Daruharidra 74Figure No. 4 Bala 74Figure No. 5 Palasha 74Figure No. 6 Dhataki 75Figure No. 7 Shivalingi 75Figure No. 8 Misreya 75Figure No. 9 Putranjeevaka 75Figure No.10 Prepared trial drug powder 76Figure No.11 Capsules of Ghansatwa 76
  18. 18. LIST OF GRAPHS Graph No. Name of the Graphs Page No.Graph No. 1 Distribution of patients according to Age 83Graph No. 2 Distribution of patients according to Marital Status 84Graph No. 3 Distribution of patients according to Socio-economic status 85Graph No. 4 Distribution of patients according to Education 86Graph No. 5 Distribution of patients according to Infertility duration 87Graph No. 6 Distribution of patients according to Menstrual history 88Graph No. 7 Distribution of patients according to Occupation 89Graph No. 8 Distribution of patients according to Bleeding duration 90Graph No. 9 Distribution of patients according to Interval period 91Graph No.10 Distribution of patients according to Character of bleeding 92Graph No.11 Distribution of patients according to Dysmenorrhoea 93Graph No.12 Distribution of patients according to Uterus position 94Graph No13 Distribution of patients according to Fornix 95Graph No14 Distribution of patients according to Oligomenorrhoea 96Graph No 15 Distribution of patients according to Vaginal discharge 97Graph No 16 Over all Result of Group A 110
  19. 19. Graph No. Name of the Graphs Page No.Graph No 17 Over all Result of Group B 110 
  20. 20. Introduction   INTRODUCTION Existence of the human race revolves around the women to whom is alsoassigned the name “Janani” because of her power to bring a new life in the universe.Women are the makers of the home, the nation and world. It is indeed the woman whoshapes the generation. Women is placed in a high position in society since the time immortal , butwhen a lady never conceives for some period it is a curse for her. She looses all hername, fame, faith & belief from family for being barren. This makes a gap in therelation. Motherhood is a great dream for a woman in her life, but when a couple isunable to initiate the reproduction after one year marital relations, they are said to beInfertile. Infertility is a major problem in our society. Now a days the rate of infertilityis steadily increasing, because of change of life style of human begins. People wants to lead luxurious life for that they are running behind the money& thus people get more stressed & tensed out at work. Delayed marriage, higher education & high ambitions are the cause forinfertility. Today’s life is very fast, the food habits are also changed, the intake of fastfood, junk food & adulterated food also impacts fertility. Infertility does not cause any serious effect on the body; the psychoneuroticupset resulting from infertility affects her physical as well as mental health. TheClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      1  
  21. 21. Introduction  problem of female infertility is more serious than the problem male infertility in themale dominating society of India. In Ayurveda we know four important factors are helpful in conception. Thatare Rutu, Kshetra, Ambu, Beeja ( Pumbeeja or sperm & stree beeja or ovum) are theimportant factors among all. With the help of modern techniques we are detecting thecondition of sperm & ovum. Now a day so many defects in these two may lead theinfertility, which needs correction & fruitful result. Defective ovulation is increasingday to day due to global warming, taking of synthetic food articles, stress & otherhormonal imbalance conditions. Statistical analysis shows in 40-60% of female infertility about 20% are due toovulation defect. The treatment of ovulation defects in general practice are mainly starts withhormonal treatment for ovulation, which has other side effects. In this clinical study anon-hormonal, herbal, safe remedy to treat menstrual irregulaties & ovulation defectis conducted. The observation, assessment & results were taken using modern &Ayurvedic techniques to study the efficacy of the trial drug & presented in the form ofthesis. Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      2  
  22. 22. Objective of the study   OBJECTIVE OF THE STUDY 1. To assess the efficacy of Ayurvedic remedy in the management of infertility 2. To conduct conceptual study of female infertility and to establish the correlation with Apraja vandhya (Primary infertility) Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  3  
  23. 23. Review of Literature   AYURVEDIC REVIEWHISTORICAL REVIEW : History of any particular subject enables us to understand the origin, progressand other aspects of that subject. Vandhyatva has been a long standing problem ofhuman community right from ancient period up to this modern era. If we think the antiquity of the Vandhyatva, we can see the praise of thewomen having children and slander of the barren women and the solutions to herbarrenness are also mentioned in the Vedas, Upanishadas and Puranas.VEDA KALA The Vedas are considered as most ancient literature available in the world.There are four vedas Rig-veda, Yajur-veda, Sama-veda, and Atharva-veda. Ayurvedais considered as the Upaveda of Atharva-veda. We find the references of Vandhyatva & its treatment even in Vedas, Puranas& Upanishadas. The oldest epic Rig-veda describes about the miraculous work ofAshwinee kumars, the divinely physicians, as it is written that Ashwinee kumarstreated infertile Badh-rimatee & she was blessed with a son named Hiranya Hasta1. In Atharva-veda Purandhriyosha is mentioned which means that when a manenters into Grihasthashrama he prays to God, & he wishes that his wife should be"Purandhriyosha"( pregnant). In this we find descriptions regarding conception byenchanting mantra.2&3. Mantras are also advocated to cure the Garbha dosha 4.Emphasis has been put on the herb Apamarga to procedure a male child 5Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction     4  
  24. 24. Review of Literature  PURANA KALA. In Padma Purana it is mentioned that a woman having one child is called as"Kaka Vandhya"6. In Brahma Purana, while explaining the importance of "Sri Krishna DurgaStrotra", it is said that a woman who as a Vandhya, Kakavandhya, Mrtavatsa orDurbhaga can conceive by reciting this strotra, within one year6.SAMHITA KALA Caraka and Vagbhata, have referred Vandhya due to abnormality of Bijamsaand mentioned as the Upadrava of Yoni Vyapada.7&8 In Sushruta Samhita, Vandhyatva has been described under the title ofVandhya Yonivyapada, which is included amongst twenty gynaecological disorders(Yoni vyapada) 9 In Kasyapa Samhita under the description of Jataharinis, he has mentionedone Puspaghni having useless Puspa and certain others characterised with repeatedexpulsion of foetus of different gestational periods 10 In Harita Samhita, Harita has described Vandhyatva as a disease, in eightyVatajaVyadhi. He has defined Vandhyatva as a failure to achieve a child rather thanpregnancy, because he has included Garbhasravi, Mritavatsa also under theclassification11 In Madhava Nidana, the types of Vandhyatva have been described12 InSarangadhara Samhita, Rasaratna Saumuccaya, Yoga Ratnakara and BhaisajyaRatnavali etc. have described some therapeutics of Vandhyatva.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction     5  
  25. 25. Review of Literature  VANDHYATVA AS A DISEASE : We does not find unequivocal description of Vandhyatva in any of theAyurvedic classics except Harita Samhita. But in Harita Samhita also, he has givenclassification only, no specific etiology or pathogenesis was explained. Vandhyatvaas a disease is only given by Harita while describing eighty Vataja Vyadhi. Whileother Acharyas has not considered it as a independent disease, rather a cardinalfeature of so many diseases. Apart from this they have not used word Vandhyatva, but it is the onlysymptom i.e.failure to achieve pregnancy, has been referred under various conditionslike coitus with old, young or diseased woman; coitus in abnormal posture, womanhaving diseased yoni or abnormality of Artava etc. In Kasyapa Samhita he mentioned that, the couple having number of childrenwith proper growth and development due to effect of nature (Savbhavat) or their owndeads (Svakarmaparinamat) are fortunate, otherwise should be treated, i.e. it will be adisease condition which needs Chikista. Acarya Harita in classification of Vandhyatva includes Garbhasravi, Mrtavatsaetc. From above references we can consider Vandhyatva as a disease. Vandhyatvamay be defined as the inability of a couple to achieve child rather than pregnancy bytheir Svabhava and Svakarma.      Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction     6  
  26. 26. Review of Literature   DISEASE REVIEW(AYURVEDIC)VYUTPATTI:Vandhya: The word "Vandhya" is derived from the root "Vandha" with Yak suffixwhich means barren, unproductive, fruitless and useless.NIRUKTI: rÉxrÉÉ aÉpÉïkÉÉUhÉ qÉÉaÉïÂmÉ oÉlkÉlÉÇ xÉÇmrÉÌiÉ xÉuÉlkrÉÉ | ( zÉ.Mü.SìÓqÉ 395) The woman in whom there is hindrance of any kind to the normal process of conception is VandhyaDEFINITION: A woman whose Artava is perished is called Vandhya9SYNONYMES: Vasa VIphala Nisphala Aprajashv Aparyasunyago Avatoka Avakesi Sravatgarbha AphalaCLASSIFICATION:Vandhyatva has been classified in the following ways according to differentAcarayas.Caraka Samhita: In Caraka Samhita, classification is not given but considering the references together it can be as follows:Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      7  
  27. 27. Review of Literature  (1) Vandhya - Vandhya refers to incurable congenital or acquired abnormalitiesresulting into absolute sterlity.(2) Apraja : Infertility in which woman conceives after treatment13(3) Sapraja : Sapraja is a condition in which woman in her active reproductive agedoes not conceive, after giving birth to one or more children.Harita : Harita has described six types of Vandhya11(1) Garbhakosabhanga - During childhood in case there is Garbhakosabhanga(injury to the uterus) and loss of Dhatus, woman never conceive.(2) Kakavandhya - one child infertility.(3) Anapatya - No child(4) Garbhasravi - Repeated abortion(5) Mritavatsa - Repeated still births(6) Balaksaya - Infertility due to loss of Bala.Rasaratna - Samuchaya : He classified Vandhyatva in nine types14(1) Adivandhyatva (2) Vataja(3) Pittaja (4) Kaphaja(5) Sannipataj (6) Bhutaja (7) Daivaja (8) Raktaja (9) AbhicarajaMADHAVA NIDANA:Madhavakara has described nine types of vandhya12.(1) Adivandhya (2) RaktajaClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      8  
  28. 28. Review of Literature  (3) Vataja (4) Pitaja(5) Kaphaja (6) Tridoshaja(7) Bhutaja (8) Daivaja(9) Abhicharaja. Avandhya--The word Avandhya suggest a childless woman, but capacity toconceive with quite delay ( Chakrapani). Kasyapa samhita The available portion of kashyapa samhita presents anunique chapter in its kalpa sthana as “Revati Kalpadhyaya". In this chapter thirtydifferent types of Revaties inflicting various disorders to females are described.NIDANA OF VANDHYATA In classics specific causitive factors of Vandhyatva are not given. To get thecomplete picture of Nidana, the subject matter from all related places are recapulatedhere. First of all we will see the factors responsible for fertility / conception. Acarya Susruta15 equating germination of seed with achievement ofconception quoted that if Ritu (period near ovulation i.e. Rtukala), bija (ovum andsperms), Ksetra (female reproductive system) and Ambu (nourishment) assembletogether the conception will definitely occurs. While Caraka16 quoted that when both male and female after observing theadvocated dietetic regimen and other mode of life and perform coitus and ejaculatedunvitiated sukra, passing through healthy yoni, reaches healthy garbhasaya and getsmixed with disease free sonita, then conception is definite. Vagbhata has given importance to Ksetra and Bija. while Vagbhata II17 hasemphasize that besides healthy Garbhashaya, Marga, Rakta (ovum), Sukra, properlyClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      9  
  29. 29. Review of Literature  functioning Vayu and normal psychological status (happy mood) are also essential. Summarizing the above description it can be said that for achievement ofconception, (1) Healthy and properly functioning female reproductive system (Yoni). i.e includes ovary, fallopian tubes, uterus, cervix, vagina. (2) Healthy sperms and ovum (3) Proper functioning Vayu (4) Normal psychology (5) Healthy partners (6) Proper nursing factor (7) Proper coitus (8) Healthy Diet When these factors are in favorable condition cause conception, but the diseasedcondition of any one or many of these factors cause Vandhyatva.18NIDANA OF VANDHYATVA W.S.R. TO ANOVULATION: Failure of the ovary to produce a matured ovum is anovulation. Menstrual cyclewithout having a mature ovum is called as anovulatory cycle, and is the main cause ofinfertility. Some conditions with their Nidanas, are available in classics, which seemsto be related with anovulation causing vandhyatva are being mentioned here: (1) Revati Jatharini (Puspaghni):10 Under the description of jatharinies Kasyapa has mentioned one Puspaghni, thewoman affected menstruates in regular interval, but is unable to conceive. The othersymptoms given are, she has corpulent and hairy cheeks.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      10  
  30. 30. Review of Literature  (2) Astartava Dusti: Acharyas have mentioned that Astartava Dusti if remains untreated or notproperly treated then it causes Abijata i.e. it is unable for Prajotpadana19. Susruta, just after describing eight disorders of Sukra, has enumerated eightdisorders of Artava. Dalhana has clarified that the clinical features of Artava are identical to thosefor Sukra. Both the Vagbhatas have expressed similar views20. Disorders of Artava have been classified by Susruta on the basis ofpredominance of Dosas and disorders of Sukra on the basis of main clinical feature.Actually there is no difference in both these, at one place (in Artava), the causativefactor has been given the importance and at other, the clinical features. Since all the classics have mentioned that Artava also exhibits similar clinicalfeatures of Sukra disorders of Artava are being given on the basis of description ofdisorders of Sukra.Classification of Artava Dusti:(1) On the basis of Causative Dosa (a) Vataja (b) Pittaja (c) Slesmaja (d) Raktaja (e) Vata Pittaja (f) Pitta Kaphaja (g) Vata Kaphaja (h) Tridosaja(2) On the basis of specific clinical features (a) Vataja (b) Pittaja (c) Kaphaja (d) Kunapa Gandhi (e) Granthi - Bhuta (h) Putipuya (i) Kshina and (j) Mutrapurisa Tulya orMalatulyaClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      11  
  31. 31. Review of Literature  Clinical features21:(1) Vataja Artava Dusti: The Artava Vitiated by Vata is Red, black or dark violet incolour. Thin dry, frothy and scattered. It is excreted slowly and with pain speciallyperforating or piercing type pain.(2) Pittaja Artava Dusti: The Artava vitiated by Pitta is –Yellowish or bluish in color. It is free from unctuousness, smells like pus, fungusblood or has putrid smell. At the time of excretion is hot, associated with severeburning and feeling of heat.(3) Kaphaja Artava Dusti : The Artava vitiated by Kapha is - Whitish or slightly yellowish in colour mixed with Majja. It is too much thick,slippery or lubricous, unctuous and settles down if put in the water.(4) Kunapa Gandhi Artava Dusti : The Artava vitiated by Rakta - It smells like a dead body. Artava discharged more and red like fresh blood. Itis also associated with heat and burning etc. features of Pitta.(5) Granthibhuta Artava Dusti : The Artava vitiated by Vata and Slesma - It has clotted appearance associated features are of both the dosas (pain due toVata and unctuousness due to Kapha etc.(6) Putipuya or Puya Artava Dusti: The Artava vitiated by Pittakapha- Putipuya means it is putrid and purulent. It is characterised with other featuresof Pitta and Kapha (burning, fever, heat due to Pitta and heaviness etc. due to Kapha).(7) Ksina Artava Dusti: The Artava vitiated by Pitta and Vayu - It is scanty, less in quantity and delayed. Associated with pain in Vagina andClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      12  
  32. 32. Review of Literature  also the features of Vata and Pitta Dosas.(8) Mutra Purisa Gandhi Artava Dusti : The Artava vitiated by Tridosa- It smells like urine and feces.Nidana of Artavadusti 22 Authors have not described any specific etiology of these Astartava dusti. Butas it is similar to that of Sukra Dusti. We can correlate Sukradusti Nidana with itscausative factor in some extent. (1) Viharajanya - Excessive sexual indulgence, untimely sexual congress,sexual abstinence, sexual congress with an unresponsive woman, supression of thenatural urges. (2) Aharajanya - Habitual use of unwholesome diet, habitual use of dry bitter,astringent very saltish, acid or hot articles. (3) Other - Owing to old age, worry grief or lack of mutual confidence, injuryby weapons, caustics or fire, owing to fear, angry, black magic, emaciation due todisease, vitiation of body elements. Due to this Nidanasevana, the Dosas get provokedeither sinlgy or collectively and reaching the (Retovaha Sira) Rajovahi sira, soon theyvitiate the (semen) Artava excessively. In classics Sudhaartava has been told as one of the essential factor for theconception, complete growth and development of the foetus along with its normal fullterm birth. In the quotation as given in the vitiated Artava has been mentioned as oneof the main cause of infertility. This means that if the Artava (Bahipuspa,menstruating blood) is vitiated by the Dosas then there will be no production of Bija(Antapuspa, ovum).Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      13  
  33. 33. Review of Literature   In Sushruta Samhita, the Garbhotpatti has been compared with the AnkurUtpatti and it has been mentioned clearly that the Artava of a woman vitiated by thederanged Vata, Pitta, Kapha or Rakta either singly or in combination of two or moreDosas, should be likewise considered as unfit for the purpose of fecundation. In modern science the menstrual phenomenon and the ovulation are correlated.In many ovarian dysfunctions the menstrual pattern get disturbed. In Kasayapa Samhita some Nidanas are given for Artava Dusti.23(1) Use of Nasya during menstruation.(2) Consumption of excessive not eatables and drinks.(3) Use of excessive medicines for Sodhana purpose to the woman of Mrdu Kosthahaving received Snehana and Svedana.Avarana24 In the concept of Artavanasa both Susruta and Vagbhata has described thatboth Vata and Kapha when aggravated, obstruct the path, thus Artava is destroyed.Though Artava is not finished completely however it is not discharged monthly. Acarya Kasyapa has defined clearly the bad effect of Tiksna Virecana in aperson having Mrdukostha. According to him, due to this, Vata is aggravated andcauses Svasa, Kasa etc. along with Bijopaghata in case of female. Vata mainly ApanaVata responsible for all type of abnormalities25Artava Vaha Srotasa Viddhata 26 According to Acarya Susruta the trauma on the Artava Vaha Srotasa causeanovulation and is the cause of infertility.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      14  
  34. 34. Review of Literature  Beejadusti 27 During antenatal period if mother takes Vata Prakopaka Ahara and Vihara, theVata get aggravated and spoil the Beeja or Beejabhaga or Beejabhagavayava infemale child and that in turn results in the congenital abnormality of female genitalorgans which is termed as Vandhya in Caraka Samhita Sarira Sthana and Sandhi Yoniin Cikistasthana by all acharyas.Dietic habit23 Due to Ati Usna Annapana, Virya, Artava, Beeja become Upachita. Use ofexcess hot water & diet accumulation (maturation / formation) of retas( semen) asrk(ovum) & egg ( implantation) get vitiated.Yonivyapada : Acarya Caraka mentioned that Yoni (reproductive system) of woman whenafflicted with Dosas or diseases, causes, Apatyavighata, does not retain Sukra andGarbha, i.e. become infertile. Also causes Upadravas like Gulma, Arsa, Pradara andother Vata disorders, Stambha and Sula28&29 Some specific Yonivyapada related to Vandhyatva. W.S.R. to Anovulation.Acharana yonivyapada30&31 Dalhana mentioned that in this disease the woman is hyperexcited duringcoitus than the man or she feels excessive itching and therefore fertilization also notoccurs. Madhava Nidana, Bhavaprakasa and Yogaratnakara also mentioned the samedescription.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      15  
  35. 35. Review of Literature  Aticharana 32&33 Susruta explained that Aticharana yonivyapada is cause due to excessivesexual act and she doesnot retain the Beeja. While commenting Dalhana quotes that iswoman does not achieve conception.Putraghni / Jatagni 34&35 The aggravated Vata due to predominance of Ruksa property, repeatedlydestroy the foetus. Dusta Sonita is also a causative factor which was given by Susrutaalso in different manner as "Raktasansravat".Suska 36 Only Adhamalla has mentioned Nasta Artava as the onlysymptom of SuskaYonivyapada.Vamini 37 All Acharyas mentioned that the disorder, in which Sukra (sperm) only oradmixed with Raja, is expelled with or without pain within six to seven days of itsentry into uterus is termed as Vamini.Vandhya 9 Susruta defined the Vandhya Yonivyapada with the absence of Artava.Sandhi yonivyapada : It is explained in Bijadustijanya Nidana.Asrja or Apraja38 Acharya Caraka, only explain that due to aggrevation of Rakta and Pitta, thereis bleeding even after achievement of conception. Chakrapani in addition commentsthat excessive bleeding leads to abortion, thus the woman remains without progencyClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      16  
  36. 36. Review of Literature  (Praja) hence; it is also termed as Apraja. Summarizing all those references, it can be stated that the Nidana ofYonivyapada given by Acharyas can be taken as the Nidana of Vandyatva and alsofor the anovulation causing Vandhyatva(1) Aharaja Nidana - Mithyaahara, Dustabhojana(2) Viharaja Nidana - Mithyavihara Coitus with Ruksa, Durbala, Bala, Excessivecoitus, Use of foreign bodies for sexual organisms(3) Pradusta Artava -(4) Beeja Dosa i.e,. Abnormalities of sperm or ovum(5) Daiva - unknown or idiopathic factor39 Thus etiologies of Vandhyatva can be boldly categorized under 4 headings asspecified by the classics. Though we find number of reasons for Anovulation they gono,where beyond these four Vyapaka Nidana.SAMPRAPTI 40 The Vyadhijanaka, Vyapara is called as Samprapti. In detail, the manner inwhich the vitiated dosa diffuses in the body to liberate the disease is known asSamprapti. It is also called Jati and Agati41. Susruta, while explaining Vyadhiformation specify the "Kha Vaigunya" "Kha" means the Akasa or Avakasa and theAvakasayukta Bhava (organ) of Sarira are Srotasa42 Srotasas play very important role because no substance in the body can growand develop or waste and atrophy independent of Srotasa. The general causes of Srotodusti given by Charaka are related to Dosa andDhatu43. Also the general Srotodusti Laksanas are Atipravrtti Sanga. Siragranthi,Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      17  
  37. 37. Review of Literature  Vimargagamana, among these Sanga may be explained by three ways,(1) The substance to be produce is less.(2) The production is normal but the channel is small3) Or the channel may be obstructed. Vagbhata stated the importance of Agni in Roganirmana. The Agni and Amaare interrelated. Also the normal or vitiated state of Dosa depends on Agni. TheSamprapti of Vandhyatva W.S.R. to Anovulation begins with the various factorsexplained under Nidana and ends up with Anovulation which is the main cause for thesymptomatology of Vandhyatva.SAMPRAPTI GHATAKA:Dosa - Tridosa with predominant VataDhatu - Rasa, RaktaUpadhatu – ArtavaSrotasa - ArtavavahaSrotodusti - SangaUdbhavasthana - Pakvasaya (Mulasthana of Vata)Adhisthana - Yoni & GarbhasayaMarga - Abhyantara (Garbhasaya as Kosthanga) The specific etiological factors mentioned previously cause provocation ofvata, pitta and kapha. Vata the main dosa vitiates with its own causative factors also.vata on account of its quality of subtleness (suksmatvata) is really the impeller ofother two humours. Vitiated vata agitates the other two humors and throw them in theClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      18  
  38. 38. Review of Literature  place having kha vaigunya. Here the khavaigunya is in artavavaha Srotasa specially inthe beejagranthi. Due to nidana sevana, dosa and agni get vitiated, mandagni is the main causeof ama formation. The ama formed executes hazardous effects, it adhers to srotasaand forms avarodhatmaka dusti. Ama spreads throughout the body, propelled by thevitiated vata along the rasavaha srotasa and in modern physiology, a variety oftransforming and transmitting substances present in the body like enzymes, hormones,catalyst etc. When these are unable to function properly entirely different metabolitesare formed which the body is not acquainted to process. These accumulated in thebody in different systems affecting the normal mechanism of that particular system.These may be formed as ama. Due to hypo functioning of jatharagni, dhatvagni mandya also occurs. Due tomandagni and nidanasevana, rasa, rakta dhatu get vitiated. Also the dhatvagnimandyacauses the ksayatmaka effect on the artava i.e. the production of artava, upadhatu ofrasadhatu or raktadhatu becomes less. Thus it is the Upadhatvatmaka dusti. Visvamitra has clarified that hair thin vessels fill the uterus for whole monthto receive bija and due to rasadusti posanatmaka dusti can cause Anovulation. The vitiated apanavayu and kapha when get mix can cause avaranatmaka dusticausing Anovulation. The vitiated Vata along with Pitta causes the artavaksaya i.e.ksayatmaka dusti causing Anovulation.Line of treatment:1. Treatment of specific causes responsible for infertility such as treatment of all the Gynecological disorders including injury to the uterus or its prolapsed, diseases ofClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      19  
  39. 39. Review of Literature   shukra & artava & yonyarsha etc to be done. The acharyas have mentioned unequivocally that pregnancy occurs only in case of healthy reproductive organs.2. For saking of different etiological factors such as abnormal diet and mode of life, coitus before or after ritukala, psychological trouble etc.3. Use of strength producing and brumhana articles to compensate the loss of bala and dhatus.4. After using oleation, sudation, emesis, purgation, astapana & anuvasana basti in consecutive order, the man should be given milk and grita medicated with sweet drug and oil & masha to the women according to the opinion of some authors. Kashyapa said that after using cleansing measures ie panchakarma both the partners should be prescribed congenial diet.5. Infertile woman should be prescribed with emesis, purgation & astapana basti, with the help of these procedures the woman conceives positively and delivers normally.6. The use of basti in infertility due to diseases of vata is highly beneficial. By the use of basti the yoni becomes healthy & even a sterile woman would conceive. The basti is beneficial to the woman having repeated abortions, short lived & weak children who are delicate & indulge daily in coitus.7. The drugs prescribed for pumsavana karma can also be used.Specific treatment: The drugs prescribed for gynecological disorders to be used to eradicate thecauses of infertility, but there are certain recipes were described by our ancient rishiswhich are indicated for achievement of conception by an infertile woman. They wereadvocated in various forms. Some of them are used externally& some internally. TheClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      20  
  40. 40. Review of Literature  externally applied drugs are in the form of nasya, abhyanga & basti. Whereasmedicines to be taken orally is numerous.• Nasya(nasal instillation):-1. Lakshmana triaturated with cow’s milk.2. Amulet of root of lankakara lakshamana tied round the neck & nasya of lakshamana triaturated with cow’s ghrita.3. Narayana taila.4. Shatapushpa taila.• Abhyanga (massage)1. Narayana taila.2. Shatapushpa taila.• Basti (enema) Narayana taila. Shatapushpa taila. Lasuna taila. Shatapaka taila. Trivrita sneha. Bala taila. Shatavaryadi anuvasana. Guduchyadi Rasayana. Sahacharyadi yapana. Mustadi yapana. Shatavryadi Rasayana. Jeevantyadi anuvasana.• Drugs for oral use:Kalka:1. Paste of chandana, ushira, manjista,girikarni & sugar candy mixed with cow’s milks.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      21  
  41. 41. Review of Literature  2. Paste of sweta-girikarni, sweta-gunja, sweta-punarnava with cow’s milks.3. Paste of roots of swetarka in milk or Paste of sweta-girikarni or sweta-agrikarni in milk.4. Paste of triphala, girikarni, aragvadha, vatsaka, payasa in cow’s milk.Churnas:1. Baladhy churna, chandanadya churna, drakshadya churna, khandakadya churna, & punarnavadya churna.2. Shatapushpa kalpaSwarasa or juices:1. 8 leaf buds of vata, lakshmana & cow’s milk.2. Bala, sharkara, atibala, madhuka, leaf buds of vata, gajakeshara mixed with honey, milk & ghee.3. Root of lakshmana (taken in pushya nakshatra) & pounded with milk by a virgin.4. Root of kuranta flowers of dhataki leaf buds of vata & neelotpala triturated with milk.5. Parswa pippala with jeeraka & white visikha punkha.Kwath (Decoction)1. Maharasnadi Kwatha2. A woman having taken bath after menstruation, if uses milk medicated with decoction of Ashwagandha in the morning hours, definitely conceives.Pana1. Lakshamana with milkClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      22  
  42. 42. Review of Literature  2. Tila taila, milk, phanita, curd and ghee churned and mixed.3. Entire seeds of one matulunga pounded with milk.Gutika (Tablets)1. Yogaraj GugguluTaila (Oils) Narayana Taila Shatavari taila Baladya taila Satapusphpa tailaGhritas Laghuphala ghruta Phala ghruta Kamadeva ghruta Paniya kalyanaka ghruta Seetakalyanaka ghruta Brihat shatavari or Shatavari ghruta Kashmaryadi ghruta Jeevaniya Ghana siddha gruta Shatavaryadi ghruta Lasuna ghrutaAristas1. Dashamoola AristaRasa aushaddhi1. Khandakadya LouhaPaka1. Puga paka Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction      23  
  43. 43. Review of Literature   MODERM REVIEW FUNCTIONAL ANATOMY OF OVARYOVARY:The ovaries are paired sex glands or gonads in female. Each gland is oval in shapeand pinkish grey in colour measuring 4 x 2.5 x 1.5 cm. one on each side near the freeend of the fallopian tube, hanging from the broad ligament by a fold of peritoneumcalled mesovarium. They are richly supplied with blood vessels and nerves. Fig no. 1 Internal Structure of ovaryHISTOLOGY OF OVARY :There is no organ in the female body which show so much histological variations atdifferent phases of life i.e. childhood, puberty, pregnancy and menopause. Ovaryconsists of the following six elements :(1) Germinal epithelium: It is outmost covering by a single layer of cuboidal cells,continuous with the peritoneum, derived from the coelonic epithelium. It is the parenttissue from which the primitive graffian follicles develop.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  24  
  44. 44. Review of Literature  (2) Tunica albuginia : This layer of eosinophilic collagenous connective tissue oflow cellularity under germinal epithelium.(3) Stroma: It is a connective tissue network continuous with the tunica albuginia andcontaining spindle shaped cells with a few involuntary muscle fibers. It supports theessential ovarian tissues and carries blood vessels, lymphatics and nerves.(4) Vesicular follicles or Graffian follicle : Small Islands of cells in various stages ofdevelopment are scattered mostly at the peripheral part of the ovary. These immatureones are called as the primordial follicles. The central cell is the ovum. The remainingcells surround the ovum in a single layer forming a sort of capsule.(5) Corpus luteum : When the graffian follicle ruptures corpus luteum develops onthe remnants of the ruptured follicle.(6) Interstitial cells : Groups of polyhedral cells containing lipid granulesrepresenting stored active principle. They develop the stroma cells or from the cells ofthe unruptured follicles.FUNCTIONS OF OVARY : The ovaries have two functions, Exocrine function i.e. the production of ova(ovulation) and Endocrine function i.e. the production of hormones. The latter is secondary to the former and is present to a limited extent for afew years before regular ovulation is established and for some time after ovulation. Both these functions are controlled through the hypothalamic - pituitaryovarian axis by endocrine, paracrine and autocrine pathways.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  25  
  45. 45. Review of Literature  ESTABLISHMENT OF OVULATION: The ovary probably first sheds an ovum (ovulation) about the time of the onsetof menstruation, but ovulation is not usually established as a regular phenomenonuntil 2-3 years after the menarche. It than continues until the age of 45-50 years,although it may get less frequent and less regular after the age of 40 years. Ovulation occasionally precedes the establishment of menstruation andsometimes occurs even after the cessation of menstrual period. This accounts for therare cases of pregnancy reported to have occurred before the menarche and after themenopause. Lipshutz Law of follicular constancy, according to the law the ovulation ismaintained every month even if one ovary is removed.THE NUMBER OF OVA IN OVARY : In embryonic life period, in yolk sac, primordial germ cells originate in theendoderm and ovary is formed by genital ridge. Oogenesis begins in ovary - 6-8 weeks gestation Formation of oogonia - 16 to 20 weeks gestation Transformation of oogonia to oocyte - 11 to 12 weeks gestation. Here the oocyte enter the 1st meitotic phase and arrest in prophase. The primary oocyte at birth in both ovary - 2 millions The primary oocyte in both ovary at puberty - 3,00,000 to 5,00,000 From this number of primary oocyte, not more than 500 are destined to mature during the individuals lifetime and the remainder will be lost by some form of generative process.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  26  
  46. 46. Review of Literature  OVULATION : Ovulation is the process by which an ovum, in the form of secondary oocyte,is discharged from the ovary to become a gamete.PROCESS : In the ovarian cycle, which occupies approximately 28 days, ovulation takesplace at the midphase, having follicular and luteal phase before and after theovulation. The two phases are separated by ovulation.Changes during follicular phase : In this phase the ovum is prepared for ovulationby follicle ripening, primordial follicle grows to graffian follicle. The commencementof ripening of a follicle is heralded by an increase in size of the ovum and of itsnucleus. The surrounding granulose cells become cuboidal and multiply quickly tobecome many layered. At the same time, they begin to secrete liquor follicule, whichform small pools separating groups of cells. These pools later run together to form asingle lake and the system becomes a graffian follicle. This cystic structure is lined byseveral layers of granulosa cells which are collectively called the membranegranulosa. The ovum is surround by a palestaining non-cellular porous area ofglycoproteins the zona pellucida. Between the ovum and zona pellucida is theperiviteline space. The granulosa cells immediately around the ovum constitute thecorona radiata outside the membrane granulosa, the layer of stromal cells, thecainterna and outside this again theca extrena. During the process of ripening, the graffain follicle, by asymmetricaldevelopment seen particularly in the form of a cone shaped theca interna, makes itsClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  27  
  47. 47. Review of Literature  way to the surface of the ovary, easily piearcing the tunica albaginea. It thus arrangesitself so that the discuss proligerous with the ovum lies on the side of the follicleadjacent to the peritoneal cavity. Thus in this stage the ovum is awaiting for releasefrom ovary in the form of a primary oocyte surrounded by granulosa cells. Follicular ripening does not take place at an even ratio throughout the earlier14 days and the major histological changes only appear within the last few hours ordays. An immature follicle is only 0.03 mm in diameter. A ripe follicle is 16-24 mmdiameter immediately before rupture, so it is visible to the necked eye.Maturation of the ovum : All the primary occyte in the ovary of a newborn baby are already in the earlystages of the meiotic division. The process becomes arrested in the late prophase stageand remains dormant until follicular ripening is established. In the midcycle, due to preovulatory LH surge, meiosis is resumed and iscompleted within the 35-45 hours prior to the ovulation. This first maturationdivision, during which the number of chromosomes in the nucleus is halved, results inthe formation of a secondary oocyte and a polar body. The latter comes to lie in theperivitelline space of the oocyte. The second division, which results in the oocytecasting off another polar body and the 1st polar body dividing into two, only occursafter the ovum is liberated and probably only after it is fertilized. During maturation, the ovum increases in a diameter from 0.2 to 0.1 mm andat the end its nucleus is off centre and displays a prominent nucleolus.Rupture of the follicle - ovulation : The word rupture implies an explosive or dramatic occurrence, but thedischarge of the ovum from the follicle is a comparatively gradual process occupyingClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  28  
  48. 48. Review of Literature  many seconds if not minutes during which the ovum, still surrounded by a coronaradiata of variable thickness, oozes out. The follicular fluid escapes with the ovumand occasionally slight bleeding takes place from the site of rupture. Ovulation usually occurs from 13th to 17th day (day 14th) of 28 day menstrualcycle. It occurs 14 days before onset of next menses irrespective of length ofmenstrual cycle (Knaus, 1934).Life time : Unless fertilized, the ovum survives only 12-24 hours and then disintegrates inthe tube without leaving any trace. Nevertheless ova have been recovered from thefimbria and from the lumen of the tube 2-4 days after ovulation, and from the uterus4-5 days after ovulation. Such if not already fertilized is probably degenerate orcertainly incapable of being fertilized.Causes of ovulation :(1) Ovulation occurs as a result of thinning and degeneration of the cyst wall, thisbeing associated with the production of proteolytic enzymes. The activity is enhancedby progesterone.(2) The progesterone induced mid-cycle rise in FSH also serves to free the oocytefrom its follicular attachments.(3) Plasminogen activators activate plasmin which generates active collagenaseleading to degeneration of the collagen in the cell wall, especially at the follicularapex or stigma.(4) Exit of the ovum may possible be encouraged by contraction of micromuscle cellspresent in the theca externa and the stroma. These being activated by prostaglandinswhich are said to be essential to follicle rupture and the ovarian content of which isClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  29  
  49. 49. Review of Literature  increased by the action of LH.Changes during Luteal phase : Just after the ovulation profound changes takes placein the wall of follicle. The cyst collapses and the lining cells undergo leuteinization, aprocess in which they enlarge by limbering fluid. Their bloatedness causes them tobecome closely packed and makes their nuclei look relatively small. Luteinization,which is brought about by enzyme action, affects both the granulosa layer (granulosalutein cells) and the theca interna (theca lutein cells), the latter being more prominentin the early stages and former in the later stages. The corpus luteum is 1-2 cm in diameter and projects from the surface of theovary. Some of the expansion is taken up by the layers of cells folding into the oldcavity and this gives the corpus luteum its characteristic crehatel shape on section.The mature structure has a yellow colour on naked eye examination because of thepresence of lipoids. In its early stages, the corpus luteum is grey or greyish yellow.Within 2-3 days of ovulation, the corpus luteum becomes supplied with blood vesselswhich grow down the core of each invagination from the theca interna. During thisprocess there is often a little bleeding into the cavity where the blood mixes andmakes the appearance red or orange, the corpus haemorrhagicum. The development is completed in 5 days during which time, it is alreadyfunctioning. Its activity is at a maximum during following 3-4 days, but when thereafter as degenerative changes commence 4-6 days before the near menstrual period. Degeneration is 1st made evident by the cells becoming vacuolated, there afterthey lose their staining capacity, colloid degeneration and fatty changes are described.But these are followed by hyalinization so that ultimately the corpus luteum isconverted into hyaline tissues, known as a corpus albicans. It is absorbed over thecourse of 6-12 months.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  30  
  50. 50. Review of Literature  Hormonal control : The cyclical production of FSH and LH in the adult woman is itself largelycontrolled by the ovarian cycle. This is by way of a feedback mechanism, whichoperates through the hypothalamus and which can be explained in a simplified formas follows. The discharge of FSH and a little LH from the pituitary, initiated by thehypothalamus, causes follicle in the ovary to ripen and secrete estrogen. It resultinghigh level of estrogen in circulation increases GnRH receptor concentration. A surgein GnRH accompanies the LH surge. A high level of LH induced ovulation andcorpus luteum formation with a consequent increase in the secretion of progesterone.Control of ovulation (pituitary ovarian relations) : The neurohormonal connections are again illustrated by the control ofovulation in certain animals such as rabit. In those follicular ripening proceedsspontaneously but ovulation only occurs as a result of coitus. This act by mechanicalstimulation of the cervix. From the cervix, nerve impulses travel through the spinalcord to the hypothalamic pituitary system which liberates LH to cause ovulation 18hours after the initial stimulus. In woman, ovulation ordinarily occurs independent ofcoitus and is spontaneous but this does not excludes the possibility that it maysometimes be determined by outside influence.Correlation of endometrial and ovarian cycles : By the end of, if not just before the onset of a menstrual period, a new follicleis beginning to ripen in the ovary; endometrial proliferation therefore occurs duringthe follicular phase in the ovary and is the direct result of a mounting estrogeninfluence. Ovulation marks the change over from the proliferative to the secretaryphase in the endometrium. Secretary activity and decidual reaction are manifestationsClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  31  
  51. 51. Review of Literature  of the luteal phase in the ovary and are brought about by progesterone acting in theabsence of estrogens. The Shrinkage of the endometrium menstrually coincides with commencingfailure of corpus luteum activity and is the direct result of the withdrawal, of thesupporting effect of estrogen and progesterone. For the practical purpose, in maturewomen regular menstruation means regular ovulation. Post menstrually the endometrium is only 1 mm thick where as at the end ofproliferative phase (i.e. 10 days after the end of menstruation the fourteenth day of thecycle), it measures 2-3 mm. In the periovulatory period it appears sonographically asa triple layer in the long axis of the uterus and is usually about 10-12 mm in diameter.In luteal phase endometrium loses both the hyperechogenicity and the triple layeredappearance.CHANGES DURING OVULATION :(1) Myometrial changes: The activity of uterine muscle increases with the estrogenstimulus of approaching ovulation, which is i.e. contractions are small and frequentand having limited response to oxytocis in the follicular phase.(2) Tubal changes : The muscles of the fallopian tube behaves like myometrium inthat it shows increased movement about the time of ovulation. This is an estrogeneffect as is the increased cilial activity at that time. These changes are timed to propelthe ovum towards the uterus.(3) Cervical changes : At the time of ovulation the secretion is so profuse that it maybe noticeable as a vaginal discharge the ovulation cascade. Under the influence ofestrogen, actively secreted mucus shows some characteristic features. The mucus willstretch into threads measuring more than 6.5 cm, and even 10-15 cm, at the time ofClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  32  
  52. 52. Review of Literature  ovulation. This property is known us spinnbarkeit. The mucus absorbs water and saltsand when allowed to dry, deposits crystals of sodium chloride and potassium chloridein a characteristic pattern which suggest the fronds of fern. All these special characters at this time make for its easy penetration byspermatozoa. With comparison to luteal phase i.e. after ovulation the position ofcervical spincter which is due to tone of muscles of the isthmus and internal os, is lesstighter and competent during (ovulation) follicular phase which is due toprogesterone.(4) Vaginal changes : It show histological changes in the vaginal epithelium, but theyare not clearly defined in tissue sections.DIAGNOSIS OF OVULATION : The following methods are available for diagnosis.(A) Analysis of symptoms during ovulation :(a) Cyclical bleeding : The occurrence of regular normal menstrual losses is strongpresumptive of monthly ovulation.(b) Ovulation pain (Mittelschmerz) : Many women feel some discomfort in thehypogastrium or in one or other iliac fossa for 12-24 hours just before or just afterovulation.(c) Ovulation bleeding or discharge (Mittelblut) : Some women experience a slightloss of blood or of mucus tinged with blood at the time of ovulation. This may beassociated with ovulation pain although each can occur independently.(d) Premenstrual mastalgia : Premenstrual pain and tenderness in the breasts is insome way related to corpus luteum action. So its occurrence is fairly reliable evidencethat ovulation has occurred during that particular cycle.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  33  
  53. 53. Review of Literature  (B) Temperature changes : The body temperature shows variations during follicularphase, luteal phase, pregnancy also. For this test to be of value it is essential for thetemperature to be recorded daily under standard conditions, before rising from bed inthe morning and before eating or drinking. The biphasic curve in the chart is evidence of ovulation as opposed toanovular menstruation and the thermal shift is a fairly accurate indication of the timeof ovulation.(C) Endometrial changes : By histological changes in the endometrium can diagnoseevidence of ovulation not the time of ovulation.(D) Changes in cervical mucus: The different effects of estrogen and progesteroneon the physicochemical properties of cervical mucus are utilized in the fern test. Afailure to demonstrate ferning during the premenstrual week, denote dominantprogesterone influence and suggest that ovulation has occurred. Also the amount andnature of cervical mucus shows the changes in preovulatory and ovulation stage.(E) Hormone assay : Ovulation can be reliably confirmed by an estimation of themid luteal phase plasma progesterone level i.e. 5-8 days after ovulation. A minimumof 6.5 ng/ml is taken to indicate ovulation.(F) Ultrasound : It has been used to describe ovarian and follicular characteristicsthroughout the cycle.(G) Direct observation : Recent ovulation can be diagnosed by the finding of anactive corpus luteum on inspecting the ovary during laparoscopy or laparotomy.OVULATION DETECTION METHODSClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  34  
  54. 54. Review of Literature  Table. No 1: Showing Method Day of cycle Observations Method Day of cycle Observation B.B.T Throughout cycle Secretary Endometrium Cervical mucus 12-14days 21-23days Nature Clear watery, thick viscid Spin barkeit 12-14 & 21-23 + - Fern pattern + - 12-14 21-23 Discreade cells Folded edges Vaginal Cytology 12-14 & 21-23days pyknotic nuclei inclumps. Background clear Background dirty Serum progesterone 8 & 21 On 8th < 1 ng/ml 21st > 6 ng/ml Follicular measurements Serial USG 12-14 approaching 20 mm Laparoscopy Secretary phase Recent corpus luteum seenClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  35  
  55. 55. Review of Literature  ANOVULATION Anovulation is a very common problem that present in a variety of clinicalmanifestations including amenorrhea, irregular menses and hirsutism. seriousconsequences of chronic anovulation are infertility & a greater risk for developingcarcinoma of the endometrium and perhaps the breast. The clinician must recognizethe clinical impact of anovulation and undertake therapeutic management of allanovulatory patients to avoid these unwanted consequences. Normal ovulation requires co-ordination of the menstrual system at all levels :a) central hypothalamic – pituitary axis,b) The feedback signals, andc) Local responses within the ovary. The loss of ovulation can be due to any one of assortment of factors operatingat each of these levels. the end result is a dysfunctional state, anovulation andpolycystic ovary.CENTRAL DEFFECTS The hypothalamic pituitary axis may be unable to respond, even if givenadequate and appropriately timed feedback signals. Normal pituitary ovulatoryresponse to the follicles steroid signals requires the presence of gonadotropinreleasing hormone (GnRH) pulsatile secretion within a critical range. Increasingintensity of GnRH suppression is associated with increasing dysfunction and achanging clinical presentation. A variety of problems such as stress and anxiety, borderline anorexia nervosaand acute weight loss after a crash diet, is associated with an inhibition of normalGnRH pulsatile secretion, the mechanism for this suppression of GnRH is excessiveClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  36  
  56. 56. Review of Literature  hypothalamic activity of corticotrophin - releasing hormone(CRH), a response tostress. these patients present more commonly with amenorrhea. However if GnRH isonly partially suppressed homeostatic pituitary – ovarian function is maintained, andthe patients will be anovulatory. Anovulation and polycystic ovaries have been reported to be more prevalentin women with epilepsy. This is another example of how any disruption of normalovulation. Specific clinical syndrome of central anovulatory dysfunction has beenrecognized hyper-prolactinemia. Increasing levels of prolactin can cause a woman toprogress through a spectum, beginning with an inadequate luteal phase to anovulationto the amenorrhea associated with complete GnRH suppression. A search forgalactorrhea and measurement of the prolactin level are important screeningprocedures for all women who are not ovulating normally.ABNORMAL FEEDBACK SIGNALS:LOSS OF FSH STIMULATION : In order to achieve recycling a nadir in blood sex steroid level must occur sothat the initial event in the cycle, the rise in FSH, can take place. Sustained estrogen atsuch a key movement would not permit FSH stimulation of follicular growth andmaturation and recycling would be threatened.PERSISTENT ESTROGEN SECRETION : The most common clinical example of anovulation associated with continuedsecretion of sex steroids is pregnancy. Persistent and elevated secretion of estrogencan be encountered rarely with an ovarian or adrenal tumor. In such a caseanovulation or amenorrhea may be present.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  37  
  57. 57. Review of Literature  ABNORMAL ESTROGEN CLEARANCE AND METABOLISM : The clearance and metabolism of estrogen can be impaired by otherpathologic condition, such as thyroid or hepatic disease. Both hyper-thyroidism andhypo-thyroidism can cause persistent anovulation by altering not only metabolicclearance but also the peripheral conversion rates among the various steroids. Whenhypo-thyroidism associated with elevated prolactin levels, demands screening of anovulatory and amenorrheic women with a thyroid stimulating hormone(TSH)measurement.EXTRAGLANDULAR ESTROGEN PRODUCTION : Extra glandular contribution to the blood estrogen level can reach significantproportions. This is accomplished by the extragonadal peripheral conversion of C-19androgenic precursors, mainly androstenedione to estrogen. Psychological or physicalstress may increase the adrenal contribution of estrogenic precursor. Adipose tissue iscapable of converting andostenedione to estrogen: hence the percent conversionincreases with increasing body weight. LOSS OF LH STIMULATION: A failure in gonadal production of estrogen need not be absolute, obviously,the patient with gonadal dysgenesis and ovarian failure will present with amenorrheaand infertility because of total lack of estrogen secretion. The failure to achieve acritical midcycle level of estradiol necessary to trigger the gonadotropin surge may bedue to a relative deficiency in steroid production.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  38  
  58. 58. Review of Literature  LOCAL OVARIAN CONDITIONS : A follicle can fail to grow and ovulate because of inadequate expression orimpaired function of any of the following local ovarian activities.1. Selection of the dominant follicle is established during days 5-7 and consequently peripheral levels of estradiol begins to rise significantly by cycle day 7.2. Derived from the dominant follicle , etradiol levels increase steadily and through negative feedback effect, exert a progressively greater suppressive influence on FSH release.3. Insulin like growth factor Ⅱ (IGF-II) is produced in theca cells in response to gonadotropin stimulation, and this response is enhanced by estradiol and growth hormone. In an autocrine action IGF-II increases LH stimulation of androgen production in theca cells.4. IGF-II stimulates granulose cell proliferation aromatizes activity, and progesterone synthesis.5. FSH inhibits IGF binding protein synthesis and thus maximizes growth factor availability.6. FSH stimulates inhibin and activin production by granulose cells.7. Activin, augments FSH activities :FSH receptor expression aromatization, inhibin /activin production, and LH receptor expression.8. Inhibin enhances LH stimulation of androgen synthesis in the theca to provide substrate for aromatization to estrogen in the granulose.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  39  
  59. 59. Review of Literature  9. While directing a decline in FSH levels, the mid-follicular rise in estradiol exerts a positive feedback influence on LH secretion. LH level rises steadily during the late follicular phase, stimulating androgen production in the theca.10. The positive action of estrogen also includes modification of the gonadotropin molecule, increasing the quality (the bioactivity) and the quantity of LH at mid- cycle.11. Inhibin and less importantly, follistain, secreted by the granulose cells in response to FSH : directly suppress pituitary FSH secreation.12. FSH includes the appearance of LH receptors on granulosa cells, and the final maturation of the follicle requires LH support.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  40  
  60. 60. Review of Literature   DISEASE REVIEW (MODERN) INFERTILITYInfertility:- in + fer + til + i + ti ( lack of ability to reproduce).Synonym:- Absolute: - Due to removal of genital organs like hysterectomy, radiation or oopherectomy, impossible to conceive.Partially: - Due to ill health conception does not occur till she achieve good health.Definition: - Infertility is defined as the inability of a couple to achieve conceptionafter one year of unprotected coitus.1) Sterility : Implies that inability to conceive. It is an absolute term.2) Infertility : Implies that failure to conceive. Infertility is again divided into twotypes i.e. a) Primary Infertility : Infertility where conception has not occurred. b) Secondary Infertility : The conception has failed to occur after a period of fertility.Incidence:- 10 to 15% of marriages prove to be childless. Fertility also varies from time to time in the same individual. In the male theseare not obvious except during childhood and less absolutely in old age, but in thefemale physiological infertility is seen. • Before pubertyClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  41  
  61. 61. Review of Literature   • After puberty & before maturation. ( fertility is low until the age of 16-17 years) because anovular cycle. • During pregnancy when ovulation is suppressed. • During lactation • Before the menopause • After the menopause. Conception rates also depend on many factors such as • The tendency for smaller families. • Elderly age at marriage. • Use of contraceptions for 1 or 2 years for carrier benefit • Changing life styles like DINK, SINK.Causes of Infertility The main etiological factor is found in Female 40%, Male 35%, Combined 10 to20%, Unexplained --05%.Female1) Ovarian factor (5%) In women menstruating regularly is a cause operating in about 15% of cases ofinfertility. Regular anovulation in menstruating women can be a feature ofhypothalamic anovulation, hyperprolactinaemia; other causes of anovulation includepituitary adenoma or primary hypothyroidism, polycystic ovaries, subclinical adrenalfailure and diabetes mellitus. Luteinized unruptured follicles & luteal phasedeficiency are two other clinical entities where infertility is seen.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  42  
  62. 62. Review of Literature   Generally, failure to ovulate is associated with amenorrhea oroligomenorrhoea and has the same causes. These include sex chromosomedisturbances premature ovarian failure due to premature menopause or resistant ovarysyndrome is also seen. Anovulation is also a feature of luteal phase deficiency and theluteinized enraptured follicle. Luteal phase defect can be short or long, but is more often the latter. There isdecreased hormone production by the corpus luteum as well as decreased levels offollicle stimulating hormone (FSH) and luteinizing hormone (LH). Some women havehyperprolactinaemia and hypothyroidism; others have unexplained infertility withnormal cycles, or habitual aborters.2) Peritoneal Factors:- 1. Pelvic adhesions:- 2. Defective ovum pickup: - May operate by preventing the tube performing its "octopus" function at the time of ovulation or by creating a mechanical barrier between the ovary & the tubal ostium. They result from pelvic peritonitis of any kind but especially that seen in association with appendicitis, and post abortal or puerperal infections. 3. Endometriosis:- Is seen in at least 15% of women investigated for infertility, if all grades are Considered.3) Tubal Factors Obstruction – (a) Complete - peritoneal & tubal factors may account for up to 35% of all cases of infertility. Partial or complete bilateral tubal obstruction results from previous salpingitis. Most commonly this is post abortal, puerperal, gonococcal,Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  43  
  63. 63. Review of Literature   chlamydial or tuberculoses in nature (b) Partial - loss of cilliary function.4) Uterine Factors • Uterine absence, congenital anomalies, septatet uterus, bicorn uterus, atrophy or hypoplasia at a degree sufficient to bar the ascent of spermatozoa causes amenorrhea as well as infertility. • Tubercular endometritis. • Intrauterine adhesions (Ashermans syndrome) due to previous overzealous curettage or previous surgery on the uterus • Submucous polyp, endometrial polyp • Uterine leiomyomas unresponsive endometrium, hypoplasia, devoid of secretary gland.5) Cervical Factors • Thick-impenetrable cervical mucus or poorly penetrable mucus • Presence of local sperm antibodies • To low PH of the mucus at mid cycle. • Loss of mucus due to amputation of the cervix, cone biopsies or overenthusiastic cervical diathermy. • Faculty direction of the cervix such as is found in retroversion or severe prolapse • Chronic cervicities.Clinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  44  
  64. 64. Review of Literature  6) Vaginal Factors Purulent discharge - This is doutful cause of infertility because spermatozoa can thrive in pus under in vitro conditions.COITAL ERRORS Apareunia & dyspareunia 1-2% of couple found not to have consummated their marriage due to fear ofpain during sexual act Frequency & timing of coitus Some couple never know the fertile period 72 hrs during ovulation is theperiod when conception takes place but due to lack of proper knowledge they missedto do coitus has to take place every 48 hours during the fertile period to offer theoptimum chance of conception Lubricants For easy sex act in dry vagina, or less lubricated vagina many couples uselubricants without realizing that these have a contraceptive action. [Proprietary jelliesare often acidic & therefore spermicidal]OTHER FACTORS Orgasm It is unnecessary for the woman to experience orgasm in order to conceive if itwere otherwise pregnancy would never result from rape. Effluvium Seminis Immediately after coitus most of the semen escapes from the vagina is knownClinical Study on Apraja Vandhya (Primary Infertility) By an indigenous compound W.S.R to Ovulatory dysfunction  45  

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