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Identifying Best Practice Diagnosis & Management of Male Infertility in Ayurveda

Identifying Best Practice Diagnosis & Management of Male Infertility in Ayurveda
Programme: MSc Ayurvedic Medicine Module: MSc Dissertation
Chris Gribble BSc. PG Dip Ayurveda

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    • Identifying Best Practice Diagnosis & Management ofMale Infertility in AyurvedaProgramme: MSc Ayurvedic MedicineModule: MSc Dissertation IPH4095Student Name: Chris Gribble BSc. PG Dip AyurvedaStudent Number: M00047552Supervisor: Dr Joshi M.D. Ph.D. (Ayurveda)Submission Date: Friday 4th May, 2007Abbreviations (Citations – Classical Authors)Classical Authors Book SectionsAH Aṣṭāñga hrdayam Ci cikitsasthanaBP Bhāvaprakāśā Ni nidanasthanaCS Caraka saṁhitā Su sutrasthanaSH Suśruta saṁhitā Uk uttara khaṇḍaSS Sārṇgadhara saṁhitāReference ExamplesCS Ci 2/4:5-6Refers to Caraka saṁhitā, cikitsasthana, 2nd chapter, 4th quarter: verses 5-6CS Su 17:63-72Refers to Caraka saṁhitā, sutrasthana, 17th chapter: verses 63-72© Chris St. Clair Gribble
    • AcknowledgementsThis paper acknowledges the support, guidance, and encouragement of the followingpeople.The study would not have been possible without the generosity of Dr. B. S Prasad whoallowed me to investigate the treatment of his patients, and was willing to share hisexpertise in such an open, honest and inspiring fashion.Thanks also to the Director of SDM College of Ayurveda & Teaching Hospital, DrPrasanna Rao, who allowed the study to take place, and ensured I got the support Ineeded. Thanks also to all the staff and interns at SDM College of Ayurveda & TeachingHospital, who assisted me in collecting and interpreting the case history data.And big thank you to my dear friends, Alison Packer, who provided me with a conduciveenvironment to write up the thesis and the sustenance to keep me going, and DeniseNaniche who provided me advice on statistical analysis.And finally a very big thank you to Dr Joshi, my academic supervisor, who has providedme continual support and encouragement in the pursuit of my ayurvedic studies.© Chris St. Clair Gribble
    • AbstractThis study explored the contemporary ayurvedic treatment of male infertility to identifybest practice diagnosis and a preferred list of medications. It also investigatedalternative treatment options for pathologies associated with male infertility. This workprovides newly qualified ayurvedic professionals a contemporary practice guideline toexplore in their own clinics, and makes recommendations for the research communitywith respect to exploring the effectiveness of the treatment strategies explored.The approach employed a retrospective case series analysis of 31 cases for patientstreated by a recognised expert. Qualitative analysis identified 46 preferred medicinescategorized against ayurvedic semen quality parameters which appear to havediagnostic value. Reference values are provided to enable their derivation fromallopathic semen data. The qualitative analysis has also identified ayurvedic options forvaricocele (grades 1-3). A further 6 herbs have been identified that warrantinvestigation, and this investigation recommends that future effectiveness studiesinclude radical purification therapies to identify the most beneficial treatment approach.The quantitative analysis of patient outcomes suggests that the treatment strategiesused improved semen quality of the patients. The sample population showed astatistically significant improvement in sperm count (P=0.025, 24.8%) and motility(P=0.002, 134.5%), but a non-significant improvement in morphology (P=0.248,17.0%). In relation to individual cases, this represented attainment of normal values for14.3% of cases, and an improvement in a further 42.9%.This study has not been able to investigate idiopathic male infertility or demonstrate theeffectiveness of the preferred medicines against their identified pathologies. This was aretrospective study constrained by its methodology, the available data, and a smallsample size. However, the evidence does suggest a positive improvement in response totreatment modality for the population as a whole. It has also provided valuableinformation to help in the design of future effectiveness studies and clinical audits.© Chris St. Clair Gribble
    • Table of Contents1 INTRODUCTION & STUDY AIMS ..................................................................... 12 LITERATURE REVIEW ................................................................................... 3 2.1 WHAT IS THE PROBLEM? .............................................................................. 3 2.2 WHAT ARE THE IMPLICATIONS OF THE PROBLEM?.................................................. 4 2.3 WHAT IS KNOWN ABOUT THE PROBLEM? ............................................................ 5 2.4 WHAT IS THE ALLOPATHIC RESPONSE TO MALE SUB FERTILITY? ................................. 7 2.5 WHAT IS THE AYURVEDIC RESPONSE TO MALE SUB FERTILITY? .................................. 8 2.6 WHAT IS THE RESEARCH QUESTION AND THE VALUE OF THIS STUDY? ........................ 263 METHODOLOGY ......................................................................................... 27 3.1 RESEARCH APPROACH, DESIGN & SETTING ......................................................... 27 3.2 ETHICAL APPROVAL .................................................................................... 28 3.3 SAMPLING APPROACH .................................................................................. 28 3.4 DATA COLLECTION ..................................................................................... 29 3.5 DATA ANALYSIS ........................................................................................ 32 3.6 CONSTRAINTS & LIMITATIONS ........................................................................ 344 RESULTS .................................................................................................. 34 4.1 SAMPLE DEMOGRAPHICS .............................................................................. 35 4.2 PRESCRIBED MEDICINES .............................................................................. 40 4.3 PREFERRED MEDICINES ................................................................................ 45 4.4 INDICATIVE TREATMENT RESPONSE .................................................................. 50 4.5 RESULTS SUMMARY .................................................................................... 545 DISCUSSION ............................................................................................ 546 CONCLUSION ............................................................................................ 647 REFERENCES ............................................................................................ 668 APPENDICES ............................................................................................. 73 8.1 BHĀVAPRAKĀŚĀ HERBS, FORMULATIONS, AND DIETETIC SUPPLEMENTS ........................ 73 8.2 SPEMAN (HIMALAYA COMMERCIAL FORMULA) ...................................................... 85 8.3 LITERATURE SEARCH STRATEGY ...................................................................... 85 8.4 MIDDLESEX UNIVERSITY ETHICAL APPROVAL ....................................................... 86 8.5 SDM HOSPITAL STUDY APPROVAL ................................................................... 87 8.6 DATA COLLECTION TEMPLATE - SEMEN ANALYSIS.................................................. 88 8.7 ALLOPATHIC SEMEN QUALITY REFERENCE DATA.................................................... 89 8.8 DATA TRANSFORMATION RULES ...................................................................... 89 8.9 AYURVEDIC SEMEN QUALITY REFERENCE DATA (SDM HOSPITAL) ............................... 90 8.10 DAŚAMŪLA HERBS ................................................................................... 91 8.11 PHYSICAL EXAMINATION (MALE INFERTILITY) ................................................... 91 8.12 CASE HISTORY TAKING (INFERTILITY)............................................................ 92 8.13 SYSTEMIC AYURVEDIC DIAGNOSTIC PARAMETERS (DIGESTIVE IMBALANCE) ................ 93 8.14 SYSTEMIC AYURVEDIC DIAGNOSTIC PARAMETERS (CHANNEL IMBALANCE) .................. 94 8.15 SYSTEMIC AYURVEDIC DIAGNOSTIC PARAMETERS (TISSUE IMBALANCE)..................... 95 8.16 MUSTĀDYA YĀPANĀ ENEMA......................................................................... 96 8.17 TRADITIONAL CHINESE MEDICINE (MALE INFERTILITY) ........................................ 97 8.18 GLOSSARY (AYURVEDIC TERMS) ................................................................. 100© Chris St. Clair Gribble
    • Table of FiguresTable 1 - Aetiology and Distribution (%) of Male Infertility ....................................... 5Table 2 - 8 Types of Seminal Morbidity ............................................................... 10Table 3 - Caraka Śukra Janana Herbs - Sperm Increasing ...................................... 14Table 4 - Caraka Śukra Śodana Herbs - Sperm Purification ..................................... 15Table 5 - Caraka Jīvana Herbs - Age Related Impotence ........................................ 15Table 6 - Caraka Vayasthapan Herbs - Seminal Dimunition..................................... 15Table 7 - Suśruta Muṣkadhī Herbs - Seminal Disorders .......................................... 16Table 8 - Suśruta Kaṇṭakī Pañcamūla Herbs - Seminal Disorders ............................. 16Table 9 - Suśruta Vallī Pañcamūla Herbs - Seminal Disorders.................................. 17Table 10 - Suśruta Āmalakyādi Herbs - Vrsha (Aphrodisiac) ................................... 17Table 11 - Suśruta Kākolyādi Herbs - Vrsha (Aphrodisiac) ...................................... 17Table 12 - Comparison of Caraka & Suśruta Herb Groups ....................................... 18Table 13 - Sārṇgadhara - Male Infertility Herbs .................................................... 18Table 14 - Allopathic Semen Quality Characteristics .............................................. 31Table 15 - Guiding Questions for the Consultant Interview ..................................... 32Table 16 - Allopathic Semen Quality Classification (Baseline) .................................. 35Table 17 - Allopathic Diagnosis Classification (Baseline) ......................................... 37Table 18 - % Allopathic Diagnosis Classification (Baseline) ..................................... 38Table 19 - Ayurvedic Diagnostic Parameters (Baseline) .......................................... 39Table 20 - % Types of Prescription ..................................................................... 40Table 21 - Number Prescribed Medicines - Vata Seminal Morbidity ........................... 41Table 22 - Number Prescribed Medicines - Non Vata Seminal Morbidity .................... 42Table 23 - Number Prescribed Medicines - Specific Clinical Action ............................ 43Table 24 - Number Prescribed Medicines - Common Fertility Related Pathologies ....... 44Table 25 - Medicines with Multiple Applications ..................................................... 45Table 26 - Preferred Medicines - Vata Seminal Morbidity ........................................ 46Table 27 - Preferred Medicines - Non Vata Seminal Morbidity .................................. 47Table 28 - Preferred Medicines - Non Vata Seminal Morbidity (Continued) ................. 48Table 29 - Preferred Medicines - Common Associated Pathologies ............................ 49Table 30 - Preferred Medicines - Common Associated Pathologies (Continued)........... 50Table 31 - Changes in Semen Count, Motility, and Morphology (End State) ............... 51Table 32 - % Change in Allopathic Semen Classification (End State) ........................ 52Figure 1 - % Distribution - Allopathic Semen Characteristics (Baseline) .................... 36Figure 2 - % Allopathic Diagnosis Classification (Baseline)...................................... 38Figure 3 - % Distribution of Ayurvedic Diagnostic Parameters (Baseline) .................. 40Figure 4 - % Type of Prescription ....................................................................... 41Figure 5 - % of Medicines with Multiple Applications .............................................. 45Figure 6 - Mean Change for Sperm Count, Motility, & Morphology (End State) ........... 52Figure 7 - Change in Ayurvedic Semen Parameters (End State)............................... 53© Chris St. Clair Gribble
    • 1 Introduction & Study AimsMale infertility is becoming a major concern both in developed and developing countries.In Europe 25% of couples do not achieve pregnancy within 1 year with 15% of thesepatients seeking medical treatment for their infertility (Dohle et al., 2005). In the past,the main focus of clinical investigation was the female partner. However, research hasshown that the male is solely responsible in 20% of cases and contributory in another30-40% (Thonneau et al., 1991). Further, over 50% of infertile males are classified ashaving idiopathic male infertility as there is no known cause for their reduced semenquality (De Kretser and Baker, 1999).As the pathology behind idiopathic male infertility is largely unknown there are fewtreatment options available. The few options that do exist i.e. assisted fertility are bothexpensive and invasive, move the problem from the male to the female, and are notreadily extensible to developing nations where medical resources are limited (Vayena,Rowe and Griffin, 2002). There are also emerging concerns for the health of IVFoffspring who have been shown to suffer more serious illness and hospitalisation thancontrols (Bonduelle et al., 2005).Given that allopathic medicine has limited treatment options for idiopathic maleinfertility, alternative systems of medicine warrant investigation. Ayurveda is theindigenous medical science of India that has been in continual practice for over 5000years. This field of medicine is recognised by the World Health Organisation (WHO) as amajor contributor to world health (World Health Organization, 2002).Ayurveda has a branch of medicine, vājīkaraṇa, that specifically addresses maleinfertility and all aspects of healthy reproduction. Śukra kashaya, or seminal diminution,is well described across most classical ayurvedic texts, and there is an extensive rangeof herbs and formulations provided.Although ayurveda provides a well described treatment option and extensivepharmacopoeia to treat the infertile male, there is little contemporary literature orclinical research to substantiate the effectiveness of the treatment approach or identifypreferred medicines or treatment approaches.© Chris St. Clair Gribble 1
    • A new student of ayurveda must rely solely on acquired clinical experience andobservational learning of successful treatment modalities. Observing best practice inthe UK is limited. Ayurveda in the West is still in its infancy, with limited residentexpertise, few patients seeking treatment and a limited subset of the pharmacopoeiaand treatment techniques that would be available in India & Sri Lanka.This situation presents several research questions and associated study aims:o To understand and document what constitutes best practice ayurvedic diagnosis of male infertilityo Identify the preferred ayurvedic herbs and formulations used to treat male sub- fertilityo Investigate if there are alternative ayurvedic options to treating common pathologies associated with male sub-fertilityo Explore the effectiveness of the ayurvedic treatment of male infertilityThis study retrospectively investigates the treatment of 31 male infertility cases, treatedat SDM College of Ayurveda & Teaching Hospital India, under the care of Dr. B. SPrasad, one of the few ayurvedic consultants specialising in male infertility treatment.This venue provided a rich environment to investigate best practice ayurvedic clinicaldiagnosis and treatment of the disease.The main value of the study will be in providing newly qualified ayurvedic professionalsa contemporary practice guideline for the diagnosis and treatment of male infertility. Italso makes recommendations for the research community regarding standards forevidence based medicine, and identifies herbs of therapeutic use that do not appear tohave been researched in the West.This paper first reviews the literature to more fully understand the implications of maleinfertility, to understand the contemporary theories behind its pathophysiology, and tooutline the treatment approach as prescribed by classical ayurveda. The literature isthen searched for any evidence to substantiate the use of the ayurvedic pharmacopoeia.Within this framework, the remaining sections explore the clinical setting and outline themethodology used to analyze the selected cases. The results of this analysis are thendiscussed in respect of the specified research aims and the contemporary literature.© Chris St. Clair Gribble 2
    • 2 Literature Review2.1 What is the problem?What is the prevalence of male sub fertility in the world today?Infertility is becoming a major concern both in developed and developing countries. It iscommonly accepted that infertility affects more than 80 million people worldwide, with 1in 10 couples experiencing either primary or secondary infertility. Infertility rates varyenormously among countries from less than 5% to greater than 30%. The highest ratesoccur in the developing countries, where there are few resources that could supportassisted fertility programs, and where there is often the highest cultural pressure on thefemale partner to conceive a child (Vayena, Rowe and Peterson, 2002).In Europe, 25% of couples do not achieve pregnancy within 1 year, with 15% of thesepatients seeking medical treatment for infertility (Dohle et al., 2005). Research hasshown that the male is implicated in over 50% of presenting cases (Thonneau et al.,1991).As women delay parenting, there is a corresponding decline in their ability to conceive.A woman in her 20’s has a 74% chance of conception. After the age of 31, her fertilityfalls 3.5% per year representing a 21.5% chance of conception by age 45 (Zaadstra etal., 1991). A man’s semen quality also declines with age. A systematic reviewinvestigating the effects of paternal age on semen quality showed decreases in semenvolume (3%-22%), motility (3%-37%), and morphology (4%-18%) comparing 30 yearolds to 50 year olds (Kidd, Eskenazi and Wyrobek, 2001). In addition, studies haveshown that in some countries and cities there is a decline in sperm count, whilst otherareas remain unaffected (Becker and Berhane, 1997). A decline in semen quality, eitherthrough age or geographical decline, further exacerbates a female’s reduced fecunditythrough delayed parenting. Consequently more men are now presenting with male sub-fertility.For those men presenting with male infertility, about 60% exhibit associated pathologiesknown to affect their semen quality. However, the remaining 40% are classified ashaving idiopathic male infertility where there is no known cause for their reduced semenquality (De Kretser and Baker, 1999). Idiopathic male infertility is prevalent both in© Chris St. Clair Gribble 3
    • developed and developing countries, and there are few treatment options available asthe cause is largely unknown.2.2 What are the implications of the problem?What are the main implications to male sub-fertility?The main response to male factor infertility has been in the field of assisted fertilitytechnology (ART). In vitro fertilization (IVF) was first introduced in 1978 to alleviatefemale factor infertility, and almost 2 million babies have been born through thistechnique. When IVF was applied in couples with male infertility the expectedfertilisation rate reduced significantly, and in 1992 the intracytoplasmic sperm injection(ICSI) was developed to introduce a single sperm directly into the oocyte (Oehningerand Kruger, 2006, p393).As a technique to address male factor infertility, ICSI moves the problem from the maleto the female partner who has to undergo an IVF procedure which is both invasive andexpensive. Even with vast improvements in technique, the success rate of IVF or ICSIremains less than 30%, and with such a low success rate it is doubtful the expensecould be justified in developing countries (Vayena et al., 2002).An emerging area of concern is the risk to the health of the offspring conceived usingART techniques. A systematic review of 25 studies between 1978 and 2002, involvingboth matched and unmatched cohorts, showed a significant increased risk of pregnancycomplications. For single births there was a significant increased risk of pre-termdelivery, low birth weight, small for gestational age, caesarean section, admission toneonatal intensive care, and perinatal mortality (Jackson, Gibson, Wu and Croughan,2004). Further, a multi-centre cohort study of the physical health of 5 year oldsconceived after IVF and ICSI show increased odds of congenital malformations of 2.77for ICSI and 1.8 for IVF children. These children were also more likely to have suffereda significant childhood illness, had a surgical operation, or required medical therapyinvolving hospitalisation (Bonduelle et al., 2005). The higher rate in ICSI was partlyattributable to an excess of male urogenital problems.Consequently, using ICSI for male factor infertility is not without its risks. And the risk isincreasing in Europe, as it is becoming apparent that conventional IVF is being replacedby ICSI, even when sperm parameters are normal (Andersen, Gianaroli, Felberbaum, de© Chris St. Clair Gribble 4
    • Mouzon and Nygren, 2006). However, ICSI does not address the underlyingpathophysiology behind either male factor infertility or sub fertility. Nor is the techniquea cost effective therapy for developing nations whose scarce medical resources mustaddress more primary health care needs (Andersen et al., 2006).2.3 What is known about the problem?How is male infertility classified, and what is known about the underlyingcause?Male factor infertility is classified according to the underlying causative physiopathology.Reduced male fertility can be the result of congenital and acquired urogenitalabnormalities, infections of the genital tract, increased scrotal temperature (varicocele),endocrine disturbances, genetic abnormalities and immunological factors.The aetiology and distribution (%) of male infertility among 7,057 men is summarised intable 1 below (Dohle et al., 2005).Table 1 - Aetiology and Distribution (%) of Male Infertility Aetiology (%) Sexual factors 1.7 Urogenital infection 6.6 Congenital anomalies 2.1 Acquired factors 2.6 Varicocele 12.3 Endocrine disturbances 0.6 Immunological factors 3.1 Other abnormalities 3.0 Idiopathic abnormal semen (OAT syndrome) i.e. no known cause 75.1From reviewing these statistics, varicocele, OAT syndrome and infection are the mainareas of clinical significance. This study also shows the highest proportion of cases(75.1%) have no known cause for their reduced semen parameters (idiopathic maleinfertility). The semen analysis of this group reveals a decreased number ofspermatozoa (oligozoospermia), decreased motility (asthenozoospermia) and manyabnormal forms on morphological examination (teratozoospermia). Usually, theseabnormalities present together and are described as the oligo-astheno-teratozoospermia(OAT) syndrome. These men present with no previous history associated with fertilityproblems and have normal findings on physical examination and endocrine laboratorytesting (Dohle et al., 2005).© Chris St. Clair Gribble 5
    • Little is known about the pathophysiology of idiopathic male infertility as theintroduction of ICSI removed any incentive to investigate the cause. However, recentstudies have shown that the spermatozoa of sub-fertile males exhibit both an impairedcapacity for fertilization and higher rates of damage to both mitochondrial and nucleargenomes. More significant is the finding that these higher rates of DNA damage arenegatively affecting both pregnancy and the health of the offspring. DNA damage hasbeen shown to reduce rates of fertilization, exhibit impaired pre-implantation embryodevelopment, increase rates of early pregnancy loss, and high rates of morbidity in theoffspring including dominant genetic disease, infertility and cancer (Oehninger andKruger, 2006, p257).In response to mounting health concerns, there is now a growing body of researchinvestigating possible mechanisms behind idiopathic male infertility. Male sub-infertilitymay be the result of several factors, such as chronic stress, endocrine disruption due toenvironmental pollution, reactive oxygen species (ROS) induced oxidative stress, andgenetic abnormalities. However, the dominant theory is that oxidative stress is theprimary cause of both defective sperm function and DNA damage in the spermatozoa(Henkel et al., 2005).The human spermatozoon is rich in unsaturated fatty acids which are susceptible to ROSchain reactions leading to a rapid loss of membrane dependent functions. Thelipoperoxidative potential of spermatozoa is closely correlated to impaired spermmotility and sperm-oocyte penetration (Aitken, Harkiss and Buckingham, 1993).Elevated levels of oxidative DNA damage have been observed in the spermatozoa ofinfertile men compared to fertile controls (Henkel et al., 2003). In studies of clinicallycharacterized samples, high levels of oxidative stress have been found in groups ofpatients exhibiting oligozoospermia, varicocele and unexplained infertility. The 2 mainsources of oxidative stress in the ejaculate are leukocytes, mostly neutrophils, and thedefective spermatozoa themselves. It is postulated that spermatozoa with highlipoperoxidative potential reflect defects in the underlying spermatogenesis process(Oehninger and Kruger, 2006, p261). The point at which the spermatozoa are exposedto the leukocytes reflects the resultant oxidative damage. Early exposure in the retetestes or epididymis is likely to have a deleterious effect. Later exposure is likely to beprotected by the powerful anti-oxidants in the seminal plasma (Aitken, West andBuckingham, 1994).© Chris St. Clair Gribble 6
    • Whilst varicocele is seen in 12% of sub fertile patients it is also observed in men whohave no fertility problems, and as such there is no conclusive evidence that varicocele isa major cause of infertility (Vernet, Rigaudiere, Ghyselinck, Dufaure and Drevet, 1996).However, it has also been shown that increased oxidative stress is present in theejaculate of varicocele patients (Agarwal, Prabakaran and Allamaneni, 2006).Natural protection against lipid peroxidation includes membrane associated antioxidantssuch as hydrophobic vitamin E, radical scavenging molecules such as vitamin C, uricacid, tryptophan and taurine, and mitochondrial and cytosolic antioxidant enzymes suchas superoxide dismutase. The detoxification of lipid peroxides occurs by glutathioneperoxidase within the presence of phospholipase A2 (Suleiman, Ali, Zaki, El-Malik andNasr, 1996). In addition, there are extracellular antioxidants present in the malereproductive tract such as glutathione peroxidase 5, and extremely large quantities ofsuperoxide dismutase (SOD) in the epididymal and seminal plasma (Vernet et al.,1996).Differences in patient susceptibility are thought to arise from individual variations in themolecular composition of the plasma membrane, the degree of ROS exposure during thespermatozoa life history, and level of protection afforded by free radical scavengers,chain breaking antioxidants, and ROS metabolising enzymes.2.4 What is the allopathic response to male sub fertility?So what is the allopathic treatment response to male sub fertility, and what arethe limitations?ICSI has been the main response which, as outlined, is invasive, expensive, and movesthe problem to the female partner. Emerging heath concerns for children born of IVFand ICSI have renewed interest to treat the underlying cause and not just circumventthe problem.Clearly, recent research has associated oxidative stress with defective sperm function,especially with respect to OAT syndrome, infection and varicocele. The researchsuggests that the origins of oxidative stress include leukocytic infiltration, excess freeradical generation from the spermatozoa, and defects in the antioxidant protectionprovided to cells.© Chris St. Clair Gribble 7
    • Based on this body of knowledge, antioxidant supplementation is being investigated asone rational therapy. In this respect a limited number of antioxidants (glutathione,lycopene, vitamin E) and sperm vitalizers (carnitine, CoQ10) have been shown to havesome therapeutic benefit (Kumar, Gautam and Gupta, 2006).But is oxidative stress actually cause or effect? More research is required to understandthe underlying causes behind excess ROS production in spermatozoa, defects inspermatogenesis, and why antioxidant protection mechanisms are compromised insome individuals. Antioxidant supplementation could be considered palliative, and adeeper understanding of the pathophysiology is needed in order to develop rationalapproaches towards prevention as well as treatment.Also little is understood of other major systems of medicine in terms of their owndefinition of the underlying pathophysiology, and treatment options available. Ayurvedicmedicine has a well described response to male sub-fertility. An integratedunderstanding across both allopathic and indigenous medicine may shed more light asto the causes of male sub-fertility, and provide a wider spectrum of therapeutic options.2.5 What is the Ayurvedic response to male sub fertility?What are the Ayurvedic causes of male sub-fertility?Ayurveda has a well documented disease called klaibya which means impotence orinfertility. The Sanskrit term literally translates as “all things which make a manincapable of copulation”.The classical description of this disease and its treatment starts with Caraka and is thenaugmented by the clinical experience of Suśruta, Aṣṭāñga Hridaya, Mādhava Nidānam,Sārṇgadhara and Bhāvaprakāśa, in chronological order.Caraka says that a patient who suffers from a reduction of semen suffers fromweakness, dryness of mouth, pallor, lassitude, exertion, impotency, and non -ejaculation of semen (Sharma, 2004, CS Su 17:63-72). This definition can be seen toencompass both functional and non functional impotence.Caraka provides two levels of klaibya classification. One specifically relates to seminalmorbidities and the other to various categories of impotence.© Chris St. Clair Gribble 8
    • Seminal MorbiditiesCaraka defines the primary cause for impotency as resulting from seminal morbidities.He indicates that any type of seminal morbidity can result in infertility. Thesemorbidities are said to relate to one of 14 factors that vitiate one or more bio-energies(vata, pitta or kapha), reach the seminal channels, and vitiate the semen. 1. Excessive sexual indulgence 8. Sex with non passionate women 2. Excessive physical exercise 9. Old age, worry, grief, low confidence 3. Intake of unwholesome food 10.Injury by instruments, alkalis (kṣāra) or 4. Untimely intercourse cauterization (agnikarma) 5. Sex other than through female genital 11.Fear, anger, and black magic tract 12.Emaciation from disease 6. Abstinence from sexual rapport during 13.Suppression of natural urges the appropriate time 14.Injury or vitiation of the tissue elements 7. Intake of foods excessively ununctous, bitter, astringent, saline, sour and hotHealthy or pure semen is defined as thick, sweet unctuous, without putrid smell, heavyslimy, non-irritating, white or transparent like a crystal, and in large quantity (Sharma,2004, CS Ci 2/4:50)o Semen vitiated by vata is frothy, ununctuous, thin and ejaculated with pain and small quantity. This type of semen is indicated to inhibit conception.o Semen vitiated by pitta is blue or yellow in colour, excessively hot and putrid in smell. There is also a burning sensation on ejaculation.o Semen obstructed by kapha is exceedingly slimy in character.o Semen mixed with blood results from excessive intercourse, ulcers, or injuryo Semen which is knotty (granthi) and sinks in water (avasādi) results from aggravated vata obstructing the semen through suppression of sex. This semen is ejaculated with difficulty.© Chris St. Clair Gribble 9
    • These various types of derangement are classified as 8 types of seminal morbiditiesidentified in table 2:Table 2 - 8 Types of Seminal Morbidity Ayurvedic Category English Translation Phenila Frothy semen Tanu Thin semen Rūkṣa Ununctous semen Vivarṇa Discoloured semen Pūti Semen with putrid smell Piccilla Slimy semen Anya-dhātu-saṁṣṣṭa Semen mixed with other tissue elements Avasādi Semen sinking in waterImpotenceCaraka next outlines the general symptoms of impotence as dyspnoea, perspiration,frustration, and lack of erection. However, his description also includes a systematicdescription of 4 major types depending on its chief causative factor.1. Bījopaghātaja klaibya is impotence caused by seminal diminution2. Dhvajabhaṅgaja klaibya is impotence caused by a non erectile phallus3. Jarāja klaibya is impotence caused by old age4. Śukra-kṣayaja klaibya is impotence caused by excessive loss of semen through sexual intercourse or masturbationThere is no substantive variation in the disease cause or its classification between theclassical authors. The most recent author, Bhāvaprakāśa (Murthy, 2001, BP Uk 1:2-10),defines seven types of male infertility:1. Psychological impotence2. Dietary impotence i.e. excessive pungent, sour, salty foods3. Excessive sex, loss of semen, or vilification therapy leading to non erection4. Abstinence5. Major diseases of the penis6. Rupture of semen channels resulting in non erection which was considered incurable7. Congenital or genetic impotence which was also considered incurable© Chris St. Clair Gribble 10
    • Clearly both these classical descriptions can encompass the various known pathologiesassociated with male infertility such as UTI, varicocele, hormonal dysfunction, testicularfailure, cryptorchidism, and karyotype disorders (Turek, 2005). More interestinglyayurveda recognizes diet and various behaviours and lifestyle factors as causes for maleinfertility.What is the Ayurvedic view of the underlying pathology of male sub-fertility?Clearly the classical authors have described two main areas of male sub-fertility alongwith their associated causes. They have described defects in the semen and seminalfluid which are treated by addressing the underlying energetic imbalance visible in theresultant pathology. They have also described a disorder of reduced seminal tissue asone of the 80 vata disorders.In ayurveda, health is defined as homeostatic balance of mind, bio-energies, digestionincluding metabolism, tissue formation, body channels both gross and minute, wasteproducts and immunity. Ayurveda considers disease not as a sudden onset, but as aprocess evolving in 6 sequential stages, causing functional and physiological imbalanceof these same factors.The body bio-energies are in continual flux trying to maintain homeostasis against bothendogenous factors arising from diet and lifestyle, and exogenous factors arising fromchanges in the environment. Disease arises when the body’s capability to maintainhomeostasis is exceeded for a sustained period of time.In ayurvedic physiology, Caraka says that the seminal fluid is derived from the bonemarrow. This bone marrow when heated produces an oily bi-product from which semenis produced. This semen is secreted through the pores of the bone marrow and pervadesthe whole body, eventually collecting in the testes (Sharma, 2004, CH Ci 15/32).In a similar fashion, Suśruta describes 7 anatomical layers, kala, each successivelydeeper within the body. The seventh kala is śukradharakala and is a unique concept. Itis said that śukra is spread all over the body just as fat is contained within milk. Hencesemen is present everywhere, not just in the seminal vesicles as identified in allopathicanatomy (Murthy, 2004, SH Sa 4:21-23).© Chris St. Clair Gribble 11
    • Fertility depends on more than semen produced in the testes. It also depends on thecirculating gonadotropic (luteinising and follicle stimulating) hormones which stimulatethe testes to produce testosterone that governs spermatogenesis, bone marrowdevelopment, and secondary sex characteristics. At puberty the red bone marrow isconverted to yellow fatty bone marrow which is a significant source of cholesterol, andcholesterol is the substrate for testosterone. In this sense the classical description ofśukra pervading the body may have some basis in modern endocrinology (Rao, 2005,p294).What constitutes best practice classical Ayurvedic treatment of male sub-fertility?Ayurveda has been in continual practice for over 5000 years. To answer the question asto what constitutes best practice treatment one has to answer several questions.o What has been classically defined as the optimal treatment for the disease?o What new formulations have been developed and how effective are they?o What evidence based clinical studies exist to guide treatment?o Is there any scientific evidence to support the ayurvedic therapeutics?Classical TreatmentThe basic principle of ayurvedic treatment is to assist the body to heal itself. Thetherapeutic principles of repletion and depletion both consist of a radical expulsion ofimbalanced energies and bio toxins (shodana) followed by conservation treatment(shamana).Shodana serves to expel the excess dosha (vata, pitta and kapha) out of the body usingone or more of 5 purification techniques called panca karma. Shamana or pacificationtreatment then balances the system through medicine, diet and lifestyle to restorehomeostasis and eliminate the disease (Singe, 2005).The classical texts define shodana as a pre-requisite for any shamana treatment ineither disease management or heath promotion. The saying goes that a dirty cloth mustbe cleaned before dye is applied. For any medicine to have its full effect, the bodyshould be suitably purified, and this therapy would constitute best practice.© Chris St. Clair Gribble 12
    • In this respect, Suśruta indicates shodana is applied to seminal disorders according tothe specific doshic involvement. This particularly applies to the easily curable disordersvitiated by a single dosha.Suśruta in his chapter on anuvasana-uttaravasti says that the use of 18 medicatedenemas (alternating 9 oil and 9 decoction enemas) cure all disorders of semen. The firstoil enema lubricates the urinary bladder and groins, the second mitigates vata in thehead, the third bestows strength and colour, the fourth, fifth, sixth and seventh, eighthand ninth lubricate plasma, blood, muscle, fat, bone and bone marrow tissues insuccession so that by the 18th enema all semen disorders are cured (Murthy, 2004, SHCi 37:71-74).He also specifically indicates that in all seminal disorders, each therapeutic action shouldbe followed by urethral injections (uttara-basti). This therapy is mentioned for bothvitiated semen and premature ejaculation (Murthy, 2004, SH Ci 37:125-126).Understanding what constitutes best practice herbs or dietetic supplements for malesub-fertility is more complex.Several ayurvedic terms pertaining to male sub-fertility and sexual dysfunction are usedin the classical literature. The terms are often used in their broadest sense, so it can bedifficult to understand the target action or morbidity for which a particular herb hasbeen indicated. A working definition is provided here, so as to enable correlation to anallopathic understanding of male sub-fertility.The following terms relate to the production of sperm and seminal fluid at the level ofthe testes and ancillary organs:o Vrsha (aphrodisiacs) promotes the quality of sperm and seminal fluid through the correct functioning of the body and mind. Vrsha is the metabolic strength contained in the blood, the quality of its resultant tissue, and strength of orgasmic control that leads to this high quality sperm and seminal fluid.o Śukrajanna (sperm promoting) refers of actual spermatogenesis and the development of the spermatozoa. Substances which are sukrajanna increase sperm count.© Chris St. Clair Gribble 13
    • o Śukra pravartana (increasing flow) refers to increasing the fluidity and volume of semen. It is the coordinating function that eases expulsion of the seminal fluid.o Śukra shodana refers to sperm purification, and is thought to improve semen quality with respect to both morphology and counto Śukrala is a broad term thought to encompass vrsha, śukra jannana, and śukra pravartana.The following term relates to local pelvic controls as governed by the endocrine system,blood supply, and the central nervous system.o Vajikaraka refers to the reproductive capacity and would encompass functional capacity and sexual arousal at the level of the brain. Functional impotence would be addressed by substances that are vajikaraka.Three classical authors, Caraka, Suśruta and Sārṇgadhara provide the greatest clarityregarding an indication of a herb with respect to its target action.What herbs does Caraka recommend to improve the reproductive capacity ofthe healthy male?Caraka specifically identifies 2 herb groups classified as sperm purifying (śukrashodana) or sperm producing (śukra Jarana) that have particular relevance for idiopathicmale infertility (Sharma, 2004, CH Su 4:9-20).The śukra janana group indicated for increasing semen is listed in tables 3 and 4:Table 3 - Caraka Śukra Janana Herbs - Sperm Increasing Sanskrit Latin Common Name Name Name Jaṭāmāṁṣī Nardostachys jatamansi Spikenard Jīvantī Leptadenia reticulata None Kākolī Roscoea procera Kakoli Kṣīra-kākolī Lilium polphyllum White lilly Kuliṅgā (guṇjā) Abrus precatorius Wild Liquorice Root Māṣaparṅī Teramnus labialis Rabbit vine Medā Polygonatum verticillatum Whorled Solomons seal Mudgaparṇī Phaseolus trilobus Wild gram Śatāvarī Asparagus racemosus Wild asparagus Vidārīkañda Pueraria tuberosa Indian kudju© Chris St. Clair Gribble 14
    • The śukra śodana group indicated for sperm purification is listed in table 4:Table 4 - Caraka Śukra Śodana Herbs - Sperm Purification Sanskrit Latin Common Name Name Name Elavāluka Prunus cerasus Dwarf cherry Ikṣu Saccharum officinarum Sugar cane Kadamba (gum) Anthocephalus chinensis Wild Cinchona Kāsa Saccharum spontaneum Thatch grass Kaṭphala Myrica nagi Bay berry Kokilākṣa (alkalies) Hygrophila auriculata Ribbed gourd Kuṣṭha Saussurea lappa Costus root Samudraphena Sepia officinalis Calcium carbonate Uśīra Vetiveria zizanioides Vetiver grass Vasuka Indigofera enneaphylla NoneCaraka also mentions two other herb groups as useful in treating male sub-fertility(Sharma, 2004, CH Su 4:9-20).The jīvana group taken in milk is vrsha, indicated for men up to 70 years of age, and islisted in table 5:Table 5 - Caraka Jīvana Herbs - Age Related Impotence Sanskrit Latin Common Name Name Name Jīvaka Microstylis wallichii Orchid species Jīvantī Leptadenia reticulata None Kākolī Roscoea procera Kakoli Kṣīra-kākolī Lilium polphyllum White lilly Mahāmedā Polygonatum cirrhifolium King’s Solomons seal Māṣaparṅī Teramnus labialis Rabbit vine Medā Polygonatum verticillatum Whorled Solomons seal Mudgaparṇī Phaseolus trilobus Wild gram ṛddhi Habenaria edgewothii None ṛṣabhaka Microstylis muscifera None Vṛddhi Habenaria latiabris NoneThe vayasthapan group is indicated (Sharma, 2004, CH Ci 30:202-203) for seminaldiminution and is listed in table 6:Table 6 - Caraka Vayasthapan Herbs - Seminal Dimunition Sanskrit Latin Common Name Name Name Āmalakī, Emblica officinalis Indian gooseberry Aparājita Clitoria ternatea Butterfly pea Guḍūcī Tinospora cordifolia Moonseed© Chris St. Clair Gribble 15
    • Sanskrit Latin Common Name Name Name Harītakī Terminalia chebula Chebulic myrobalan Jīvantī Leptadenia reticulata Jivanti Maṇḍūkaparṇī Centella asiatica Indian pennywort Punarnavā Boerhavia diffusa Hog weed, horse purslane Rāsnā Pluchea lanceolata English plantain Śālaparṇī Desmodium gangeticum Salpan Śatāvarī Asparagus racemosus Wild asparagusWhat herbs does the Suśruta recommend to improve the reproductive capacityof the healthy male?Suśruta outlines 3 groups as useful in treating seminal disorders, and 2 groups as beingvrsha or aphrodisiac (Murthy, 2004, SH Su 38).The muṣkadhī group is indicated for seminal disorders whose herbs are listed in table 7:Table 7 - Suśruta Muṣkadhī Herbs - Seminal Disorders Sanskrit Latin Common Name Name Name Citraka Plumbago zeylanica Leadwort Dhava Anogeissus latifolia Dhaora Kuṭaja Holarrhena antidysenterica Kurchi Madana Randia dumetorum Emetic nut Mokṣa (white) Schrebera swietenoides Mokha (alkaline substance) Palāśa Butea frondosa Bastard teak Śimśapa Dalbergia sissoo Indian rosewood Sñuhi Euphorbia nerrifolia Milk hedge Triphalā Embilica officinalis Indian gooseberry Terminalia chebula Chebulic myrobalan Terminalia bellirica Belleric myrobalanKaṇṭakī pañcamūla group is also indicated for seminal disorders. These herbs are listedin table 8:Table 8 - Suśruta Kaṇṭakī Pañcamūla Herbs - Seminal Disorders Sanskrit Latin Common Name Name Name Himsrā Capparis sepiaria Indian caper Jhiṇṭi Barleria prionitis Porcupine flower Karamarda Carissa carandas Star fruit Śatāvarī Asparagus racemosus Wild asparagus Svadaṅṣṭrā Tribulus terrestris Small caltropVallī pañcamūla group is also indicated for seminal disorders and is listed in table 9:© Chris St. Clair Gribble 16
    • Table 9 - Suśruta Vallī Pañcamūla Herbs - Seminal Disorders Sanskrit Latin Common Name Name Name Guḍūcī Tinospora cordifolia Heart leaved, moonseed Kṛṣṇa sārivā Cryptolepis buchanani Sarsaparilla Meṣaśrñgi Gymnema sylvestre Rams horn Rajanī (species haridrā) Curcuma Longa Turmeric Vidāri Pueraria tuberosa Indian kudjuĀmalakyādi group is indicated as vrsha (aphrodisiac) and is listed in table 10:Table 10 - Suśruta Āmalakyādi Herbs - Vrsha (Aphrodisiac) Sanskrit Latin Common Name Name Name Āmalakī Emblica officinalis gaertn Indian gooseberry Citraka Plumbago zeylanica Leadwort Harītakī Terminalia chebula Chebulic myrobalan Pippalī Piper longum Long pepperkākolyādi group is also indicated as vrsha (aphrodisiac) and is listed in table 11:Table 11 - Suśruta Kākolyādi Herbs - Vrsha (Aphrodisiac) Sanskrit Latin Common Name Name Name Drākṣā Vitis vinifera Grape Guḍūcī Tinospora cordifolia Heart leaved, moonseed Jīvantī Leptadenia reticulata Jivanti Jīvantī Leptadenia reticulata Jivanti Kākolī Roscoea procera Kakoli Karkaṭa-śṛngī Rhus succedanea Scarlet rhus Kṣīra-kākolī Lilium polphyllum White lily Mahāmedā Polygonatum cirrhifolium King’s Solomons seal Māṣaparṅī Teramnus labialis Rabbit vine Medā Polygonatum verticillatum Whorled Solomons seal Mugdha-parṇī Phaseolus trilobus Wild bean Padmaka Prunus cerasoides Himalayan wild cherry Prapauṇḍarīka Cassia absus Pigs senna ṛddhi Habenaria edgewothii None Vamśa Bambusa arundinacea Thorny bamboo Vidārīkañda Pueraria tuberosa Indian kudju Vṛddhi Habenaria latiabris None Yaṣṭimadhu Glycyrrhiza glabra LiquoriceSuśruta indicates that vājīkaraṇa remedies are of three kinds; those that producesemen, those that secrete semen, and those that have both effects. He provides severalremedies (Murthy, 2004, SH Ci 26:15-38), but does not delineate which remedies havewhich effect.© Chris St. Clair Gribble 17
    • So how do the herb recommendations of Caraka and Suśruta compare?The same herbs are represented by both classical authors according to different systemsof classification. Caraka classified herbs based on pharmacological action, and Suśrutagrouped them by similarity of substance.Table 12 - Comparison of Caraka & Suśruta Herb Groups Caraka Suśruta Jīvaniya Kākolyādi Śukra janana Kākolyādi Śukra śodana Vallī pañcamūla Kaṇṭakī pañcamūla Vayasthapan Kākolyādi, vidarikandadiGogte (2000, p71) notes there is a remarkable similarity between the two methods ofclassification. The correlation of these groups is outlined in table 12.What herbs does the sārṇgadhara saṁhitā recommend to improve thereproductive capacity of the healthy male?This treatise, although not comprehensive, is known for its detail concerningpharmaceutics (Murthy, 2003, p19). Here the ayurvedic terms are defined veryspecifically with respect to action. Theses herbs are listed in table 13:Table 13 - Sārṇgadhara - Male Infertility Herbs Vājikara (aphrodisiacs: increase sexual desire) Nāgabalā Grewia hirsuta Bombay presidency Kapikacchu bīja Mucuna pruriens Velvet bean śukrala (semenogogues: increases quantity of semen) Aśvagandhā Withania somnifera Winter cherry Musali Asparagus adscendens White musli Śarkarā kṣira Saccharum officinarum Sugar cane Śatāvarī kṣira Asparagus racemosus Wild asparagus Māṣa Phaseolus mungo Black lentil śukrala (and also help in ejaculation) Bhalātaka- phalamajjā Semecarpus anacardium Marking nut Āmalaki Emblica officinalis Emblic myrobalan śukrala (ejaculation and premature ejaculation) Bhatī phala (helps expel semen) Solanum indicum Indian nightshade Jātīphala (with hold ejaculation) Myristica fragans Nutmeg Haritakī (dries it up) Terminalia chebula Chebulic myrobalan© Chris St. Clair Gribble 18
    • What do the remaining classical authors, Aṣṭāñga, Mādhava Nidānam, andBhāvaprakāśā contribute?The remaining classical authors all build on the initial contribution of Caraka andSushruta. Aṣṭāñga combines both their recommendations, and adds a few additionalherbs such as kapikacchu. Mādhava nidānam does not address the disease at all.However, perhaps the most comprehensive list of both herbs and formulations isprovided by Bhāvaprakāśā who is the most recent of the classical authors.As Bhāvaprakāśā is considered to provide the most comprehensive overview, asummary of his recommended herbs, formulations and dietary supplements to treatmale sub-fertility has been included in appendix 1 for reference purposes.What constitutes best practice contemporary Ayurvedic treatment of male sub-fertility?A few ayurvedic pharmaceutical companies have produced multi-herbal formulations totreat male sub-fertility. The formulation ADDYZOA, from Carak Pharmacy, is indicatedfor male sexual dysfunction and OAT syndrome. The Nagarjuna pharmacy producesCOUNT PLUS GRANULES indicated as a general formula for male infertility andassociated problems. However, none of these companies provide any clinical evidence tosupport the use of their formulations.Only the Himalaya pharmacy, which produces Speman indicated for Oligospermia,provides any visibility regarding the clinical effectiveness of their formulation. Speman isa poly-herbal formulation comprising of powders of Orchis mascula, Asteracanthalongifolia, Lactuca scariola, Mucuna pruriens and extracts of Argyreia speciosa, Tribulusterrestris, Leptadenia reticulata, Parmelia perlata, enriched with gold ash (appendix 2).There are several recent clinical studies that investigate its effect on sub-fertile maleswith respect to semen parameters and gonadotropic index. However, most of thesestudies can be discounted on methodological grounds.All these studies were simple before and after open evaluation studies with no controlgroup or randomisation. With no control group there is less confidence that a change isa result of the intervention, and hence would be excluded for best practice clinicalevidence as defined by the Cochrane Collaboration (2007). This is especially true where© Chris St. Clair Gribble 19
    • there is so much natural variation in semen parameters over time. Nor would theseclinical trials be known to be independent or unbiased as funding sources or sponsorshipwas not declared and the papers were co-authored with a Himalaya medical advisor.However, in the absence of virtually any clinical studies of ayurvedic pharmacopoeia formale sub-fertility, these few studies at least provide some indication of effectiveness forthe ayurvedic approach. The only study using well defined measurement protocol andinclusion criteria showed that Speman increased sperm density significantly from 19.41to 26.81 million/ml at 3 months with an improvement showing at 4 weeks. The spermmotility also showed significant gradual improvement from 40.50% to 46.16% after 3months treatment, and sperm morphology improved from 53.38% to 61.62%. Themean testosterone levels increased from 3.85 ng/ml to 6.12ng/ml after 3 months oftreatment with Speman (Singh, Pandey, Sakar and Kulkarni, 2003). The authorsconclude that Speman may be improving sperm density and morphology by influencingtestosterone.Searching the literature for a clinical comparison, a small scale RCT of the powerfulantioxidant Astaxanthin has been shown to have significant improvement on semencount from 36.2 to 48.6 million/ml, motility from 28.5 to 31.9%, and normalmorphology from 9.6 to 11.4%. However, there was no significant change intestosterone levels (Comhaire, El Garem, Mahmoud, Eertmans and Schoonjans, 2005).Speman contains Mucuna pruriens which has been proven to have an anti-lipidperoxidation property (Tripathi and Upadhyay, 2002). As there is mounting evidencethat oxidative stress is the main factor in male sub-fertility, this suggests thatinfluencing testosterone may not be the only factor behind the improved semencharacteristics in the Speman study.Is there any scientific evidence to support the Ayurvedic treatment of male subfertility?A recent publication by Mishra (2004) has found some evidence in support of ayurvedictherapeutics for male infertility. The author discovered no independent human clinicaltrials, but found some evidence from animal models pertaining to several ayurvedicherbs.© Chris St. Clair Gribble 20
    • Withania somnifera was found to directly increase spermatogenesis in immature rats byexerting a testosterone like effect without raising serum levels of testosterone. Thealkaloids present in Mucuna pruriens were found to increase the number of spermatozoaand weight of testes, seminal vesicles and prostate in the albino rat. Piper longuminduced significant increase in the weight of the reproductive organs, sperm motility,and sperm count in male rats. Tribulus terrestris has been shown to increasetestosterone and spermatogenesis in male rams. An extract of this herb, Protodioscinhas been shown to improve sexual behaviour parameters in albino rats. Trichopuszeylanicus and Vanda tessellate have both been shown to stimulate sexual behaviour inmale mice. Zingiber officinale plant extracts show significant improvement in spermcount and motility.With so few studies available, a broader review of the literature was conducted lookingfor association with oxidative stress as the theoretical cause behind OAT syndrome andalso for research on male infertility, fertility agents, and hyperlipidemia. A search acrossPUBMED, AMED, Google Scholar, and the Medknow collection of Indian Medical Journalsfor 94 herbs classically prescribed for male sub-fertility has provided some indicativeevidence in support of their use. (Please refer to appendix 3 for the search keywordsemployed).A high proportion of the fertility related herbs have been evidenced as having apowerful antioxidant potential. These herbs appear to be working at the levelof spermatogenesis.The sweet fruit of Semecarpus anacardium is indicated for sperm purification andincreasing seminal flow. A study has shown an alcoholic extract of pericarp showedsignificant protection against FeSO4 induced lipid peroxidation (Tripathi and Singh,2001). However, unless the medicine is adequately purified it is considered extremelytoxic which might explain some animal studies which show that ethanolic extract causesa reduction in the number of primary spermatocytes, secondary spermatocytes andspermatids causing spermatogenic arrest in albino rats (Sharma, Verma and Dixit,2003).Mucuna pruriens is indicated when semen is depleted, and to improve virility. An alcoholextract of the seeds has an anti-lipid peroxidation property, which is mediated throughthe removal of superoxides and hydroxyl radicals (Tripathi and Upadhyay, 2002).© Chris St. Clair Gribble 21
    • Hygrophila auriculata indicated for both sperm production and purification has beenshown to have potent antioxidant potential (Vijayakumar et al., 2006).Asparagus racemosus indicated for both sperm production and purification has shownevidence of increased antioxidant defence; that is, enzymes superoxide dismutase,catalase, and ascorbic acid increased significantly, whereas a significant decrease in lipidperoxidation was observed (Bhatnagar, Sisodia and Bhatnagar, 2005). A further studyhas shown potent antioxidant properties in vitro in mitochondrial membranes of ratlivers (Kamat, Boloor, Devasagayam and Venkatachalam, 2000).Cissus quadrangularis indicated for sterility has shown both antioxidant andantimicrobial activity (Murthy, Vanitha, Swamy and Ravishankar, 2003).Curculigo orchioides used to increase semen has been shown to have immunostimulant,hepaprotective, and potent antioxidative activities (Wu et al., 2005). This herb is alsoused in Traditional Chinese Medicine (TCM).Euryale ferox indicated to increase semen and prevent premature ejaculation contains asignificant antioxidant activity (Lee, Ju and Kim, 2002).Suśruta mentions the poly herbal formula triphala in relation to male infertility andsperm purification. Research has found that all three constituents of triphala are activeand they exhibit slightly different activities under different conditions. In particular,Emblica officinalis shows greater efficiency in lipid peroxidation and plasmid DNA assay,while Terminalia chebula has greater radical scavenging activity. Thus their combinationis expected to be more efficient due to the combined activity of the individualcomponents (Naik et al., 2005). A separate study of Terminalia chebulais foundadditional evidence of its role in preventing oxidative damage in living systems (Lee etal., 2005).Anogeissus latifolia indicated for sperm purification has been shown to have potentantioxidant activity (Govindarajan et al., 2004).Plumbago zeylanica is indicated for sperm purification. It has been found that one of itsactive ingredients, plumbagin, has significant antioxidant abilities that may possibly© Chris St. Clair Gribble 22
    • explain its therapeutic effect (Tilak, Adhikari and Devasagayam, 2004). A further animalstudy has shown its ability to reduce oxidative stress in albino mice (Sivakumar andDevaraj, 2006).Vitis vinifera is indicated for semen purification. Procyanidins, an extract from Vitisvinifera, is believed to exert antioxidant protection sparing liposoluble vitamin E andreducing DNA oxidative damage (Simonetti, Ciappellano, Gardana, Bramati and Pietta,2002).Myrica nagi, indicated for sperm purification, is an effective chemopreventive agent inthe skin and capable of ameliorating cumene hydroperoxide-induced cutaneousoxidative stress and toxicity (Alam, Iqbal, Saleem, Ahmed and Sultana, 2000).Sugarcane juice, indicated for semen purification, has a phenolic extract that has showna protective effect against in vivo MeHgCl intoxication and potent inhibition of ex vivolipoperoxidation (Almeida, Novoa, Linares, Lajolo and Genovese, 2006).The beta-vetivenene, beta-vetivone, and alpha-vetivone constituents isolated fromVetiveria zizanioides, indicated for semen purification, have shown strong antioxidantactivity (Kim, Chen, Wang, Chung and Jin, 2005).Extract of Prunus cerasus indicated for sperm purification was found to have strongantioxidant activity (Wang, Nair, Strasburg, Booren and Gray, 1999).Some fertility related herbs have been shown to have antioxidant potential andbe effective in reducing hyperlipemia. High lipid content and obesity is nowconsidered a factor in reduced fertility.Emblica officinalis is indicated for increasing semen. The polyphenol fraction has beenshown to scavenge superoxide and hydroxyl radicals and inhibit lipid peroxidation invitro. It has also be shown to be useful in hypercholesterolemia and lipid peroxidation incholesterol-fed rats (Rajeshkumar, Pillai and Kuttan, 2003).Withania somnifera indicated for both sperm production and purification has shown cellcycle disruption and anti-angiogenic activity, which may be a critical mediator for itsanti-cancer action (Mathur et al., 2006). It is known to exhibit increased antioxidant© Chris St. Clair Gribble 23
    • defence (Bhatnagar et al., 2005). It has also shown significant ability to reduced serumcholesterol, triglycerides, LDL (low density lipoproteins) and VLDL (very low densitylipoproteins) in human trials (Andallu and Radhika, 2000).Glycyrrhiza glabra used as a sperm purifier was found to protect microsomalmembranes, as evident from a reduction in lipid peroxidation, and also protects plasmidDNA from radiation-induced strand breaks (Shetty, Satav and Nair, 2002). The herb hasalso been shown to be hypocholesterolaemic (Visavadiya and Narasimhacharya, 2006).The herb has also shown hypocholesterolaemic action (Sitohy, Massry, Saadany andLabib, 1991).Most research on Tinospora cordifolia reflects its clinical use in Ayurveda, supporting itshypoglycaemic and hypolipidaemic action (Stanely and Menon, 2003). More recentresearch also point to its Nitric Oxide Scavenging capacity (Jagetia and Baliga, 2004)and maintenance of antioxidant status of cells which is suggestive of achemopreventive efficacy of T. cordifolia against chemotoxicity, including carcinogenicity(Singh, Banerjee, Kumar, Raveesha and Rao, 2006).Some fertility related herbs appear to be working more at a gonadotropic levelor at the level of the brain.An aqueous extract of Centella asiatica, as a longevity promoter, has been foundeffective in preventing cognitive deficits, as well as oxidative stress (Kumar and Gupta,2003).Pueraria tuberosa has been indicated for sperm purification and increasing semen count.Some research points to its estrogenic potential (Shukla, Mathur and Prakash, 1989);other research suggests ethanolic and butanolic extracts evoke a significant anti-fertilitywhilst the aqueous extract does not show any significant anti-fertility activity in thethree animal species tested. This may indicate that this herb is acting at the level ofhormonal control (Prakash, Saxena, Shukla and Mathur, 1985).Piperine, the active ingredient in Piper longum Linn has been shown to have animmunomodulatory and antitumor capability increasing WBC count (Sunila and Kuttan,2004). It has been found to exert a significant increase in reproductive organ weights,sperm motility and sperm count (Shah, Al-Shareef, Ageel and Qureshi, 1998).© Chris St. Clair Gribble 24
    • Nardostachys jatamansi has been clinically employed for its anti-ischemic, antioxidant,anticonvulsant, and neuroprotective activities. It is also indicated for increasing semen.An ethanol extract significantly improved learning and memory in young mice and alsoreversed their amnesia. The underlying mechanism of action can be attributed to itsantioxidant property. Hence, it is possible this is acting both at the level of the brain anddirectly on spermatogenesis (Joshi and Parle, 2006).Desmodium gangeticum has shown potent antioxidant activity (Govindarajan et al.,2003). This herb also works on the brain, having been shown to be a promisingcandidate for improving memory (Joshi and Parle, 2006).What can the Ayurvedic and allopathic approaches learn from each other?One can speculate that several ayurvedic herbs targeted at male sub-fertility may beworking to reduce oxidative stress and thereby support the allopathic theory ofpathogenesis for OAT syndrome. Also a few ayurvedic herbs indicated for male infertilityshow their main benefits in regulating hyperlipidemia and obesity.Boerhavia diffusa, indicated as a longevity promoter, can induce a significant reductionin serum and tissue cholesterol, free fatty acids, phospholipids, and triglycerides (Pariand Satheesh, 2004a). Another study demonstrates remarkable anti diabetic activityand improvement in antioxidant status (Pari and Satheesh, 2004b).Gymnema sylvestre is indicated for diseases of semen and diabetes. Animal studieshave shown that this herb decreases bodyweight, regulates lipoprotein metabolism andis especially useful in multi-factor obesity syndrome.Lipid status or body weight is not widely considered as part of the diagnostic criteria formale infertility. However, studies have shown that metabolic syndrome X underpinsboth hyperlipidemia and obesity, and the bio-markers for this syndrome are becomingincreasingly prevalent, especially in the young (Eckel, Grundy and Zimmet, 2005).Further oxidative stress has been shown to be an early indictor of metabolic syndromeand obesity (Furukawa et al., 2004). So is there any correlation with hyperlipidemia,obesity and semen quality? A recent study has shown that the BMI index has a directcorrelation with semen quality characteristics. There was a significant difference in the© Chris St. Clair Gribble 25
    • total number of normal-motile sperm cells among the different BMI groups. Menpresenting with a BMI greater than 25 have fewer chromatin-intact normal-motile spermcells per ejaculate (Kort et al., 2006). Also a high incidence of hyperestrogenemia anddyslipidemia has been shown to be more prevalent in groups of infertile men (Torres,Carrera and Zambrana, 2000).One can speculate that herbs targeting fat metabolism, directly or indirectly, regulateoxidative status which has been hypothesised to affect semen quality. Also thedemographics of metabolic syndrome may go some way to explain the regionalvariations in semen count seen in the developed nations. Both Europe and the US showthe highest decreases in semen quality where obesity is also a significant factor.2.6 What is the research question and the value of this study?Although ayurveda provides a well described treatment option and extensivepharmacopeia to treat the infertile male, there is little contemporary literature or clinicalevidence to substantiate the effectiveness of the treatment approach.A new student of ayurveda must rely solely on acquired clinical experience andobservational learning of successful treatment modalities. Observing best practice inthe UK is limited. Ayurveda in the West is still in its infancy with limited residentexpertise, few patients seeking treatment and a limited subset of the pharmacopoeiaand treatment techniques that would be available in India & Sri Lanka.This situation presents several research questions that need to be addressed:o What constitutes best practice ayurvedic diagnosis of male infertility?o What are the preferred ayurvedic herbs or formulations are used to treat male sub- fertility?o Are there alternative ayurvedic options to treating common pathologies associated with male sub-fertility?o How effective is the ayurvedic treatment of male infertility?An effectiveness study or clinical audit would not be feasible given the constraints oftime, financial resources, and limited access to clinical expertise, even in India. Nor isan exploratory clinical study feasible given the lead times involved. The semen lifecycleis 3 months to maturation, so sample base lining and a minimum number of samples to© Chris St. Clair Gribble 26
    • measure patient outcomes would exceed time constraints. Sadly there is little ayurvedicresearch literature published in accredited journals.Given these constraints a pragmatic approach was to find a recognised ayurvedic expertin the treatment of male infertility, to randomly select 30 plus male patients who hadcompleted a course of infertility treatment, and conduct a retrospective qualitative casehistory analysis. To provide an indicative measure of effectiveness some quantitativeanalysis was conducted regarding sperm motility, morphology and count as dependentvariables.The main aim of this study was to understand, document and communicate ayurvedicbest practice diagnosis and treatment of male infertility, and identify which herbs orformulations should be explored further for the treatment of male infertility.The main value of the study will be to provide newly qualified ayurvedic professionals acontemporary practice guideline for the diagnosis and treatment of male infertility.3 Methodology3.1 Research Approach, Design & SettingSDM College of Ayurveda & Teaching Hospital, India is one of the few Indian hospitalswith a dedicated department specializing in infertility. This department, containing bothinpatient and outpatient clinics, is run by the consultant physician Dr. B. S Prasad, oneof the few consultants specialising in infertility treatment, and provided the settingwhere this study took place.In medicine, a retrospective case study looks backward in time, using medical recordsand interviews, for a group of patients who have a known disease. The case studyapproach uses a mix of qualitative and quantitative approaches and has long been usedby clinicians as a method for understanding a disease (Bowling, 2002, p404). In thisrespect a case series should not be confused with qualitative research as they are basedon a mix of quantitative and qualitative evidence (Yin, 2003, p14). Others would arguethat the approach lacks rigour as the case records may not reflect the actual data, andthat the data and its interpretation cannot necessarily be verified (Kyburz-Graber,2004).© Chris St. Clair Gribble 27
    • Recognising these limitations, this research approach was employed to qualitativelyinvestigate case histories regarding patient diagnosis and treatment modality for sub-fertile males who had been under the expert care of a single consultant physician, andto quantitatively assess patient outcome through analysis of semen sample records.This was an exploratory before and after investigation of a single population who hadundergone treatment. There was no control, comparison group or sample stratification.The working hypothesis was that there would be an improvement in semen qualitycharacteristics in response to treatment. It is hoped this study will inform a future largerscale clinical audit to establish agreed practice guidelines with an aim to improve patientoutcomes.3.2 Ethical ApprovalThe study commenced once Ethical approval had been granted from MiddlesexUniversity Health Studies Ethics Sub-committee (appendix 4). This approval wasobtained when written permission to access patient records had been received from thedirector of the SDM hospital (appendix 5).All patient information recorded was kept strictly confidential, and the identity ofpatients protected by using an anonymous patient number at all times.3.3 Sampling ApproachA register of patient semen samples had been provided which held records from May2000 up to the current period of sampling. This register contained semen quality datain line with WHO guidelines (Jeyendran, 2000) on semen analysis, along with 2 otherclassically defined ayurvedic semen quality parameters. (Please refer to the semen datacollection template in appendix 6).From this register it was straightforward to identify patient records that met initialsemen sample inclusion criteria. Best practice suggests that there should be at least 2baseline semen samples separated by at least 1 month (Berman, 2004). This is toestablish an accurate baseline. Natural variation in semen samples are known to varysignificantly in relation to diet, lifestyle and environmental factors (Centola andGinsburg, 1996, p19). However, in all cases, only a single baseline sample had beenrecorded. It was communicated that this had been dictated by the cost of private© Chris St. Clair Gribble 28
    • treatment rather than desired protocol. Patient records were then identified as having atleast 3 semen samples over a minimum of a 3 month treatment period. As the spermlifecycle is 72 days, this sampling rate and measurement periodicity is in line withaccepted protocol (Oehninger and Kruger, 2006, p161), and thought to provide moreconfidence that a change would have been in response to treatment. This identified 31patient records for initial case history screening.These 31 patient records were retrieved from the administration office and only selectedfor detailed analysis if they met the following inclusion criteria:o A complete diagnosis including associated pathologies was documentedo A complete treatment history including associated dosage was documentedo A single consultant had been responsible for the course of treatmentAnd rejected if they met the following exclusion criteria:o An untreatable pathology has been identified e.g. azoospermia where no response to treatment would have been expectedo Semen analysis records were not fully documentedThis resulted in a convenience sample of 21 patient records for detailed case historyanalysis. The planned strategy to randomly select patient records that met the inclusioncriteria was not possible given the small number of available records that met theinclusion criteria.This overall sampling strategy was designed to ensure the available data reflected bestpractice clinical diagnosis. Such selective screening of patient records was essential tounderstand the treatment prescribed in relation to the underlying diagnosed pathology.3.4 Data CollectionThe research instrument was implemented in 3 phases. All the original paper based casenotes had been recorded mostly in English in a standard structured format with varyingdegrees of legibility. The associated semen samples had been recorded in a log book bypatient number in chronological order. Fortunately, the structured format reflected bestpractice WHO guidelines with respect to both diagnosis and semen characteristics.© Chris St. Clair Gribble 29
    • The first phase involved the transcribing and codifying of both data sets. The datacodification involved some data transformation of the prescription history into astandard format, and translation of any Sanskrit terms into English with the assistanceof attending interns. This also enabled validation of any illegible script.Best practice allopathic reproductive history includes coital history and timing, durationof infertility and prior fertility, childhood illnesses, developmental history, systemicmedical diseases, prior surgeries, sexually transmitted infections, and gonadal toxinexposure (Berman, 2004). Best practice ayurvedic diagnosis additionally includes aqualitative assessment with respect to digestion, tissue formation, body channels, wasteproducts, immunity and mental function in relation to both the seasonal and geographicenvironments. Both sets of data had been recorded with varying degrees of consistencyand completeness. The allopathic criteria regarding the initial physical examination andprevious medical history was well recorded whilst the ayurvedic systemic diagnosticcriteria were poorly recorded if at all. In observing patient diagnosis in the clinicalsetting, it became apparent that there was detailed ayurvedic analysis of the underlyingpathology, qualitatively assessing the systemic variables, and this was implicitlyrepresented in the initial treatment plan, but not explicitly recorded.From the transcribed data, each patient was classified according to one of the clinicalgroupings as defined by Dohle et al. (2005) namely sexual factors, UTI, congenital,acquired, varicocele, endocrine, immunological, abnormality and OAT syndrome.The case histories also included a full treatment history, including both radical shodanapurification and balancing shamana treatment. For each type of treatment prescribedmedicines, dosage, and prescription period, and patient progress had been recorded.From this data, a complete list of pharmacopoeia was extracted across all records, aswell as the primary medicine(s) prescribed for each patient and whether they hadundergone shamana treatment, or both shodana and shamana treatment.The second phase involved extracting the semen quality data for each patient. Thesemen sample log contained semen quality parameters according to accepted protocols(Jeyendran, 2000). This included macroscopic parameters of appearance, coagulationand liquefaction time, odour and colour, viscosity and volume. The log also containeddata for the microscopic parameters of non-sperm cellular elements, leukocytes,© Chris St. Clair Gribble 30
    • erythrocytes, epithelial cells, micro-organisms, sperm agglutination, concentration,count, motility and morphology. Data for the ayurvedic semen quality parameters ofphenila and avasādi were also extracted.Using standard WHO reference values (Rowe, 2000), each semen sample was thenclassified into one of the categories defined in table 14:Table 14 - Allopathic Semen Quality Characteristics Semen Classification Normal semen Normal semen with agglutination (>5%) Antibody coated spermatozoa (> 20% immobilized sperm) Oligozoospermia (less than 20 million spermatozoa per ml) Asthenozoospermia (less than 25% rapid linear progression) Teratozoospermia (less than 40% of sperm of normal morphology)The remaining ayurvedic semen parameters were derived from the extracted valuesaccording to a set of defined reference criteria used at SDM hospital. The referencecriteria were aligned to accepted allopathic clinical values, except for phenila andavasādi which are unique to ayurveda.It should be noted that some data transformation was performed to enable consistentclassification of the sample population, and to understand patient outcome.Quantitative values not recorded (NR) were transposed as null values. Where a rangehad been provided the top end of the range was taken as an absolute value. Qualitativevalues were transposed as normal values when not recorded. These transformationrules were consistent with the other associated data and from having observed therecording process.Hence, the semen sample data was codified according to valid measurement protocolsagainst accepted reference standards. This provided a baseline set of values to measurechange in sperm count, motility and morphology over time. This preliminary dataprovided the basis for the 3rd phase of data extraction, the consultant interview, whichformed the basis of the qualitative data analysis.(Please refer to the appendices 7-9 for the allopathic, ayurvedic reference standards andthe transformation rules applied).© Chris St. Clair Gribble 31
    • 3.5 Data AnalysisThe primary aim of this research was to drive out what constituted best practiceayurvedic diagnosis and treatment of male sub-fertility.A qualitative analysis took place in the form of a series of informal unstructuredinterviews with the consultant responsible for the patient treatment.The raw data collected in phases 1 and 2 was used to drive the consultant interviews.Time permitting, each case history was to be reviewed against a structured questiontemplate, and responses collected for further analysis. This did not prove possible asaccess to consultant time was limited, and could not support such an in-depth casespecific analysis. A pragmatic solution was agreed whereby a consolidated list ofpharmacopoeia prescribed across the sampled cases was reviewed against a set ofguiding clinical questions as outlined in table 15.Table 15 - Guiding Questions for the Consultant Interview Guiding Questions What constitutes best practice diagnosis of male infertility? How does one clinically diagnose sperm pathology in ayurveda? What are the preferred ayurvedic herbs or formulations used to treat male sub- fertility? What are your preferred herbs to treat the various sperm pathologies? What herbs would you suggest should be investigated further, and for which pathology? Are there alternative ayurvedic options to treating common pathologies associated with male sub-fertility? What other common pathologies associated with male sub-fertility does ayurveda treat and what is your preferred treatment approach? How effective is the ayurvedic treatment of male infertility? What is the general prognosis regarding the various pathologies associated with male sub-fertility?The interview process thus comprised a series of 12 discussions occurring betweenpatient sessions at Dr Prasad’s private clinic each evening for a period of 2 weeks. Thediscussions were not recorded at the request of the consultant.© Chris St. Clair Gribble 32
    • Prior to conducting the interview, an extensive review of the classical literature forpharmacopoeia associated semen quality had been conducted. Where identified, theLatin names of the herbs had been checked against the medical databases (AMED &PUBMED) for any existing research associated with semen quality. This data informedthe discussion with respect to why specific medicines had been prescribed, andfacilitated a clinical discussion on the ayurvedic view of sub-fertility pathogenesis.This approach yielded a deeper level of information than would have been obtained by asimple survey, and enabled the documentation of the consultant’s view of whatconstituted best practice diagnosis and treatment of male sub-fertility based on hisextensive years of clinical experience.A measure of quantitative analysis on patient semen samples was also conducted. Themain value in the semen records had been the categorisation with respect to semenquality and baseline diagnosis. This was derived from the raw data using acceptedprotocols as already outlined. However, semen samples were also analyzed as to howthey changed over time to provide an indicative measure of therapeutic value. The wordindicative must be stressed as this was a small scale retrospective study with no controlor comparative group. Here the independent variable was considered the “totaltreatment intervention” with dependent variables of sperm count, motility, andmorphology.As there was no control group, no comparison group and too small a sample size toenable statistical power, the quantitative analysis is only indicative and should not begeneralised. The sample represented a mix of varying pathologies so samplestratification did not provide enough cases to assess idiopathic infertility. Also whilst themeasurement parameters used accepted protocols to ensure content validity, therewere concerns regarding measurement reliability. It was noted that there was astandard rotation of interns conducting the semen sample analysis. Although theyworked under the supervision of the consultant, this suggested poor measurementreliability, both between patients and within a set of patients’ semen samples. Internalquality control with respect to semen quality is a common problem of reliability that isoften overlooked (Cooper, Neuwinger, Bahrs and Nieschlag, 1992).© Chris St. Clair Gribble 33
    • Sample distribution was investigated using the one sample Kolmogorov-Smirnov testand changes between baseline and post-treatment patient outcomes were measuredusing the Wilcoxon Signed Rank test; the statistical package for Social Science (SPSS)was used to generate these values.3.6 Constraints & LimitationsApart from the limitations in methodology and sampling already outlined, there are afew broader constraints that should be made explicit.A preferred treatment strategy cannot be generalised as best practice when:o The sample size was small and in a single setting. However, to conduct a large multiple centre audit was beyond the study scope.o There was little visibility of the true measure of success - couple conception rates for the cases studied.o In-depth case history analysis was constrained as the systemic ayurvedic diagnostic data had not been adequately recorded.o Patient outcome and correct diagnosis could not be adequately verified in the context of a retrospective study.4 ResultsThe sampling strategy had identified 31 case histories. Screening against both theinclusion and exclusion criteria eliminated 11 cases, resulting in 21 cases for furtheranalysis. One case had no associated semen record, 6 cases had less than 3 semensamples, 3 cases had incomplete case notes, and one case was designated asazoospermia. The selected cases and associated semen samples provided a rich data setto investigate the sample demographics, disease classification, prescribed medicines andprovide an indication of treatment response.However, there was one major gap in the data, the ayurvedic systemic diagnostic data,which could have enabled an energetic analysis of both treatment programme and theunderlying pathogenesis in relation to the resultant semen parameters.© Chris St. Clair Gribble 34
    • 4.1 Sample DemographicsThe demographics of the sample population at the start of their treatment programmeare represented tables 16 to 18. The tables outline how each case presented withrespect to diagnosis, and their associated allopathic and ayurvedic semen qualitycharacteristics. A red “Y” indicates a positive indication for the corresponding categoryand an “N” indicates the opposite.Table 16 - Allopathic Semen Quality Classification (Baseline) Asthenozoospermia With Agglutination Teratozoospermia Progression (%) Abnormality (%) Progression (%) Oligozoospermia Normal Sperm Normal Sperm Concentration Coated Sperm Case Number Rapid Linear Slow Linear (MIL/ML) Antibody Sperm Total 1 10.0 0 13 58 N N N Y Y N 2 54.0 19 47 69 N N N N N Y 3 15.0 0 13 82 N N N Y Y Y 4 2.0 0 10 0 N N N Y Y N 5 35.0 9 26 73 N N Y N Y Y 6 50.0 10 12 0 N N Y N Y N 7 10.0 0 1 83 N N Y Y Y Y 8 2.0 1 24 0 N N N Y Y N 9 37.0 29 20 59 N Y N N N N 10 35.0 9 30 62 N N N N Y Y 11 24.0 19 20 70 N N N N Y Y 12 0.1 0 0 0 N N N Y Y N 13 0.5 0 0 0 N N N Y Y N 14 42.0 20 31 75 N N N N N Y 15 25.0 4 20 80 N N N N Y Y 16 18.0 0 13 80 N N N Y Y Y 17 16.0 7 13 75 N N N Y Y Y 18 233.0 12 20 64 N N N N Y Y 19 32.0 0 0 78 N N N N Y Y 20 19.0 0 15 76 N N N Y Y Y 21 12.0 0 0 96 N N Y Y N YTable 16 outlines the data extracted from the semen records for the selected cases. Thesemen quality characteristics have been classified according to WHO reference criteria(Rowe, 2000) and is summarised in figure 1 below.© Chris St. Clair Gribble 35
    • Figure 1 - % Distribution - Allopathic Semen Characteristics (Baseline) % Classification - Semen Quality Normal Sperm (Agglutination) 4.8% Oligoasthenoteratozoospermia (OAT) 28.6% Asthenozoospermia 23.8% Teratozoospermia Oligoasthenospermia 4.8% 4.8% Oligoteratozoospermia 9.5% 23.8% TeratoasthenozoospermiaFigure 1 shows that only 4.8% of cases presented with normal semen, but this singlecase was associated with agglutination. 28.6% of cases exhibited low sperm countassociated with either poor motility (oligoasthenospermia) or morphology(oligoteratozoospermia), 28.6% suffered from both poor morphology and motility(teratoasthenozoospermia) but were normal with respect to semen concentration, andonly 15% involved a single factor of either morphology (teratozoospermia) or motility(asthenozoospermia). Of all these cases, 19% had semen coated in antibodies.Analysis of the associated case histories (table 17, figure 2) was very revealing withrespect to the underlying pathology behind the semen sample characteristics. Diagnosticdata was extracted from past and current medical history, physical examination results,and any associated laboratory or biochemical investigations.© Chris St. Clair Gribble 36
    • Table 17 - Allopathic Diagnosis Classification (Baseline) Immunological Duration (Mo) Duration (Mo) Case Number Urinary Tract Secondary Secondary Varicocele Prognosis Infertility Infertility Infection Systemic Acquired Primary Primary Sodana Age 1 N N Y N Y 24 N 0 N 32 Y 2 Y N Y N Y 168 N 0 Y 41 N 3 Y N N N Y 84 N 0 Y 39 Y 4 Y Y N N Y 60 N 0 Y 36 N 5 N Y N N NR NR NR NR NR 33 Y 6 Y N N Y Y 60 N 0 Y 40 N 7 Y Y Y N Y 36 N 0 Y 29 Y 8 Y Y N N Y 60 N 0 Y 40 N 9 N N Y N Y 132 N 0 Y 40 Y 10 Y N N N Y 120 N 0 Y 35 Y 11 Y Y N N Y 60 N 0 Y 33 Y 12 Y Y N N Y 72 N 0 Y NR Y 13 Y Y N N NR NR NR NR NR 36 Y 14 N N N Y Y 108 N 0 Y NR N 15 N Y N N Y 96 N 0 Y 37 N 16 N Y N N NR NR NR NR NR 36 N 17 N Y N N NR NR NR NR NR 33 N 18 N N N N N 0 Y 74 Y 33 N 19 N N N N Y 96 N 0 Y 32 Y 20 Y Y N N Y 72 N 0 Y 35 N 21 N N N N Y 54 N 0 Y 30 YFrom reviewing the data, several aspects stand out. Where primary or secondaryfertility had been identified, the majority of cases (94%) were identified as primaryinfertility, with a median period before seeking treatment of 72 weeks. A periodexceeding 36 months is considered a poor prognosis (Rowe, 2000, p7). These patientshad also waited until quite late in life before seeking ayurvedic treatment, with a meanage of 35 years. Radical shodana treatment was employed in 52% of cases, and withinthis group 91% had an associated pathology such as varicocele.© Chris St. Clair Gribble 37
    • Figure 2 - % Allopathic Diagnosis Classification (Baseline) Idiopathic 9.5% 14.3% Infection 4.8% Immunological 4.8% Varicocele 4.8% 19.0% Varicocele with infection Varicocele with immunological Aquired with varicocele 4.8% 28.6% Aquired with varicocele & infection 9.5% AquiredTable 18 - % Allopathic Diagnosis Classification (Baseline) Aetiology % With respect to diagnosis as outlined Idiopathic 14.3% in table 18, 4 patients (19%) were Infection 19.0% identified as having acquired Immunological 4.8% Varicocele 9.5% infertility, one through a complication Varicocele with infection 28.6% of diabetes, one thought to arise Varicocele with immunological 4.8% Acquired with varicocele 4.8% from obesity and recent typhoid Acquired with varicocele & infection 4.8% fever, another from having suffered Acquired 9.5% typhoid fever shortly after puberty,and one whose employment involved excessive toxin exposure. Two of these cases alsoinvolved UTI and varicocele so could be considered resultant of the additional pathology.More significant is that a high proportion, 52% of the patients, were suffering fromvaricocele with or without coincidental UTI, immunological or systemic problems. Otherpathologies involved 19% cases resulting from infection, 4.8% with an immunologicalproblem, leaving only 14.3% with idiopathic infertility i.e. with no known cause.Table 19 represents ayurvedic diagnostic parameters for semen quality and is dividedinto 2 sections: those semen parameters aggravated by vata dosha (vata seminalmorbidity) and those aggravated by other doshas (non vata seminal morbidity).© Chris St. Clair Gribble 38
    • Table 19 - Ayurvedic Diagnostic Parameters (Baseline) Vata Seminal Morbidity Non Vata Seminal Morbidity Anya dhatu samsrsta (dryness PH >8.5) (Poor liquefaction) (low sperm count) (cellular material) (offensive smell) Alpa (low semen (discolouration) (discolouration) Case Number (Pyospermia) Aruna varna (viscosity) Avasādi Phenila volume) Vivarna Granthi Piccilla Rūkṣa Tanu Puya Pūti 1 Y Y N N N Y N N N N N N 2 N N N N P N P N N N Y Y 3 N Y Y N N Y N N N N Y N 4 N Y N N N Y N N Y N Y N 6 N N Y Y N N N N Y Y N Y 9 N N N Y N Y N N N Y N N 7 Y Y N N N Y N N N N Y N 8 N Y N N P N P N N N N N 14 N N N N P N P N N Y N N 15 N N N N P N P N N N N N 19 N N N N N N N N N Y N N 12 N Y Y N N N N N N N N N 13 Y Y Y N P N P N N N N N 5 Y N N N N Y N N N Y Y N 10 Y N N N P Y P N Y N N N 16 N Y N Y N Y N N Y N N N 17 N Y N N P Y P N N N N Y 11 Y N N N N Y N N Y Y N N 18 Y N Y N N N N N N N N N 20 Y Y Y N N Y N N Y N Y N 21 N Y N N N Y N N N N Y NOnly two factors phenila and avasādi are unique measurements, with the others derivedfrom normal allopathic reference standards. These parameters map to the seminalmorbidities outlined in the classics. The clinical reference values are based on WHOrecognised values. Within the table, under arunavarna and vivarna, a letter “P” indicatesyellow discoloration indicative of excess pitta, and although not seen in this samplepopulation the letter “K” would have indicated a milky white discoloration showingexcess kapha, and a “N” signifies the normal greyish white colour.The % distribution of these parameters across the sample population is identified infigure 3. The most common characteristic is avasādi (57%) which is most frequently© Chris St. Clair Gribble 39
    • associated with both low sperm count (tanu) and phenila which is an indication of vatadisturbance.Figure 3 - % Distribution of Ayurvedic Diagnostic Parameters (Baseline) % Distribution - Ayurvedic Parameters (Base Line) Avasādi 57% Tanu 52% Phenila 38% Piccilla 33% Vivarna 33% Aruna varna 33% Anya dhatu samsrsta 29% Puya 29% Ruksha 29% Granthi 14% Alpa 14% Puti 0% 0% 10% 20% 30% 40% 50% 60%4.2 Prescribed MedicinesReviewing the case histories for all radical and palliative treatment, across both inpatient and out patient clinics, identified a total of 132 medicines prescribed. From thedata, several observations can be been made concerning the type and usage pattern ofthe medicines prescribed. It was found that radical shodana treatment was onlyemployed in 52.4% of patients.Table 20 - % Types of Prescription By Type (%) Looking at the types of medicine prescribed Herb 30.5% (table 20) showed that only 8.4% of Commercial Preparation 8.4% Food commercial preparations had been used. In 2.3% Ayurvedic Formulation 39.7% 30.5% of prescriptions, single herbs had Ayurvedic Herbo Mineral 8.4% been used to make up simple compound Ayurvedic Mineral 3.8% Ayurvedic Rasa Preparation 6.1% medicines. The highest proportion, 39.7% of Ayurvedic Treatment 0.8% prescriptions, was pharmacy producedayurvedic formulations. 18.3% of prescriptions were mineral or rasa based. Thisinformation is represented in figure 4 below:© Chris St. Clair Gribble 40
    • Figure 4 - % Type of Prescription % Prescribed (by Type) Herb 39.7% Commercial Preparation 8.4% Food 3.8% Ayurvedic Formulation 6.1% 2.3% Ayurvedic Herbo Mineral 0.8% 8.4% Ayurvedic Mineral Ayurvedic Rasa Preparation 30.5% Ayurvedic TreatmentFrom the consultant interview these medicines were then assigned to a targetpathology, desired treatment outcome, and/or to semen quality characteristics, bothayurvedic and allopathic. The following 3 tables provide a view with respect to numberof medicines prescribed for each semen quality parameter or pathology, and also howmany of these medicines have more than one application. For each prescription, whereknown, the main ingredient has been identified.Table 21 - Number Prescribed Medicines - Vata Seminal Morbidity Vata Seminal # Prescribed medicines Morbidity Phenila 1 Muktha bhasma (pearl: herbo mineral) Tanu 22 Afcol (commercial), afrodet (commercial), āmalakī (Emblica (low sperm count) officinalis), aśvagandhā (Withania somnifera), bhallātaka (Semecarpus anacardium), bṛhatī cchagalyada grta (formulation: goats meat), cornitor (commercial), count plus (commercial), fortage (commercial), pañcatikta guggulu (formulation: Tinospora cordifolia), kapikacchu (Mucuna pruriens), Kokilaksha (Astercantha longifolia), ksira (milk), mashaparni (Teramnus labialis) mugdaparni (Phaseolus trilobus), musali (Asparagus adscendens) rajat bhasma (herbo mineral), satavari (Asparagus racemosus) tamra bhasma (copper herbo mineral), trivanga bhasma (lead, tin, zinc herbo mineral), ksira vidari (ipomia digata), vidharyadi ksyaya (formulation: ipomia digata) Rūkṣa 3 Kokilaksha (Astercantha longifolia), muktha bhasma (pearl: (dry, high PH) herbo mineral), musali (Asparagus adscendens)© Chris St. Clair Gribble 41
    • Vata Seminal # Prescribed medicines Morbidity Alpa 15 Aśvagandhā (Withania somnifera), bhallātaka (Semecarpus (low semen volume) anacardium), bṛhatī cchagalyada grta (formulation: goats meat), ikṣurasa (Saccharum officinarum), Kokilaksha ( Astercantha longifolia), ksira (milk), kushmanda rasayana (Benincasa hispida), mashaparni (Teramnus labialis), mugdaparni (Phaseolus trilobus), musali (Asparagus adscendens), narasimha rasayana (formulation), phala grta (formulation: triphala, Asparagus racemosus ), rajat bhasma (herb mineral), satavari (Asparagus racemosus), ksira vidari (ipomia digata) Kaphaja dusta retas 2 Bhallātaka vati (Semecarpus anacardium), navayasa loha (seminal morbidity) (iron)Within the category of vata related semen parameters (table 21), it can be seen that ofthe total medicines prescribed, 45.8% are targeted towards low sperm count, and31.3% towards low semen volume. There are relatively few medicines available for theother parameters.Table 22 - Number Prescribed Medicines - Non Vata Seminal Morbidity Non Vata # Prescribed Medicines Classification Avasādi 6 Kapikacchu (Mucuna pruriens), katphala (Myrica nagi), loha bhasma (iron herbo mineral), mandura bhasma (iron bi product: herbo mineral), purified shilajit(mineral), śuṇṭhī (Zingiber officinale) Vivarna 5 Cyavanaprāśa (formulation: Emblica officinalis), kapikacchu (discolouration) (Mucuna pruriens), loha bhasma (iron herbo mineral), (purified shilajit (mineral), triphala (formulation: Embilica officinalis, Terminalia chebula, Terminalia bellirica) Pūti 2 sārivā (Cryptolepis buchananii), uśīra (Vetiveria (offensive smell) zizanioides) Puya 3 Candana (Santalum album), cyavanaprāśa (Emblica (pyospermia) officinalis), purified shilajit (herbo mineral) Anya dhatu samsrsta 3 daśamūla (herb combination), katphala (Myrica nagi), (cellular material) manikya bhasma (ruby ash) Piccilla 7 Kapikacchu (Mucuna pruriens), loha bhasma (iron herbo (hyper viscosity) mineral), mandura bhasma (iron bi pyproduct: herbo mineral), navayasa loha (iron herbo mineral), purified shilajit (mineral), tankana bhasma (herbo mineral), triphala (Embilica officinalis, Terminalia chebula, Terminalia bellirica) Granthi 5 kaṭuka (Picrorhiza kurroa), palāśa ksara grta (Butea (poor liquefaction) frondosa), samudraphena (Sepia officinalis), sati (Hedychium spicatum) , satiyadi churna (formulation: Hedychium spicatum)© Chris St. Clair Gribble 42
    • Non Vata # Prescribed Medicines Classification Dusta retas 4 Elavāluka (Prunus cerasus), kadamba gum (Anthocephalus (non specific) chinensis), kustha (Saussurea lappa), samudraphena (Sepia officinalis) Rasayana 2 drākṣā kashaya (Vitis vinifera), drākṣāmalkadi leha (restorative) (formulation: Vitis vinifera)Within in the category of non vata ayurvedic semen parameters (table 22), there is amore even distribution of medicines available.Table 23 below identifies medicines that were identified with a specific clinical action orwhere a commercial preparation has been identified for its claimed therapeutic effect.No medicines were specifically prescribed for teratozoospermia.Table 23 - Number Prescribed Medicines - Specific Clinical Action Allopathic # Prescribed Medicines Classification 1 Normal sperm 1 Maha laxmi vilasa [with gold] (commercial) (with agglutination) Anti sperm 4 Katphala (Myrica nagi), mañjiṣṭhā (Rubica cordifolia), antibodies naradeeya laksmi vilasa (gold formulation), yastimadhu (Immunological) (Glycyrrhiza glabra) Oligozoopsermia 4 Afcol (commercial), afrodet plus (commercial), count plus (commercial), fortage (commercial) Asthenozoospermia 3 Cornitor (commercial), rajat bhasma (herbo mineral), trivanga bhasma (lead, tin, zinc herbo mineral) Teratozoospermia 0 None prescribedTable 24 identifies the medicines prescribed to treat the common pathologies associatedwith male infertility.© Chris St. Clair Gribble 43
    • Table 24 - Number Prescribed Medicines - Common Fertility Related Pathologies Allopathic # Prescribed medicines classification 2 Varicocele 14 Candana (Santalum album) , daśamūla (formulation), guḍūcī (Tinospora cordifolia), kaiśora guggulu (formulation: Commiphora mukul), ksira balā taila 101 (formulation: Sida cordifolia), laksha guggulu (formulation: Commiphora mukul), pinda taila (formulation), prasarinyadi kashaya (formulation: Sida cordata), sārivā (Cryptolepis buchananii), cold water bath (varicocele treatment), simhanada guggulu (formulation: Commiphora mukul), trayodshanga guggulu (formulation: Commiphora mukul), uśīra (Vetiveria zizanioides), yastimadhu (Glycyrrhiza glabra) Testicular 4 Kāñcanāra guggulu (formulation: Commiphora mukul), inflammation maha rāsnādi kashya (formulation: Pluchea lanceolata), mahāyogaraja guggulu (formulation: Commiphora mukul), nimbadi guggulu (formulation: Commiphora mukul) Hydrocele 4 Gokṣuradi guggulu (formulation: Tribulus terrestris), Filaria nithyananda rasa( cooper rasa preparation), punarnavardi guggulu (formulation: Commiphora mukul), varuṇadi (Crataeva nurvala) Benign prostrate 1 Bang shil (commercial: trivanga) hyperplasia Infection/UTI 13 Bhūnimba (Swertia chirita), candraprabhāvaṭi (formulation: Commiphora mukul), chopchini churna (TBC), guḍūcī (Tinospora cordifolia), jayamangala rasa (rasa preparation), kaiśora guggulu (formulation: Commiphora mukul), manikya bhasma (ruby ash), mañjiṣṭhā (Rubica cordifolia), mrityonjaya rasa (rasa preparation), sudarśana gana vati (formulation: Crinum latifolium), svarna malini vasantha rasa (cooper iron pyrite rasa preparation), tribhuvan kiriti rasa (rasa preparation), varuṇadi (Crataeva nurvala)The number and proportion of medicines appears to reflect the incidence of thepathologies observed. There also appears a disproportionately high incidence of rasapreparations to treat infection.Excluded from these tables are a further 13 medicines which had been prescribed forsystemic related illnesses and 17 medicines for general purposes, mostly related tostimulating digestion or digesting toxins (ama). Also excluded from these tables are 14medicines for sexual dysfunction, mostly pertaining to premature ejaculation.Table 25 outlines how many of these medicines have been prescribed for more than onetherapeutic application.© Chris St. Clair Gribble 44
    • Table 25 - Medicines with Multiple Applications Count (by prescription) It can be seen that in 70.2% of Mutiple Application prescriptions, the medicine was thought to Single Application 70.2% Double Application target a single pathology. However, 21.4% 21.4% Triple Application 5.3% have the potential to address 2 or more Quadruple Application 3.1% pathologies or target actions.This information is represented in the figure 6:Figure 5 - % of Medicines with Multiple Applications % Prescribed (By Multiple Action) 3.1% 5.3% Single Application 21.4% Double Application Triple Application 70.2% Quadruple Application4.3 Preferred MedicinesUsing the medicines recorded, preferred medicines to treat male infertility andcommonly associated pathology were identified. The preferred medications andtreatment approach were obtained through an informal unstructured interview with anexperienced ayurvedic consultant physician who specialises in male infertility. Therecommendations do not include preferred rasa medicines as these are restricted in theUK. It should also be noted that full panca karma radical therapy, including uttara-basti,is recommended for all seminal morbidities.© Chris St. Clair Gribble 45
    • Preferred medicines for vata dosha related semen quality parametersTables 26 indicates 2 preferred medicines for phenila, 10 for tanu, 7 for rūkṣa, and 7 forapla. All these morbidities are considered to have a good prognosis.Table 26 - Preferred Medicines - Vata Seminal Morbidity Phenila (good prognosis) Indication Indicated by frothy semen (bubbles > 1cm) Dominant in the rūkṣa quality Treatment Promote snigdha substances to increase surface tension Approach Preferred Mukta (pearl) bhasma Shatarvari (but contraindicated in Medicines high viscosity) Tanu (good prognosis) Indication Thin seminal fluid, less than the consistency of sesame oil, and with a sperm count < 20 million/ml Dominant in the laghu quality Treatment Promote heavy sweet substances Approach Promote herbs classified as sperm promoting (sukrajanaka) Herbs in italics although not classically defined as sukrajanaka are clinically assigned to this group. Preferred Aśvagandhā (Withania somnifera) Mashaparni (Teramnus labialis) Medicines Ikṣurasa (Saccharum officinarum) Mugdaparni (Phaseolus trilobus) Jaṭāmāṁsī (Nardostachys jatamansi) Musali (Asparagus adscendens) Kapikacchu (Mucuna pruriens) Satavari (Asparagus racemosus) Kokilaksha (Astercantha longifolia) Ksira vidari (ipomia digata) Rūkṣa (good prognosis) Indication Indicated by a PH above 8.5 Treatment Promote snigdha substances Approach Preferred Āmalakī (Emblica officinalis) Pravala bhasma (coral ash: when Medicines Kokilaksha (Astercantha longifolia) an allergic manifestation) Mukta (pearl) bhasma Satavari (Asparagus racemosus) Musali (Asparagus adscendens) Ksira vidari (ipomia digata)* Alpa (good prognosis) Indication Decreased seminal fluid (volume < 1.5ml) indicates maturation arrest Treatment Promote substances with qualities similar to seminal fluid i.e. Snigdha, Approach guru, madura Maturation arrest, and stimulation of both ejaculation & spermatogenesis (śukrasutikara) is a clinical theory of Dr. B. S Prasad Preferred Āmalakī (Emblica officinalis) Musali (Asparagus adscendens) Medicines Ikṣurasa (Saccharum officinarum) Satavari (Asparagus racemosus) Kokilaksha (Astercantha longifolia) Ksira vidari* (ipomia digata) Ksira (milk)* Please note that vidari kanda (Pueria tuborosa) is highly oestrogenic and should notbe used in males.© Chris St. Clair Gribble 46
    • Preferred medicines for non vata dosha related semen quality parametersTables 27 & 28 indicate the medicines prescribed for non vata seminal morbidity.Table 27 - Preferred Medicines - Non Vata Seminal Morbidity Vivarna (good prognosis) Indication Discoloured, other than grey white Pitta imbalance (pita varna) indicated by yellowish white appearance Kapha imbalance (sweta varna) indicated by milk white appearance Treatment Prescribe herbs from sukrashodana group depending on other Approach parameters Preferred Pitta reducing substances Kapha reducing substances Medicines Cyavanaprāśa (formulation: Aśvagandhā (Withania somnifera) Emblica officinalis) Kapikacchu (Mucuna pruriens) Satavari (Asparagus racemosus) Loho (iron) bhasma Sārivā asava (formulation: Purified shilajit (herbo mineral) Cryptolepis buchanani) Triphala (formulation: Embilica officinalis, Terminalia chebula, Terminalia bellirica) Pūti /localised infection (poor prognosis) Indication Putrid smell Suppuration (pus) Treatment Pitta reducing substances aimed at eliminating suppuration Approach Preferred Candraprabhāvaṭi (formulation: Sārivā (Cryptolepis buchanani) Medicines Commiphora mukul) Purified shilajit (herbo mineral) Candana (Santalum album) Uśīra (Vetiveria zizanioides) cyavanaprāśa (formulation: Emblica officinalis), Puya (poor prognosis) Indication More than 5 pus cells / hpf (high power field) High cellular debris High amorphous matter Treatment Treat for fever and infection Approach Preferred 1. Fever reducing medicines Medicines prescribed for pūti Medicines o Guḍūcī (tinospora cordifolia) o Bhūnimba (swertia chirata) o Sudarśana gana vati (formulation: crinum latifolium) 2. Infectious conditions o Manikya bhasma (ruby ash)© Chris St. Clair Gribble 47
    • Table 28 - Preferred Medicines - Non Vata Seminal Morbidity (Continued) Anya dhatu samsrsta (medium prognosis) Indication Mucoid positive Associated with significant levels of cellular material: macrophages, immature cells, epithelial cells, mucus threads, gelatinous bodies, RBC, antisperm antibodies, amorphous matter Treatment Vatakapha reducing substances Approach Oedema reducing substances Preferred Daśamūla (herb combination) ** Katphala (myrica nagi) Medicines in any form e.g. Aristha, rasayana, Kustha (saussurea lappa) uttara-basti Avasādi (good prognosis) Indication Drop of semen in water not mixing uniformly, and sinking to the bottom Indicates aggravation of vata and kapha Treatment Promote herbs to balance vata and kapha Approach Preferred Aśvagandhā (Withania somnifera) Mandura bhasma (iron bi Medicines Katphala (Myrica nagi) pyproduct: herbo mineral) Kustha (Saussurea lappa) Purified shilajit (herbo mineral) Loho (iron) bhasma Śuṇṭhī (Zingiber officinale)triphala (formulation: Embilica officinalis, Terminalia chebula, Terminalia bellirica) Piccilla (good prognosis) Indication Hyper viscosity (grades > 0) indicates low motility When a drop is released from a dropper thread formation indicates hyper viscosity Grade 1: <10cm Grade 2: <30cm Grade 3: >30cm Treatment Promote kapha reducing substances Approach Oppose kapha, guru and snigdha qualities by promoting substances that are visadha, laghu, rūkṣa Preferred Aśvagandhā (Withania somnifera) Purified shilajit (mineral) Medicines Kapikacchu (Mucuna pruriens) Tankana bhasma (herbo mineral) Loha bhasma (iron herbo mineral) Triphala (Embilica officinalis, Mandura bhasma (iron bi Terminalia chebula, Terminalia pyproduct: herbo mineral) bellirica) Granthi /kapha vata dusti (good prognosis) Indication Poor liquefaction (> 40 mins) Treatment Promote vata kapha reducing substances Approach Promote substances that are visadha and laghu Preferred Palāśa ksara grta (Butea frondosa) Purified shilajit (mineral) Medicines Sati (Hedychium spicatum) Bhallātaka vati** Please refer to the appendix 10 for the herbs contained in daśamūla© Chris St. Clair Gribble 48
    • Preferred medicines for common pathologies associated with male infertility.Tables 29 & 30 indicate the medicines prescribed for pathologies associated with maleinfertility.Table 29 - Preferred Medicines - Common Associated Pathologies Acute inflammation (scrotal swelling) Indication Pain, swelling, tenderness and sometimes history of scrotal injury Treatment Prescribe anti inflammatory & analgesic (VK) medicines Approach Preferred Target action is identified in brackets. Medicines 1. Guggulu preparations (formulations: Commiphora mukul) Kanchara guggulu [VK] Triphala guggulu [VK] Kaishora guggulu [when associated with P: varicocele] Trayodashanga guggulu [VK] Laksha guggulu [VK: and internal bleeding] Goksuradi guggulu [fluid collection] Purnavardi guggulu [fluid collection] Maha yogaraja guggulu [VK] 2. Herbal decoction Maha rāsnādi kashya (formulation: Pluchea lanceolata) [pain] Rasna erandadi (formulation: Pluchea lanceolata) [anti inflammatory/pain] Dashamula arishta [KV; shota] Varuṇadi (formulation: Crataeva nurvala) [fluid collection] Varicocele (grades 2, 3) Indication Clinical examination o Palpate spermatic chord; feels like a bag of worms o Cough impulse (laterally expansive) o Ask patient for changes in size and consistency (<18ml or 20% reduction) Positive scrotal scan Pitta body type more prone to both varicocele, and damage through heat. Clinically finds varicocele involved in about 70% cases Treatment Internal medicine is grade is below 3 Approach Surgery is indicated if testicular consistency is soft and size has decreased to below 18ml (20% reduction) Preferred 1. Vatarakta ahara Medicines Kaishora guggulu (p: varicocele) Trayodshanga guggulu (vpk: varicocele) 2. Substances dominant if cold quality to testes temperature Sārivā (cryptolepis buchananii) Uśīra (vetiveria zizanioides) Candana (santalum album) 3. Restorative medicines to restore blood vessel walls Guḍūcī (tinospora cordifolia) Yastimadhu (glycyrrhiza glabra) 4. External application to reduce temperate and restore vessel walls Pinda taila (formulation) [external]© Chris St. Clair Gribble 49
    • Table 30 - Preferred Medicines - Common Associated Pathologies (Continued) Hydrocele Indication Palpable fluid mass Transillumination Positive scrotal scan Treatment 1. Surgery Approach 2. Diuretics Preferred Following 2 diuretics are useful in reducing fluid mass: Medicines Punarnavardi guggulu (formulation: Commiphora mukul) Gokṣuradi guggulu (formulation: Tribulus terrestris),) Systemic: toxin exposure Indication Environmental toxin exposure Addictions: smoking, alcohol BMI: obesity related infertility Treatment Gradual reduction with the help of restorative medicines Approach Provide antioxidants to combat toxins exposure Preferred Shodana treatment Medicines Full panca karma Antioxidants (ayurvedic restoratives) Cyavanaprāśa (formulation: emblica officinalis) [p] Āmalakī (emblica officinalis) Aśvagandhā (withania somnifera) [k] Satavari (asparagus racemosus) Lekana (obesity) Viḍañga arista (embellica ribes)4.4 Indicative Treatment ResponseThe analysis of the sample demographics had suggested this population might not havea normal distribution with respect to underlying pathology. It also revealed a highlystratified sample providing too few cases in each pathology group to enable any cohortanalysis given the sample size. It is also known that there is natural variability insemen quality based on many co-founding variables with respect to diet and lifestylethat had not been measured.Within these limitations, an indicative measure of change was observed in the samplepopulation as outlined in table 31. No generalisation of these results should be madewith respect to potential patient outcomes.© Chris St. Clair Gribble 50
    • Table 31 - Changes in Semen Count, Motility, and Morphology (End State) Sperm Conc (Mil/Ml) Sperm Conc (Mil/Ml) Sperm Conc (Mil/Ml) % Total Abnormality % Total Abnormality % Total Abnormality % Motility (RLP) % Motility (RLP) % Motility (RLP) Case Number OAT Status OAT Status Base Line End State Base Line End State Base Line End State Base Line End State Delta Delta Delta 1 10 40 30 0 21 21 58 0 58 OA A 2 54 64 10 19 37 18 69 58 11 T N 3 15 6 -9 0 7 7 82 60 22 OAT OA 4 2 30 28 0 4 4 0 0 0 OA A 5 35 50 15 9 25 16 73 76 -3 AT T 6 50 60 10 10 13 3 0 60 -60 A A 7 10 15 5 0 0 0 83 75 8 OAT OAT 8 2 13 11 1 15 14 0 77 -77 OA OAT 9 37 60 23 29 31 2 59 0 59 NA N 10 35 90 55 9 22 13 62 0 62 AT A 11 24 110 86 19 6 -13 70 80 -10 AT AT 12 0 1 1 0 0 0 0 0 0 OA OA 13 1 5 5 0 0 0 0 0 0 OA OA 14 42 45 3 20 35 15 75 64 11 T T 15 25 50 25 4 22 18 80 99 -19 AT AT 16 18 16 -2 0 0 0 80 86 -6 OAT OAT 17 16 19 3 7 42 35 75 59 16 OAT O 18 233 105 -128 12 37 25 64 0 64 AT N 19 32 20 -12 0 0 0 78 0 78 AT A 20 19 9 -10 0 9 9 76 90 -14 OAT OAT 21 12 30 18 0 0 0 96 95 1 OT ATLooking at each case individually, 14.3% cases reached normal reference values, 38.1%cases had 1 or more parameters returned to normal, 42.9% showed no change withrespect to normal values, and 4.8% cases saw a decline in 1 or more parameters.How the total sample population changed with respect to classification is outlined intable 32. There were reductions in oligoasthenoteratozoospermia, oligoasthenospermia,oligoteratozoospermia, teratoasthenozoospermia, no change in teratozoospermia, butincreases in asthenozoospermia and oligospermia.© Chris St. Clair Gribble 51
    • Table 32 - % Change in Allopathic Semen Classification (End State) % Change - Allopathic Classification Base Line End State Delta Normal Sperm 0.0% 14.3% 14.3% Normal Sperm (Agglutination) 4.8% 0.0% -4.8% Oligoasthenoteratozoospermia (OAT) 23.8% 19.0% -4.8% Asthenozoospermia 4.8% 23.8% 19.0% Teratozoospermia 9.5% 9.5% 0.0% Oligospermia 0.0% 4.8% 4.8% Oligoasthenospermia 23.8% 14.3% -9.5% Oligoteratozoospermia 4.8% 0.0% -4.8% Teratoasthenozoospermia 28.6% 14.3% -14.3%Looking at the relative change in mean with respect to count, motility, and morphologyis represented in figure 6:Figure 6 - Mean Change for Sperm Count, Motility, & Morphology (End State) % Total Abnormality End State Mean - Sperm Count, Motility & Morphology % Total Abnormality Base Line 46.6 56.2 % Motility (RLP) End State 15.5 % Motility (RLP) 6.6 Base Line 39.9 Sperm Conc (Mil/Ml) 32.0 End State Sperm Conc (Mil/Ml) Base Line 0.0 10.0 20.0 30.0 40.0 50.0 60.0The semen data in table 31 was assessed for normal distribution and statisticalsignificance.The one sample Kolmogorov-Smirnov test showed normal distribution for all 3parameters (count, motility, and morphology) at both baseline and at end state.The Wilcox Signed Rank Test was used to assess differences between pre and posttreatment values. It is a more stringent test for significance as its calculation assumes anon normal distribution of sample data which is often present in biological systems.© Chris St. Clair Gribble 52
    • For sperm count there was a significant increase in median value (+7.9) betweenbaseline (21.5) and end state (35.0) measurements for the sample population(P=0.025). For motility, the change was also significant (P=0.002) with an increase inmedian value (+11.5) between baseline (2.5) and end state (14.0). Given both thesechanges are statistically significant, the increases in median values suggest they areattributable to the treatment intervention. However, for morphology the improvementwas not statistically significant (P=0.736), with a reduction of abnormal forms (-10.0)from a median value of at baseline (69.5) to end state (59.5).In terms of biological significance there was a mean change (+7.92) representing a24.8% improvement in semen count, for motility (+8.9) representing an improvementof 134.5%, and a reduction in abnormal morphology (-9.6) representing a 17.0%improvement. As the sample population was not homogeneous with respect topathology and each patient received a tailored treatment plan, this argues forappropriate individualisation of the treatment plans.There was also a measurable change in the ayurvedic semen parameters as outlined infigure 7:Figure 7 - Change in Ayurvedic Semen Parameters (End State) vivarna 43% 33% avasādi 43% 57% aruna varna 43% 33% tanu 38% 52% piccilla 33% 33% granthi 29% 14% anya dhatu samsrsta 29% 29% puya 14% 29% phenila 14% 38% ruksha 10% 29% alpa 5% 14% puti 0% 0% 0% 10% 20% 30% 40% 50% 60% Base Line End State© Chris St. Clair Gribble 53
    • The were improvements in phenila (24%), rūkṣa (19%), tanu (14%), avasādi (14%), puya (14%), alpa (10%), no change in anya dhatu samsrsta, pūti , andpiccilla, and a degradation in vivarna (-10%), aruna varna (-10%) and granthi (-14%).4.5 Results SummaryThus far the results section has outlined the sample population demographics, a clinicalpicture with respect to both allopathic and ayurvedic diagnosis, a summary of theprescribed medicines by pathology and/or target action, the preferred medicines, and anindicative measure of therapeutic response.5 DiscussionHow representative was the sample population with respect to expecteddemographics?The analysis of the population demographics shows a non normal distribution withrespect to both causative factor and associated pathology. From consulting theliterature a normative distribution would expect 75.1% idiopathic infertility, 12.3%varicocele and 6.6% UTI representing 94% of expected cases (Dohle et al., 2005).Our sample shows 14.3% idiopathic infertility, 52.4% varicocele and 19.0% UTI alonewhich differs markedly from the expected demographic. Further, 54.6% of varicosepatients also had infection. Although our sample showed 52.4% of varicocele, theconsultant reported an expected 70% of cases to involve varicocele. Clearly there is abias towards both varicocele and infection with or without varicocele.Whilst the higher incidence of varicocele cannot be explained, it is no surprise that therewas a correspondingly high incidence of co-infection. Studies have shown that menpresenting with varicocele have a higher incidence of accessory gland infection,epididymal pathology or immunological factors (Rowe, 2000, p51). Consequently, thesample population showed a disproportionately high number of medicines prescribed forthese 2 pathologies.Another observation was that the majority of infertile couples (94%) suffered primaryinfertility with a median period of 72 weeks before seeking treatment, and a mean ageof the male partner of 35 years. Time before treatment is highly significant as delayingtreatment by 1 year can seriously affect treatment response and patient outcomes© Chris St. Clair Gribble 54
    • (Rowe, 2000, p7). This differs from Europe where couples seek treatment much earlier,increasing the chances of a successful outcome. It has also been shown that semencharacteristics diminish with age (Kidd et al., 2001). These factors would be expected tonegatively impact both semen characteristics and successful outcomes.Generally the sample population appeared free from lifestyle factors such as smoking ,alcohol, and a diet deficient in natural antioxidants which is known to contribute tooxidative stress and reduce semen quality (Centola and Ginsburg, 1996, p19).Practically 100% of male patients were vegetarian and consuming a diet of freshunprocessed food. This is perhaps one reason why so few patients presented withidiopathic infertility, and why large variations are seen within single countries indeveloped nations (Becker and Berhane, 1997). It may also explain thedisproportionately high incidence of varicocele patients seen at SDM hospital.What constituted best practice Ayurvedic diagnosis of male infertility?Best practice diagnosis is a combination of using both allopathic and ayurvedicapproaches. A full case history and physical examination is prescribed by both systemsof medicine and is essential to illicit evidence of causation. A thorough analysiscombined with a few laboratory tests can often identify the underlying causative factorbehind the reduced semen quality. For men with sperm concentrations below 10million/ml , a screening of serum testosterone or FSH levels detects most clinicallysignificant endocrine abnormalities such as azoospermia (Sigman and Jarow, 1997).Above this threshold, concentration of inhibin B is a better measure of spermatogenesisand can be used to distinguish between testicular and non testicular causes of abnormalsperm concentration (Pierik, Vreeburg, Stijnen, De Jong and Weber, 1998). However, inmost cases reviewed the minimum level of laboratory investigation either reflected alack of results sharing between allopathic and ayurvedic institutions, or that the test hadnot been conducted on cost grounds. An overview of the case SDM history taking andphysical examination protocol is provided in the appendices 11-12.Of more interest are the ayurvedic semen quality parameters and their relevance todiagnosis. All the parameters except avasādi and phenila have been correlated withallopathic reference values. This provides both consistency of measurement and enablesa quantitative measure of the qualitative ayurvedic semen parameters. It also enables© Chris St. Clair Gribble 55
    • the ayurvedic physician to translate semen sample data from other sources and whereno direct qualitative assessment has been made.These parameters correlate directly to ayurvedic bio-energetics. Caraka outlined thatsperm that is phenila (frothy semen), tanu (low sperm count), rūkṣa (dryness: high PH),alpa (thin with low seminal volume) is vitiated by vata and said to inhibit conception.These are referred to as the vataja reto dhustis (vata seminal morbidity). The remainingparameters relate to pitta and kapha vitiation. Semen which is pūti (excessively hot andputrid) and puya (pyospermia) and has pita varna (blue or yellow discoloration) isvitiated by pitta. Semen that is avasādi (sinks in water) and piccilla (excessively slimy)or has kapha varna (milky white discoloration) is obstructed by kapha. Semen which isknotty (grathita) and sinks in water (avasādi) results from aggravated vayu obstructingthe semen through abstinence. Semen mixed with blood through excessive intercourse,ulcers, or injury is aruna varna and would have a slight reddish colour. Hence, theseparameters can be best used to identify the doshic imbalance which enables correctselection of the shodana and shamana medicine.In our sample population, the 2 unique ayurvedic parameters were in the top 3 withrespect to frequency at baseline sampling with avasādi (57%) closely followed by tanu(52%) and then phenila (38%). It was also observed that when avasādi was present,50.0% of cases also exhibited phenila and 66.7% of these cases were also tanu (lowsperm count). When phenila is present, 75.0% also exhibit avasādi and 50% of thesecases have tanu (low sperm count). Based on this observation, it suggests that avasādiand phenila are more closely associated with low sperm count, and there is a higherincidence of low sperm count when avasādi is present. Another observation was thatabstinence did not appear to be associated with co-presentation of avasādi and granthiwhere our sample showed an average abstinence time of 3.4 days (data not shown).However, in no single case, was an ayurvedic parameter not present, suggesting theseancient qualitative parameters do have diagnostic value.It is suggested that the ayurvedic community promote their use as allopathic measuresare becoming increasingly questioned with respect to predictors of both infertility andconception rates. Some evidence suggests there is extensive overlap between the fertileand the infertile regarding the accepted valid measurement protocols of count, motilityand morphology. Although each of these measures helps to distinguish between fertile© Chris St. Clair Gribble 56
    • and infertile men, none was a powerful discriminator. They conclude that none of themeasures can be considered a diagnostic measure of infertility (Guzick et al., 2001).An essential part of diagnosis is to understand the underlying pathogenesis in order totarget the treatment. Diminished semen is classically defined as involving vata, pitta,and kapha, with an emphasis on vata and pitta. These disturbed bio energies affect theplasma, bone marrow, and seminal tissues. Also affected are food digestion (jartharaagni) and tissue metabolism (dhatva agni), and the channels of plasma, sperm and themind. Hence the disease starts in the digestive system, travels via the channels ofplasma until finally the disease resides in the testes and penis.When there are indications of impaired rasa (level 1) one supports food digestion(jarthara agni). When there are indications of impaired bone marrow tissue (level 2pathogenesis) or hormonal problems one supports bone marrow tissue metabolism(dhatva agni). When there are signs of diminished sperm (level 3) one targets spermtissue metabolism (dhatva agni) & spermatogenesis. When the testes and supportingorgans are compromised (level 4) these are treated according to the associatedpathology. When there is no evidence for the previous levels then one investigatesgenetic abnormality and family history for infertility (level 5). This view was derivedfrom the consultant interview regarding levels of pathogenesis.Clinically, the consultant has observed that pitta body types with sour and pungentcharacteristics are more prone to low sperm count & premature ejaculation. They arealso more prone to varicocele.The indications for impaired digestion, channels and tissues relating to infertility areprovided in the appendices 13-15So what constitutes best practice treatment and how closely did the treatmentmirror expectations?Best practice discussed here is being positioned as the preferred treatment of anexperienced consultant specialising in male infertility.Shodana is considered an essential starting point in the treatment programme. In oursample radical shodana treatment was employed in 52% of cases and within this group© Chris St. Clair Gribble 57
    • 91% had an associated pathology such as varicocele. When inquired as to why so fewpatients underwent radical therapy it was explained that several factors limited its use.The correct implementation of shodana ideally requires an in-patient clinical setting ofbetween 1- 3 weeks or a series of ½ day hospital visits over this period. Howeverachieved, this adds considerable inconvenience and cost that is not practical for mostpatients. As such, this prevents an essential best practice treatment. It should beremembered that Suśruta informs students that 18 medicated enemas (alternating 9 oiland 9 decoction enemas) cure all disorders of semen (Murthy, 2004, SH Ci 37:71-74).Clinically, the consultant prefers to use a mustādya yāpanā enema. (Please refer to theappendix 16 for the formulation).Considering enema treatment, a PHD study investigated shodana treatment as opposedto shamana treatment in relation to oligospermia on 22 patients (Prashant, 2006). Thisresearch showed that ardha matrika enema treatment by Chakradutta showedsignificant differences in semen count (+ 98.9%), RLP (- 25.8%) and volume (+ 11.7%)over administration of aśvagandhā (Withania somnifera). The study is indicative thatshodana can influence semen parameters both positively and negatively. This wouldsuggest that researchers should ensure that shodana and non shodana cohorts areintegrated into any evidence based evaluations of ayurvedic treatment in order toelucidate the optimal treatment approach.The shaman treatment of the sample population mirrored the classical definitions withsome minor alterations in clinical application. The preferred list of 46 medicines can bereferred to in tables 26 to 30. What is discussed here is where an application differedfrom its common classical description and/or whose usage is derived from clinicalexperience or where contemporary medicines have been prescribed.For treating reduced count, motility and morphology, Saccharum officinarum indicatedas an aphrodisiac is being used to purify sperm and treat low motility and volume.Mucuna pruriens, classically indicated as the best aphrodisiac, is also being prescribedfor viśuska retas (azoospermia) and tanu (low count, hypo spermatogenesis).Astercantha longifolia and ipomia digata are all used to target spermatogenesis toincrease sperm count.Benincasa hispida classically indicated as śukravardhaka (sperm increasing) andaphrodisiac is clinically being used for alpa retas (low volume).© Chris St. Clair Gribble 58
    • The following herbs have been found clinically useful to treat both low sperm volumeand stimulate ejaculation. A clinical theory of Dr B.S. Prasad is that the low ejaculatevolumes indicate maturation arrest (śukrasutikar). Consequently Emblica officinalis,Saccharum officinarum, Astercantha longifolia, Milk, Asparagus adscendens, Asparagusracemosus, Ipomia digata are used to treating both tanu and maturation arrest.It was noticed that there was an absence of non rasa medicine to treat poormorphology. It was suggested that in the West where rasa is not permitted one shouldtarget spermatogenesis to improve morphology.For treating other seminal morbidities, muktha and pravala bhasma are being used totreat both phenila and rūkṣa. Granthi bhuta is being treated with both Picrorhiza kurroaand Hedychium spicatum. Shatarvari can also be used for phenila but is contraindicatedwhere there is high viscosity.As a medicine to treat sperm with agglutination, maha laxmi vilasa with gold, wasprescribed. It was communicated that this and other gold compounds would begenerally prescribed as a sexual tonic, but cost restricted their use. Clinical studies haveshown that gold bhasma significantly promotes the testicular tissues in animal modelsand increases both sperm count and motility human trials with particular reference toaesthenospermia (Prasad, 1997).For treating antisperm antibodies Myrica nagi, Rubica cordifolia, naradeeya laksmivilasa, and Glycyrrhiza glabra are prescribed.The application of these medicines are listed for consideration by other ayurvedicpractioners as possible treatment options pertaining to the relevant pathology.Are there alternative Ayurvedic options to treating common pathologiesassociated with male sub-fertility?Treatment options are available for the most common pathologies. As discussedpreviously varicocele was very common, and it was communicated that grades 1 to 3can be treated with medication. This provides an alternative to allopathic medicinewhere correction requires surgery and warrants further investigation.© Chris St. Clair Gribble 59
    • For treating hydrocele, goksuradi guggulu, Tribulus terrestris, and Crataeva nurvala areall used.For both varicocele & premature ejaculation the 8 guggulu formulations (kaishore,kāñcanāra, laksha, maha yogaraja, punarnavardi simhanada, trayodshanga andtriphala) are useful. Kaishore is specifically indicated for pitta dominance, andtrayodshanga for tri-dosha dominance. In addition, Cryptolepis buchananii andGlycyrrhiza glabra, both indicated for increasing semen, are being used to purify semen,treat semen antibodies, and also treat varicocele. Tinospora cordifolia indicated as anaphrodisiac and Sida cordifolia indicated as śukrala were also being used to treatvaricocele.For excessive semen count or seminal fluid Terminalia chebula, classically indicated asan aphrodisiac, is being clinically used. Pueraria tuberosa indicated for increasing semenis also prescribed for excessive secretion. Piper nigrum and Rauwolfia serpentine, notclassically indicated, is also being used for the same purpose.For premature ejaculation Abelmoschus moschatus, Papaver somniferum, Cinnamomumcamphora, Myristica fragrans, Strychnos nux vomica and Datura metal, all classicallyindicated as aphrodisiacs, are being used.For anejaculation, Asparagus racemosus, classically indicated to increase semen, isbeing used to stimulate ejaculation.Can the preferred medicines identified be used in the UK?Fortunately, a high proportion i.e. 47.8% of preferred herbs, were single herbs and37.0% were commonly available formulations. Also 50.0% were applicable to more thanone indication. This will simplify both sourcing the herb and future licensing with respectto the emerging legislation.Please note that at the time of writing, UK legislation does not permit the use of mineralor herbo-mineral compounds, rasa medicine, or any medicine that contains an animalproduct. Also some preferred medicines have been banned such as Holarrhenaantidysenterica and Embelia ribes due to toxicity, and some herbs are controlled.© Chris St. Clair Gribble 60
    • Rauwolfia serpentina and Strychnos nux vomica are prescription only, and Datura metalrequire both prescription and are have limitations with respect to dosage. Over time,other herbs are likely to be restricted, so please refer to Ayurvedic Practioners Website(Ayurvedic Practitioners Association, 2007) for an up to date listing on banned andrestricted use ayurvedic herbs.This will exclude or restrict 15.2% of medicines on the preferred list.How effective is the Ayurvedic treatment of male infertility, and what evidenceexists to support its application?The quantitative analysis of patient outcomes (table 31) has provided indicativeevidence in support of the treatment strategies. The sample population showed astatistically significant improvement in sperm count (P=0.025, 24.8%) and motility(P=0.002, 134.5%), but a non-significant improvement in morphology (P=0.248,17.0%).It was thought that the sample might have a non-normal distribution as the underlyingpathology did not reflect expected distribution. The one sample Kolmogorov-Smirnovtest found normal distribution with respect to all 3 semen parameters. The data alsoindicates that there was an increasing trend towards normal distribution as the semencharacteristics approached normal reference values.In terms of biological significance there was a mean change (+7.92) representing a24.8% improvement in semen count, for motility (+8.9) representing an improvementof 134.5%, and a reduction in abnormal morphology (-9.6) representing a 17.0%improvement.In relation to individual cases this represented attainment of normal values for 14.3% ofcases, and an improvement in a further 42.9% of cases where 1 or 2 parametersachieved normality. One case (4.8%) showed degradation, and the remaining casesshowed no improvement.Another approach was to try to evidence the herbs for their prescribed function. Asearch of the literature for common ayurvedic pharmacopoeia used in male infertility© Chris St. Clair Gribble 61
    • had found 6 herbs evidenced specifically for their affect on fertility. Of the preferredherbs, Tribulus terrestris, Withania somnifera were shown to increase spermatogenesisand Zingiber officinale to increase motility. A broader search for antioxidant activity aswould support the allopathic theory of oxidative stress found 22 herbs. Of the preferredherbs, 5 herbs were evidenced as having high antioxidant capacity (Asparagusracemosus, Mucuna pruriens, Myrica nagi, Saccharum officinarum, Terminaliachebulais), 3 herbs were found to have both antioxidant and anti-hyperlipidemic effect(Emblica officinalis, Glycyrrhiza glabra, Tinospora cordifolia), and 1 herb with bothantioxidant and improved cognitive function (Nardostachys jatamansi), suggesting itwas also acting on brain function. In this respect 28.3% of the preferred herbs could beevidenced directly or indirectly. Please refer to the literature section for the associatedreferences.The following 5 herbs found in the literature appear to demonstrate some influence onfertility, but were not on the preferred medicines list. Piper longum (Shah et al., 1998)was shown to increase sperm motility count and have a gonadotropic effect. BothTrichopus zeylanicus and Vanda tessellate have shown to be aphrodisiac in animalmodels (Subramoniam, Madhavachandran, Rajasekharan and Pushpangadan, 1997).Pueraria tuberosa was shown to have a gonadotropic effect with high estrogenicpotential. And Euryale ferox (Lee et al., 2002) was shown to have both antioxidantactivity and increase semen.The following 6 preferred herbs do not appear to be evidenced in the Western literature(PUBMED and AMED) with respect to either infertility and/or oxidative potential:Asparagus adscendens, Astercantha longifolia, ipomia digata to improve both count andmotility, Saussurea lappa to treat avasādi , and both Butea frondosa and Hedychiumspicatum to treat granthi. These herbs are suggested for future investigation.So what are the main contributions of this study?Thus far this discussion has centred on the available data, what this had to say inrespect of sample demographics, and provided a preferred list of medications for bothseminal disorders and their associated pathologies. In addition, a list of herbs for futureinvestigation has been suggested where there appears to be little contemporaryresearch. The study has also provided a clear definition of the qualitative semenparameters with associated reference values, to promote their use and recording within© Chris St. Clair Gribble 62
    • the ayurvedic community. This study has not been able to demonstrate effectiveness ofthe preferred medicines.However, perhaps the biggest contribution has been an understanding of what needs tobe assessed going forward. There was a massive gap in the data that underpins themost important aspect of best practice: the information required to diagnose and correctthe basic imbalance of the system i.e. restore homeostasis. This is the qualitative aspectof both diagnosis and treatment design that was the most elusive, and represented inthe expertise of the consultant physician.Ayurvedic diagnosis is NOT symptom identification and response, but an intricateanalysis of many system variables and underlying energetics. There is a detaileddiagnosis protocol to extract this information and plan the treatment response that israrely documented because of the sheer volume of information to document. And this isthe point where ayurveda becomes elusive and appears “qualitative” in the broadestsense of the word. Ayurveda is, in fact, a science whose methods are rarely understoodbecause the raw data is rarely exposed.In this respect, virtually no data could be extracted with regard to the systemic healthof the patient i.e. the quality of his or her digestion, tissues, and channels of circulation,waste elimination, natural immunity, and mental function. Nor was there anydocumentation of the rationale behind the treatment plan. Instead the treatment planwas reduced to a series of treatments and associated medicines.Some modern ayurvedic students and doctors could be criticised as practising allopathicmedicine using ayurvedic pharmacopoeia. In the case of semen quality, restorationshould NOT be viewed as providing a stream of antioxidant supplements or targetmedicines, but to focus on how to diagnose the imbalance, correct it, and restorehealthy seminal plasma. It is looking at the problem from the correct end i.e. ensuringhealthy seminal plasma by ensuring healthy tissue formation by promoting a balancedsystem. This view would support the emergent theories of oxidative stress in theseminal plasma or at the level of spermatogenesis as being the main factor behindreduced semen quality. It may also endorse the use of the ayurvedic pharmacopoeiawhich has a high incidence of antioxidant potential, and would be expected to limitoxidative damage.© Chris St. Clair Gribble 63
    • In this respect, ayurveda’s greatest strength could be its biggest weakness i.e. its poorapplication. It could be argued that the correct application of ayurveda should form alarge part of future evidence based investigation.Susruta advises repeated enemas to cure all seminal morbidity, including urethraldouches (Murthy, 2004, SH Ci 37:117-119). What is the true value of radical shodanatreatment? Is it to remove imbalance or toxins through the anus or bladder or is it amore direct route to target medicines to the seminal tissues? How does normal healthpromotion using shodana affect the quality of semen characteristics for both fertile andnon fertile men?Chinese medicine (outlined in appendix 17) understands male infertility as an imbalanceof the kidney system and seeks to correct kidney function. It has a defined therapeuticgoal (Lyttleton, 2004).Ayurveda would see male infertility as an imbalance of the overall system, withparticular emphasis on the plasma, bone marrow and the mind representing severaltherapeutic goals. In this sense, it is important that evidence based medicine seeks toexpose the treatment strategy in relation to a full ayurvedic diagnosis, and NOT beobscured by more convenient analysis of pathology vs. prescription.Healthy semen is more than ensuring adequate sperm motility, morphology and count.Ultimately, it is about going beyond conception and ensuring healthy offspring fromhealthy seed. It is also about preventing the long term health problems being associatedwith IVF, ICSI and no doubt in the future, artificial sperm. In this respect, a futureclinical audit should address ayurveda’s strength and not its weaknesses in application.6 ConclusionThere are two key limitations that need to be acknowledged. Firstly, to retrospectivelyanalyze best practice requires access to a large enough data set recorded in a consistentand standardised fashion. Too few cases were analyzed to ensure statistical power.Secondly, the case history recording provided limited visibility of the ayurvedic systemicdiagnostic parameters to be able to fully investigate the ayurvedic pathology, diagnosisand associated treatment plan.© Chris St. Clair Gribble 64
    • Within these limitations, a preferred list of 46 medicines for male infertility andassociated pathologies are presented for consideration. These medicines have NOT beenclinically proven so these guidelines are only recommendations to explore in one’s ownclinical practice. A review of the literature has provided indicative support for 13 ofthese preferred herbs.The quantitative analysis of patient outcomes (table 31) has provided indicativeevidence in support of the treatment strategies. The sample population showed astatistically significant improvement in sperm count (P=0.025, 24.8%) and motility(P=0.002, 134.5%), but a non-significant improvement in morphology (P=0.248,17.0%).The study indicates diagnostic value in the ayurvedic semen parameters, and provides aset of reference criteria with the hope that UK practioners will record these statistics intheir clinical practice. Shodana therapy is not being fully exploited and may bepotentially limiting therapeutic benefit. The study has also highlighted that there are nonsurgical alternatives for treating varicocele grades 1-3, but the reported benefit couldnot be evidenced from the available data.Moving forward, it is suggested that ayurvedic physicians should agree a baseline ofcase history diagnostic criteria, agree the ayurvedic semen reference standards, andensure they are recorded at monthly intervals. Data recording should also include costdata and couple conception rates to enable cost benefit analysis. It is further suggestedthat ayurvedic researchers ensure that shodana and non shodana cohorts are integratedinto any evidence based evaluations to elucidate the optimal treatment approach. It alsosuggests that the ayurvedic treatment of varicocele grades 1-3 warrants investigationas allopathic medicine can only provide a surgical solution.© Chris St. Clair Gribble 65
    • 7 ReferencesAgarwal, A., Prabakaran, S. & Allamaneni, S. S. (2006). Relationship betweenoxidative stress, varicocele and infertility: a meta-analysis. Reprod Biomed Online. 12,(5), p.630-3.Aitken, R. J., Harkiss, D. & Buckingham, D. (1993). Relationship between iron-catalysed lipid peroxidation potential and human sperm function. J Reprod Fertil. 98,(1), p.257-65.Aitken, R. J., West, K. & Buckingham, D. (1994). Leukocytic infiltration into thehuman ejaculate and its association with semen quality, oxidative stress, and spermfunction. J Androl. 15, (4), p.343-352.Alam, A., Iqbal, M., Saleem, M., Ahmed, S. & Sultana, S. (2000). Myrica nagiattenuates cumene hydroperoxide-induced cutaneous oxidative stress and toxicity inSwiss albino mice. Pharmacol Toxicol. 86, (5), p.209-14.Almeida, J., Novoa, A. V., Linares, A. F., Lajolo, F. M. & Genovese, M. (2006).Antioxidant activity of phenolics compounds from sugar cane (Saccharum officinarum)juice. Plant Foods Hum Nutr. 61, (4), p.187-92.Andallu, B. & Radhika, B. (2000). Hypoglycemic, diuretic and hypocholesterolemiceffect of winter cherry (Withania somnifera, Dunal) root. Indian J Exp Biol. 38, (6),p.607-9.Andersen, A. N., Gianaroli, L., Felberbaum, R., de Mouzon, J. & Nygren, K. G. (2006).Assisted reproductive technology in Europe, 2002. Results generated from Europeanregisters by ESHRE. Hum Reprod. 21, (7), p.1680-97.Ayuvedic Practitioners Association. [online]. (21 March 2007). London: APA. Availablefrom: http://www.apa.uk.com/ [Accessed 18 April 2007].Becker, S. & Berhane, K. (1997). A meta-analysis of 61 sperm count studiesrevisited. Fertil Steril. 67, (6), p.1103-8.Berman, M. (2004). Report on optimal evaluation of the infertile male. Fertil Steril.82 Suppl 1, p.S123-30.Bhatnagar, M., Sisodia, S. S. & Bhatnagar, R. (2005). Antiulcer and antioxidantactivity of Asparagus racemosus and Withania somnifera in rats. Ann N Y Acad Sci.1056, p.261-78.Bonduelle, M., Wennerholm, U. B., Loft, A., Tarlatzis, B. C., Peters, C., Henriet, S., Mau,C., Victorin-Cederquist, A., Van Steirteghem, A., Balaska, A., Emberson, J. R. &Sutcliffe, A. G. (2005). A multi-centre cohort study of the physical health of 5-year-oldchildren conceived after intracytoplasmic sperm injection, in vitro fertilization andnatural conception. Hum Reprod. 20, (2), p.413-9.© Chris St. Clair Gribble 66
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    • 8 Appendices8.1 Bhāvaprakāśā Herbs, Formulations, and Dietetic SupplementsBhāvaprakāśā nighantu, compiled in the 16th century, is the most comprehensiveclassical summary of Ayurvedic pharmacopeia. There are 22 sections grouped bysimilarity which list 220 substances with relevance to male infertility:karpūra (odorous substances) group Sanskrit Latin Latin English Fertility name name Family Name Effect Dārusitā Cinnamomum Lauraceae Cinnamon Increases semen (dālcini) zeylanicum Gandha None None Civet cat Increases semen mārjāra vīrya secretion Guggulu Commiphora Burseraceae Indian bdellium Aphrodisiac (fresh) mukul Karpūra Cinnamomum Lauraceae Camphor laurel Aphrodisiac (uncooked) camphora Kastūrī None None Deer musk Increases semen (dried) Latā kastūrī Abelmoschus Malvaceae Wild okra Aphrodisiac moschatus Prapauṇḍarīk Cassia Fabaceae White lotus Increases semen absus Prṛkkā Anisomeles Lamiaceae Malabar catmint Aphrodisiac malabarica Silhaka Liquidambar Altingiaceae Oriental Aphrodisiac orientalis sweetgum Increases semen Sthāuṇeyaka Polygonum Poacae Knot grass Increases semen granthiparnā aviculare Tvak patra Cinnamomum Fabaceae Cassia cinnamom Destroys semen aromaticumvaṭādi (trees) group Sanskrit Latin Latin English Fertility name name family Name Effect Kaṭabhī Albizia Fabaceae Black siris Decreases semen procera Mokṣha Schrebera Oleaceae Mokha (alkaline Cures disorders (śveta) swietenioides substance) of semen Palāśa Butea Leguminosae Bastard teak Aphrodisiac frondosa (papilioneae) Pārīṣa pippala Thespesia Malvaceae Portia tree Increases semen populnea Putrajīva Putranjiva Putranjivaceae None Aphrodisiac roxburghii Śālmalī Salmalia Bombacaceae Silk cotton tree Aphrodisiac mocarasa malabarica (gum resin) Tūṇī Cedrela Meliaceae Toon Aphrodisiac toona© Chris St. Clair Gribble 73
    • hāriṭakyādi (fruits or roots) Sanskrit Latin Latin English Fertility name name Family Name Effect Ajamodā Apium Apiaceae Celery seeds Aphrodisiac graveolens Āmalakī Embilica Euphorbiaceae Indian Aphrodisiac officinalis gooseberry (best) Bhallātaka Semecarpus Anacardiaceae Marking nut Aphrodisiac (flesh anacardium Bhallātaka Semecarpus Anacardiaceae Marking nut Increases semen (seed) anacardium Dhāñyaka Coriandrum Apiaceae Coriander Excess sativum Non aphrodisiac Jīvaka* Microstylis Orchideaceae. None Increases semen Substitute: wallichii Vidārī Kākolī* Roscoea Zingiberaceae Kakoli Increases semen Substitute: procera aśvagandha Khākhasatila Papaver Papaveraceae Poppy seeds Aphrodisiac somniferum Kṣīra-kākolī* Lilium Liliaceae. White lily Increases semen Substitute: polyphyllum aśvagandha Kuṣṭha Saussurea Asteraceae Costus root Increases semen lappa Laśuna Allium Alliaceae Garlic Aphrodisiac sativum Mahāmedā* Polygonatum Ruscaceae King’s Solomons Aphrodisiac Substitute: cirrhifolium seal śatāvarī Medā* Polygonatum Ruscaceae Whorled Aphrodisiac Substitute: verticillatum Solomons seal śatāvarī Pippalī Piper Piperaceae Long pepper Aphrodisiac longum ṛddhi* Habenaria Orchidaceae None Aphrodisiac Substitute: edgewothii vārāhikanda ṛṣabhaka* Microstylis Orchideaceae None Increases semen Substitute: muscifera Vidārī Śuṇṭhi Zingiber Rosaceae Dry ginger Aphrodisiac officinale Vṛddhi* Habenaria Orchidaceae None Increases semen Substitute: latiabris vārāhikanda Yaṣṭimadhu Glycyrrhiza Fabaceae Liquorice Increases semen glabra Yavānī Trachyspermum Apiaceae Ajowan Reduces pain for ammi dischargeHerbs marked with an asterix belong to a subgroup called aṣṭa varga. Bhāvamiśra saysthat these herbs are difficult to obtain so has provided substitutes which have beenlisted accordingly.© Chris St. Clair Gribble 74
    • guḍūcyādi (5 parts or roots used) group Sanskrit Latin Latin English Fertility Name Name Family Name Effect Arka (śveta: Calotropis Apocynaceae Gigantic swallow Aphrodisiac flowers) gigantea wort Asthisaṁhāra Vitis Vitaceae Veld grape Aphrodisiac quadrangularis Aśvagandhā Whithania Solanaceae Winter cherry Produces semen (roots) somnifera Bhūtṛṇa Cymbopogon Poaceae Lemon grass Non aphrodisiac citratus Chilahinta Cocculus Menispermaceae None Efficient hirsutus aphrodisiac Gañdha Paederia Rubiaceae Maile pilau Aphrodisiac prasāranī foetida Gokṣura Tribulus Zygophyllaceae Small caltrop Aphrodisiac terrestris Guñdra Typha Typhaceae Elephant grass Aphrodisiac (roots) elephantina Jalapippalī Lippia Verbenaceae Matchweed Increases semen nodiflora Jīvaka Microstylis Orchideaceae None Increases semen wallichii Jīvantī Leptadenia Asclepiadaceae Asclepiadaceae Increases semen reticulata Kākolī Roscoea Zingiberaceae Kakoli Increases semen procera Kapikacchu Mucuna Fabaceae Velvet bean Best aphrodisiac (seeds) pruriens cowhage Karpasa Gossypium Malvaeae Cotton plant Aphrodisiac (seeds) arboreum Kokilākṣa Asteracantha Acanthaceae None Aphrodisiac longifolia Kṛṣṇa sārivā Cryptolepis Asclepiadaceae Sarsaparilla Produces semen buchanani Kṣīra-kākolī Lilium Liliaceae. White lily Increases semen polyphyllum Kumārī Aloe Alliaceae Aloe vera Aphrodisiac barbadensis Mahāmedā Polygonatum Ruscaceae King’s Solomons Aphrodisiac cirrhifolium seal Māṁsarohiṇī Soymida Meliaceae Indian redwood Aphrodisiac febrifuga Māṣaparṅī Teramnus Fabaceae Rabbit vine Increases semen labialis Medā Polygonatum Ruscaceae Whorled Aphrodisiac verticillatum Solomons seal Mudgaparṇī* Phaseolus Leguminosae Wild gram Increases semen trilobus Pṛsniparnī Uraria Fabaceae None Aphrodisiac picta ṛddhi Habenaria Orchidaceae None Increases semen edgewothii ṛṣabhaka Microstylis Orchideaceae None Increases semen muscifera Sankapushpi Convolvulus Convolvulaceae Bind weed Aphrodisiac pluricaulis© Chris St. Clair Gribble 75
    • Sanskrit Latin Latin English Fertility Name Name Family Name Effect Śatāvarī Asparagus Alliaceae Wild asparagus Produces semen racemosus Śigru Moringa Moringaceae Horseradish tree Increases semen pterygosperma Śigru (seeds) Moringa Moringaceae Horseradish tree Destroys semen pterygosperma Sveta sārivā Hemidesmus Apocynaceae Indian Produces semen indicus sarsaparilla Śvetapuṣpa Solanum Solanaceae Yellow berried Bestower of kaṇṭakārī xanthocarpum nightshade children Vidāri Pueraria Fabaceae Indian kudju Produces semen tuberosa Vṛddhadāruka Ipomoea Convolvulaceae None Aphrodisiac per-caprae Vṛddhi Habenaria Orchidaceae None Increases semen latiabris Yaṣṭika Glycyrrhiza Fabaceae Licorice Increases semen Yaṣṭimadhu glabrapuṣpa varga (flowers) group Sanskrit Latin Latin English Fertility Name Name Family Name Effect Damanaka Artemisia Asteraceae Mugwort Aphrodisiac vulgaris Kamala Nelumbo Nelumbonaceae Sacred lotus Aphrodisiac (flower tuber) nucifera Kubjaka Rosa Rosaceae Musk rose Aphrodisiac moschata Mallikā Jasminum Oleaceae Jasmine Aphrodisiac sambac Śatapatrīka Rosa Rosaceae Rose flower Increases semen centifoliaāmrādi phala (fruits) group Sanskrit Latin Latin English Fertility Name Name Family Name Effect Āmra Mangifera Anacardiaceae Mango tree Aphrodisiac (ripe fruit) indica Āmra Spondias Anacardiaceae Ripe mango Aphrodisiac mangifera Dāḍima Punica Lythraceae Pomegranate Increases semen (sweet) granatum Drākṣā Vitis Vitaceae Grape Aphrodisiac (gostanī) vinifera (big variety) Kadalī Musa Musaceae Plantain fruit tree Aphrodisiac paradisiaca Kālinda Citrullus Cucurbitaceae Water melon Reduces semen (seeds) lanatus seeds Kharbūja Cucumis Cucurbitaceae Melon Aphrodisiac melo Lakuca Artocarpus Moraceae Monkey jackfruit Destroys semen (unripe) lakoocha roxb (unripe)© Chris St. Clair Gribble 76
    • Sanskrit Latin Latin English Fertility Name Name Family Name Effect Madhūka Madhuka Sapotaceae Butter tree Increases semen (like dhakati) indica fermentation Makhānna Euryale Nymphacaeae Fox nut Aphrodisiac (fruit) ferox gorgon fruit Nārikela Cocos Arecaceae Coconut Increases semen nucifera Padmākṣa Nelumbo Nelumbonaceae Sacred lotus Aphrodisiac (lotus seeds) nucifera Panasa Artocarpus Moraceae Jack fruit tree Increases semen heterophylla Priyāla Buchanania Anacardiaceae Cuddapah Aphrodisiac lanzan almond. Seva Pyrus Rosaceael Apple Increases semen malus Śṛṇgāṭaka Trapa Trapaceae Water caltops Aphrodisiac bispinosa increases semen Vātāda Prunus Rosaceae Almond Aphrodisiac amygdalusdhātvādi (metals) group Sanskrit English Fertility Name Name Effect Abhraka bhasma Mica ash Aphrodisiac (processed well) Copulate with 100 women Hīraka Male diamond Increase vigour and vitality Nāga bhasma Lead ash (poorly prepared) Increases sexual desire (processed well) Rasa Processed mercury Aphrodisiac (processed well) Rūpya bhasma Silver ash (poorly prepared) Destroys semen (processed poorly) Suvarṇa bhasma Gold ash (well prepared) Aphrodisiac (processed well) Suvarṇa bhasma Gold ash (poorly prepared) Destroys vitality of men (processed poorly) Tāra mākṣika Iron copper pyrites AphrodisiacDhānya (corns & cereals) group Sanskrit Latin Latin English Fertility Name Name Family Name Effect Caṇaka Cicer Leguminosae Chick pea Reduces semen (imature) arietimum Cāruka Saccharum Poaceae Bengal cane Aphrodisiac (seeds) munja gremineae Godhūma Triticum Poaceae Wheat Increases semen sativum Godhūma Triticum Poaceae Wheat Increases semen (madhulī) sativum (small variety) Māṣa Phaseolus Fabaceae Black gram Increases semen mungo© Chris St. Clair Gribble 77
    • Sanskrit Latin Latin English Fertility Name Name Family Name Effect Niṣpāva Dolichos Fabaceae Flat bean, Indian Destroys semen lablab bean Rakta śāli Oryza Poaceae Rice Aphrodisiac (fresh paddy) sativa ṣaṣṭika (ripe) Oryza Poaceae Rice paddy Aphrodisiac sativa Tila Sesamum Pedaliaceae Sesame seed Increases semen indicum Uma Linum Linaceae Linseed Loss of semen usitatissimum Yāvanāla Sorghum Poaceae Jawar, guinea Aphrodisiac vulgare cornśāka (vegetables) group Sanskrit Latin Latin English Fertility Name Name Family Name Effect Alābū Lagenaria Cucurbitaceae White gourd Aphrodisiac siceraria ḍoḍikā Strychonos Loganiacae Button seed fruit Aphrodisiac Kupīlu fruit nuxvomica Seed poisonous Kalambī Ipomoea Convolvulaceae Swamp cabbage Produces semen reptans (more) Kāsamarda Cassia Leguminosae Negro coffee Aphrodisiac (leaves) occidentalis Kaseru Scirpus Cyperaceae Water chestnut Increases semen kysoor Kolaśimbī Dolichos Fabaceae Black Increases semen Kulattha biflorus Horse gram Kūṣmāṇḍa Benincasa Cucurbitaceae Ash gourd Aphrodisiac cerifera Paṭola Trichosanthes Cucurbitaceae Pointed gourd Aphrodisiac dioica Paṭola Trichosanthes Cucurbitaceae Pointed gourd Aphrodisiac (leaves) dioica (leaves) (unctous) Śālūka Nelumbium Aceraceae Egyptian lotus Aphrodisiac (tuber) speciosum Śitivāra Marsilea Marsileaceae Aquatic clover Aphrodisiac minuta Vastuka Chenopodium Chenopodiaceae Lambs quarters Bestows semen album Vṛñtāka Solanum Solanaceae Brinjal Increases semen melongena (egg plant)māṁsa (meat) group Sanskrit English Fertility name Name Effect Bhākura Fish species (unidentified) Aphrodisiac Caṭaka Sparrow or tree sparrow Increases semen greatly Chāga Goat Increases semen Eḍaka Species of sheep Aphrodisiac Illīsa Fish species (unidentified) Aphrodisiac Kośastha Animals with shells Aphrodisiac© Chris St. Clair Gribble 78
    • Sanskrit English Fertility name Name Effect Kukkuṭa Fowl or poultry Increases semen aphrodisiac Kūlecara Shore birds Aphrodisiac Madgura Fish species (unidentified) Aphrodisiac Mahiṣa Buffalo Aphrodisiac Matsya Fish Aphrodisiac Matsya All fish but especially kṣudra, Aphrodisiac a small type of fish Matsya garbha Fish eggs Aphrodisiac Mocika Fish species (unidentified) Aphrodisiac Nyaṇku Hog-deer Aphrodisiac Pādina Aquatic animals with legs Aphrodisiac Pakṣi aṇḍa Bird eggs Aphrodisiac Parṇaṁrga Tree dwellers Aphrodisiac Plava Birds that swim Increases semen Prasaha Birds that cut or pull out food Loss of semen with feet Proṣṭhī Fish species (unidentified) Aphrodisiac Rohita Red carp (best fish) Aphrodisiac Vartaka Button quail Bestows semen Viṣkira Peckers AphrodisiacIn the meats group, fish from broad wells are said to increase semen, whereas fish fromrivers, big lakes, and water falls is said to be aphrodisiac. For meat of birds, cock wingmeat is considered best. For quadrupeds the meat of the upper portion of the female ispreferred.kṛtāñna (prepared foods) group Sanskrit Preparation Fertility name Description Effect Alīka matsya A large nāgavallī (betal) leaf is coated with green gram paste Aphrodisiac and steam cooked, then fried in oil. This is consumed dry or soaked in butter milk. Aṅgārakarkaṭī Dry wheat cakes Increases semen Beḍhamikā Barley pan cakes with māṣa (green gram) Increases semen aphrodisiac Cipiṭā Paddy soaked in water, fried and flattened Aphrodisiac Dhārājala Fresh rain water Increases semen Dugdha kūpikā Solid portion of femented milk mixed into balls with rice Aphrodisiac flower and fried in ghee. Balls immersed in a water solution scented with camphor. Harīsā Thin meat stew with ghee and spices ( hiṇgu jīraka haridrā Increases ārdraka śuṇṭi and lavaṇga) with rice wheat and lemon juice semen Kṛśarā Rice porridge with pulses added with salt ārdraka and hiṇgu Increases semen Kuṇḍalinī (jalebī) A liquid mixture of soured curd, wheat and ghee is fried in Aphrodisiac ghee. This is immersed in sugar water scented with camphor. Lapsikā Wheat dough fried in ghee added to sweet milk with marica Aphrodisiac etc© Chris St. Clair Gribble 79
    • Sanskrit Preparation Fertility name Description Effect Māṁsa śrṇgāṭaka Śuddha māṁsa cut into small pieces and steamed. Small are Aphrodisiac made by mixing the steamed meat with spices (lavaṇga hiṇgu lavana marica ārdraka elā jīraka and dhānyaka), ghee and nimbū juice. The meat is used to fill envelopes of wheat flower which are then fried in ghee. Maṇṭhaka Wheat dough made with ghee is fried in ghee (poori). A sugar Aphrodisiac solution is made with elā lavaṇga karpūra (camphor) marica etc. The poori are immersed for a few minutes and removed. Nārikela kṣīrikā Sweet coconut milk pudding Aphrodisiac Sahadraka Śuddha māṁsa made with goat’s thigh meat Highly aphrodisiac Śāli saktu Rice flour drink Increases semen Sarasa vaṭaka Vaṭaka are dry cakes made from green gram dough mixed Increases with salt ārdraka and hiṇgu. Crumbled vaṭaka is then soaked semen in butter-milk added with fried jīraka hiṇgu and lavana Śarkarodaka Sugar disolved in water with powders of elā lavaṇga karpūra Increases (camphor) and marica semen Śuddha māṁsa Haridrā and hiṇgu first fried in oil and used to pan fry meat. A Highly stew is made by slow cooking with a little water. The meat is aphrodisiac macerated with cooked rice, nāgavallī (betal), lavaṇga (clove) and marica Talita māṁsa Śuddha māṁsa deep fried in ghee Increases semen/ojas Tāpaharī Māṣa or rice flower with haridrā fried in ghee Aphrodisiac Yava roṭikā Barley pan cakes Increases semen Yava saktu Barley flour drink sexual prowessvāri (water) group English Fertility Sanskrit Name Effect Name Dhārājala Fresh torrential rain water Increases semendugdha (milk) group Sanskrit English Fertility name Name Effect Āvika dugdha Sheep’s milk Increases semen Go dugdha Cows milk Aphrodisiac (best) Hastinī Elephants milk Aphrodisiac Mahiṣa dugdha Buffalos milk Increases semen Santānikā Cream of milk; milk sugar Increases semen, aphrodisiac Takrapinḍa Solid portion: fermented milk AphrodisiacIn the milks group, sheep milk is best boiled and drunk warm, and goat’s milk is bestboiled and drunk cold. Milk boiled and drunk warm mitigates vata and kapha whereasmilk boiled and cooled mitigates pitta.For the aphrodisiac effect milk should be boiled whole without dilution. Milk drunk beforenoon is aphrodisiac and at night increases semen. Milk produces semen immediately.© Chris St. Clair Gribble 80
    • dadhi (curds) group Sanskrit English Fertility name Name Effect Dadhisara Cheese Aphrodisiac Mahiṣa dadhi Buffalo curd Aphrodisiac Sarkarādi sahita dadhi Curds added with sugar Aphrodisiac Svādu dadhi Sweet (non sour) curd Aphrodisiactakra (butter milk) group Sanskrit English Fertility name Name Effect Takra Butter-milk Aphrodisiacnavanīta (butter) group Sanskrit English Fertility name Name Effect Go navanīta Cows butter Aphrodisiac Mahiṣa navanīta Buffalo butter Increases semenghṛta (ghee) group Sanskrit English Fertility name Name Effect Gavya ghṛta Cows ghee Aphrodisiac Mahiṣa ghṛta Buffalo ghee Aphrodisiactaila (oil) group Sanskrit English Fertility Name Name Effect Eraṇḍa Castor oil Aphrodisiac Khasabīja Opium seed oil Aphrodisiac Tila Sesame oil Aphrodisiacmadhu (honey) group Sanskrit English Fertility Name Name Effect Madhu All honey (big blue sized bees) Aphrodisiacikṣu ( sugarcane) group Sanskrit English Fertility name Name Effect Guḍa Molasses Aphrodisiac Ikṣu All old varieties of sugar cane Aphrodisiac Kāṇḍekṣu Sugar cane Aphrodisiac Khaṇḍa Solid sugar Increases semen, aphrodisiac Matysyaṇḍī Sugar cane variety Aphrodisiac Phāṇita Sugar cane syrup Increases semen Tāpadekṣu Wild cane (near water) Aphrodisiac© Chris St. Clair Gribble 81
    • Based on the foods, minerals and animal products above, Bhāvaprakāśa (Murthy, 2001,BP Uk 1:2-48) defines 16 aphrodisiac formulations to improve reproductive potential. Indications Formulation Aphrodisiac Vajikara yogas mixed with ghee and licked for 21 days maksika dhatu honey loha churna (bashma) (bashma) vidanga pathya Aphrodisiac Vajikara yogas mixed licked with honey guduci Ela magadhika satva Sita(sugar) Aphrodisiac Vajikara yogas Cooked as a milk pudding Milk godhuma (nursing cow) flour Excites Makaresvara rasala sexual power powdered and filtered into an earthen pot smeared with aguru & karpura left undisturbed for several days dadhi curd honey 40g sunthi (32g) lavanga (10g) 1230g ghee 40g maricha (16g) (sour & sweet) kanda 640g (candy sugar) Best Goksuradi modaka aphrodisiac Fried in ghee equal to the powder. Then cooked in milk 8X powder adding as contains sugar 2X quantity of all all goksura vajigandha musali yasti aphrodisiac iksura bija satavari kapikacchu nagabala drugs bija bala increases Madana manjari vati sexual Bhasma mixed with equal quantity of and prowess bhasma (1 shatarvari 1 part) part abhraka 4 parts vanga 2 parts Above 2X quantity of equal Added to sugar 2X quantity of all mix: added with ghee and honey caturjata nagara sugar ghee jatiphala devapuspa honey maricha lavanga kana jatipatra Best Basta anga (goat’s testicles) aphrodisiac Cooked with ghee Best Kacchapa (tortoise eggs) aphrodisiac Cooked with ghee Increases Rativallabha modaka / pūgapāka virility & Puga cooked in water, dried and powdered is cooked with milk, ghee, sugar Sexual until it reaches a thick consistency prowess pūga 400g ghee 80g sugar 2000g 40g churna each added: 40g bhasma each added: elā dhāñyaka vañga© Chris St. Clair Gribble 82
    • Indications Formulation nāgabalā kaserukā nāga balā maduka loha capalā śñgaṭaka abhraka jātīphala jīraka kastūrī liñgikā pṛthvika karpūra jātīatra yavānika tālīsapatra kamala mūla patra māmsī tvak miśī viśvā methikā vīrana vidārikañda vālkala musalī kañda musta aśvagañdhā triphalā karcūra vamśarocana nāgarkesara varī marica vāranī cārabijā drākṣā śalmalībijā ikṣura gajapippali gokṣura kamala bīja mahat kharjura sveta ksirika cañdana phala rakta cañdana lavañga Great Kameśvara modaka aphrodisiac Rativallabha plus the following drugs 10g each 10g each ½ total of khurāsānī potha other drugs ajamodā samudra śoṣa bhañgā dhattūra bīja mājūphala arkarabha khasaphala tvak Aphrodisiac Āmrapaka lehya Following mixed with 2560g water and cooked to thick consistency Taken 40g after meals ripe āmra sitā (sugar) ghee 640g nāgara 320g (mango) 2560g marica 160g 10240g pippalī 80g add 40 g each of the following after cooled add dhāñyaka grañthikā honey 320g jīraka nāgekesara pathyā ela bija citraka lavangā mustaka jātīphala tvak grañthika bṝhatjīraka© Chris St. Clair Gribble 83
    • Indications Formulation Cures Gokṣura impotence by Boiled in goat’s milk and taken with honey improper coitus Increases Mahā cañdāndi taila semen Paste made with 750mg of each of the following Paste added to 640mg taila and cooked over a mild heat An old man For anointing body becomes like cañdana latākastūri uśira nakha a youth raktacañdana silhaka māmsi rāla pattañga freś dārusitā dhātaki kusuma kālīyaka kumkuma murā grañthiparṇi aguru jātīphala karpūra mañjiṣṭhā kṛṣñāguru lavañga śaileya tagara devadāru sūkṣma elā bhadramustā sikthaka saralā mahat elā reṇuka padmaka kankola phala priyañgu tūnī tvak śrivāsa karpūra patra guggulu kastūri nāgakesara lākṣā vālaka Aphrodisiac Madhu pakva harītakī lehya 40g each of the following cooked with 2560g of pathya and 1280g water until soft daśamūla viśvā tvo niśā dhāñyaka kaṇā pippalī dhātrī devekusuma citraka saiñdhava jañtughna rājavṛkṣa kapittha rakta śihari trikaṇṭaka vibhītaki rohītaka śṛñgī vṛddhadaru mula kaṭphala dañtī devadāru kuberākṣi marica drākṣa punanavā vīraña ajājī Honey added and kept for 3 Honey added after a further 5 days, then days after another 10 days Confection put into a earthen pot smeared with ghee with more honey and kept for a few days premature Vānarī vaṭi ejaculation boiled in milk added to sugar and fried in ghee non erection Used morning/evening 3.75mg kapikaccū 160g milk 40g sugar 2X immersed in honey quantity withholds Ākārakarabhādi vati ejaculation 10g each powdered and added to ahiphena, mixed well and stored 500mg powder consumed at night mixed with honey ākārakarabha kumkuma jātīpuṣpa ahiphena śuṇṭhī kaṇā cañdana lavañga jātīphala© Chris St. Clair Gribble 84
    • 8.2 Speman (Himalaya Commercial Formula)Each Speman tablet contains: Powders Salabmisri (Orchis mascula) 130mg Kokilaksha (Hygrophila auriculata Syn. Asteracantha longifolia) 64mg Vanya kahu (Lactuca scariola Syn. L.serriola) 32mg Kapikachchhu (Mucuna pruriens) 32mg Suvarnavang (Mosaic gold) 32mg Extracts Vriddadaru (Argyreia speciosa Syn. A.nervosa) 64mg Gokshura (Tribulus terrestris) 64mg Jeevanti (Leptadenia reticulata) 64mg Shaileyam (Parmelia perlata) 32mg8.3 Literature Search StrategyA review of the literature was conducted looking for association with oxidative stress asthe theoretical cause behind OAT syndrome, and also for research on male infertility,fertility agents, and hyperlipidemia.A search across PUBMED, AMED, Google Scholar, and the Medknow collection of IndianMedical Journals for the botanical names of 94 herbs classically prescribed wasconducted using the following search terms. AMED Search on Botanical Name Botanical Name PUBMED Search on Botanical Name Botanical Name PUBMED Search on Botanical Name Antioxidant AND "Antioxidants"[MeSH] PUBMED Search on Botanical Name Infertility AND "infertility" [MESH] PUBMED Search on Botanical Name Fertility Agents AND "Fertility Agents"[MeSH] PUBMED Search on Botanical Name Hyperlipidemia AND "Hyperlipidemias"[MeSH] PUBMED Search on Botanical Name Gonadotropic AND "Gonadotropins"[MeSH] MEDKNOW Search on Botanical Name Botanical Name Google Scholar Search on Botanical Name Botanical Name© Chris St. Clair Gribble 85
    • 8.4 Middlesex University Ethical Approval© Chris St. Clair Gribble 86
    • 8.5 SDM Hospital Study Approval© Chris St. Clair Gribble 87
    • 8.6 Data Collection Template - Semen Analysis Patient ID: Date of Birth: Semen Parameters Result Abstinence (days) Container condition Collection method Masturbation/coitus Interuptus/penile vibrator Collection time Examination time Liquefaction time (mins) Appearance Normal/mucoid /gelatinous bodies Colour Greyish white Yellowish white Milky white Odour Musky Offensive Volume (ml) PH Viscosity (grade 1 2 3) Sperm Count (mill/ml) Motility RLP (rapid linear progressive) SLP (slow linear progressive) NP (no linear progressive) IMM (immotile movement) Agglutination (%) Agglutination type Immobilization (%) Round cells Pus cells Macrophages Epithelial cells Immature cells Amorphus Matter (grade 1+ to 4+) Morphology Total abnormal form Head abnormality Mid piece abnormality Headless Ayurvedic parameters Phenila (frothy semen) Avasādi (semen sinking in water)© Chris St. Clair Gribble 88
    • 8.7 Allopathic Semen Quality Reference DataIdiopathic oligospermia is indicated by less that 20 million/ml sperm concentration withno known pathological cause.Idiopathic asthenozoospermia requires normal sperm concentration but with reducedmotility. Reduced motility is defined as below 25% rapid linear progression (RLP) or lessthat 50% of combined RLP and slow linear progression (SLP).Idiopathic teratozoospermia requires normal sperm concentration and motility, but lessthan 40% normal morphology.8.8 Data Transformation Rules Qualitative Transformation rules Reference Abstinence NR transformed as 3 days Liquefaction Time NR transformed as 20 minutes Incomplete transcribed as 120 minutes Appearance Gelatinous = (gelatinous) Mucoid = (thin mucoid, watery mucoid, viscous, slight viscous, incomplete liquefaction) Normal = (nr, greyish white) Watery = (thin) Colour Greyish white = (grey white, normal, NR) Milky white Yellowish white = (whiteish yellow, yellow, pale yellow) Odour Normal = (musty, NR) Pūti = (strong) PH PH assigned as 7.5 if not recorded 9.0 if labelled as alkaline Viscosity Viscosity grade 0 = normal No liquefaction = 100 Pus Cells Higher number in range translated to absolute number. Macrophages % translated to raw number Epithelial Cells NR as 0 Immature CellsPlease note that all cells not recorded (NR) were considered normal, pathology absentor normal clinical values© Chris St. Clair Gribble 89
    • 8.9 Ayurvedic Semen Quality Reference Data (SDM Hospital) Ayurvedic Indication Prognosis Semen Parameters Phenila Indicated by frothy semen (bubbles > 1cm) when Good blowing air through sample Tanu Thin seminal fluid, less than the consistency of Good (low sperm sesame oil, and with a sperm count < 20 million/ml count) Dominant in the laghu quality Ruksha Indicated by a PH above 8.5 Good (dryness) Dominant in the rūkṣa (dry) quality Alpa Decreased seminal fluid (volume < 1.5ml) Good (low semen Indicates maturation arrest (clinical theory) volume) Aruna varna Pinkish discolouration Good (discolouration) Indicative of epithelial damage (RBC) Avasādi Drop of semen in water not mixing uniformly, and Good sinking to the bottom Indicates aggravation of vata and kapha Vivarna Discoloured, other than grey white Good (discolouration) Pitta imbalance (pita varna) indicated by yellowish white appearance Kapha imbalance (sweta varna) indicated by milk white appearance Puti Putrid smell Poor (offensive smell) Suppuration (pus) Indicative of localised infection Puya More than 5 pus cells / hpf (high power field) Poor (pyospermia) High cellular debris High amorphous matter Indicative of localised infection Anya dhatu Mucoid positive Medium samsrsta Associated with significant levels of cellular material: (cellular macrophages, immature cells, epithelial cells, mucus material) threads, gelatinous bodies, RBC, antisperm antibodies, amorphous matter Piccilla hyper viscosity (grades > 0) indicates low motility Good (viscosity) when a drop is released from a dropper thread formation indicates hyper viscosity Grade 1: <10cm Grade 2: <30cm Grade 3: >30cm Granthi Poor liquefaction (> 40 mins) Good (poor liquefaction)© Chris St. Clair Gribble 90
    • 8.10 Daśamūla Herbs Sanskrit Latin Latin Name Name Family Agnimantha Clerodendrum phlomidis none Bilva Aegle marmelos Bengal quince Bhatī Solanum indicum Large egg plant Gokṣura Tribulus terrestris Small caltrops Kaṇṭakārī Solanum xanthocarpum Yellow berried night shade Kāśmarī (Gambhārī) Gmelina arborea none Pāṭalā Stereospermum suaveolens none Pṛśṇiparṇī Uraria pcita none Śaliparṇī Desmodium gangeticum Salpan Śyonāka Oroxylum indicum Indian trumpet flower8.11 Physical Examination (Male Infertility) Examination Area Examination Criteria Testes Palpate Size: normal rage 12-25ml, maximum 30ml Look for lumps, hard nodules Inspect Scrotal folds (less indicates a swelling) Pigmentation (changes indicate pathology) Epididymis Palpate Tenderness Consistency Soft/firm/hard Nodules (implies blockage) Caput (top) Cauda (tail) Spermatic chord Palpate Roll between fingers Smooth (normal) Hard (indicates pathology) Varicocele investigation Feels like bag of worms Positive cough impulse (lateral expansion) Vas deferens Palpate Swelling Tenderness© Chris St. Clair Gribble 91
    • 8.12 Case History Taking (Infertility) Case History Information elicited Marriage History Marriage time Infertility period Duration trying time Contraception History Contraception duration Conception type Duration since stopping contraception Conception History Number of previous conceptions Conception outcome Termination/miscarriage trimester Consanguineous marriage Cervical incompetence Uterine growths Rh(+) female, Rh(-) foetus ABO incompatibility Antisperm antibodies Family History Parents/siblings Infertility Delayed conception Still birth Miscarriage Positive indication Implies either genetic imbalance (bija dosha) with poor prognosis Shodana therapy advised Childhood Illness Cryptorchidism Age correction before 8 years of attainment of secondary sexual characteristics Continuous high grade fever (mumps, typhoid) During puberty results in permanent damage After puberty is temporary and reversible Scrotal Injury Often overlooked especially when pain is intermittent or of short duration Positive indication may implicate varicocele Occupation Investigate Radiation High temp environments Polluted environments Sedentary occupations Dietetic habits Pain/inflammation will result in teratozoospermia Habits Smoking Pan masha (mixture that is chewed) Drugs Ledine (local coca cola) The above will lead to teratozoospermia© Chris St. Clair Gribble 92
    • Case History Information elicited Secondary Sexual Illicit date of attainment Characteristics Sexual History Sex life Coital frequency Satisfaction level (confirm with partner) Posture used STDs Premarital exposure UTIs STDs contracted Routine History Surgery Major illness8.13 Systemic Ayurvedic Diagnostic Parameters (Digestive Imbalance)Samagni (normal)Samagni is food is digested in the proper scheduled time, without trouble, and this typeof digestion is conducive to health. This functional state is more likely to be found inpersons of dual or triple dosa prakrtiVisamagni (erratic)Visamagni is where digestive functional capability will vary from one time to the nextproducing flatulence, abdominal pain, and obstruction to the normal passage of faeces.This functional state is more likely to be found in persons of vata prakrti or will developin people who over indulge in vatakara aharavihara (vata aggravating foods andactivities).Tiksnagni (powerful)Tiksnagni is where digestive strength is so strong that food is digested earlier than thescheduled time causing an abdominal burning sensation, sour eructation, and thirst.This functional state is more likely to be found in persons of pitta prakrti or will developin people who over indulge in pittakara aharavihara (pitta aggravating foods andactivities).Mandagni (weak)Mandagni is where digestive strength is so weak that not even a small quantity of foodcan be digested in the scheduled time causing heaviness in the abdomen, stasis of food,and difficulty in breathing. This functional state is more likely to be found in persons ofkapha prakrti or will develop in people who over indulge in kaphakara aharavihara(kapha aggravating foods and activities). Most diseases occur from mandagni.© Chris St. Clair Gribble 93
    • 8.14 Systemic Ayurvedic Diagnostic Parameters (Channel Imbalance) Channels Symptom Seat Plasma Asraddha (disrespect for food) Heart (hridaya) Aruci (anorexia) Vessels Asaya vairasya (bad taste in mouth) Arasajnata (no sense of taste) Gaurava (heaviness) Tandra (drowsiness) Pandutva (pallor) Srotavarodha (channel blockage) Klaibya (impotency/infertility) Avasadata (lassitude/low energy) Krisha angata (wasted parts emaciation) Agni nasa (poor agni) Ayadha kala valee (premature wrinkles) Ayadha kala palita (premature greying/falling of hair) Bone Marrow Parvanām ruja (joint pain) Bones & joints Bhrama (giddiness) Murhca (fainting/coma) Tamo dashana (blackouts) Parva mula arūnśi (wounds in the joints) Sperm Klaibya (infertility) Vrsana (testes) Aharshana /nasta kamata (impotency) Sepha (penis) Alpayu (short life) Mental Poor memory Mind Low enthusiasm Heart Loss courage Loss affection Loss strength Loss happiness© Chris St. Clair Gribble 94
    • 8.15 Systemic Ayurvedic Diagnostic Parameters (Tissue Imbalance) Dhatus Vrddhi (increase) Ksaya (decrease) AH Sutrastana, Chap 11, p156 AH Sutrastana, Chap 11, p158 Plasma Swadu dwesa (aversion to sweet Hrtpida (heart pain) (Rasa) foods) Hrddrava (palpitation) Dyspepsia ( agni mandya) Skin dryness (twak rukshata) Excess salivation (praseka) Malaise (glani) Lassitude (aalasya) Dehydration (sosha) Feeling of heaviness (gourava) Exhaustion (srama) White colouration (sweta varna) Noise intolerance (sabdaashuinutha) Faeces Urine Eyes Skin Flaccidity (saithilya) Dyspnoea (swasa) Cough (kasa) Narcolepsy (atinidrata) Bone Metacarpo phallageal swelling (parva Parva bheda (cutting pain in joints) Marrow stoula Alpa sukrata (reduced semen) (Majja) Arumsika (small ulcers) Oestoeporosis (asthi sausirya) Heaviness Vertigo (brama) Eyes (netra gourava) Vision blurring ( tamo darsahana) Body (anga gourava) Nervous disorders (pratata vata rogas) Semen Sukradhikya (increased semen) Pain in penis & testes (medhara (Sukra) Excessive libido (ati stree kamata) vrsha na) Seminal calculi (shukra ashmari) Feeling of hot fumes from the urethra Ejaculation with blood Anejaculation Impotence (klaibya) Low ejaculate (alpa shukra) Feeling of heat in urethra (Medhra dhumayana) Tiredness (srama) Flaccidity (sadana) Anaemia ( pandu) Debility (dourbalya) Dry lustreless face ( mukha sosha)© Chris St. Clair Gribble 95
    • 8.16 Mustādya Yāpanā Enema Formulation mustādya yāpanā basti [SDM College, Hassan, Karataka] Reference caraka saṁhitā kalpa siddhi staña 12-16 Karmas brmhana, Vrsha , vājīkaraṇa, bala Indications promotes Cures semen, muscle, strength Stiff knee joints, thighs, calf regions, and region of the urinary Cures bladder kṣata kṣīna (consumption) kasa , Cures gulma, colic pain, viṣama jvara aśmarī, unmada, arśa, prameha, vardana (inguinal swelling), flatulence, vāta rakta, PK kuṇḍala (circular movement of diseases wind) udāvarta (upward movement Instantly promotes strength of wind) , pelvic pain, dysuria, Rejuvenates body asg-ṛajaḥ (menorrhagia), visparpa (erysipelas), pravāhikā (dysentery), headache Contra indications None Kalpa (order is always Saindhava, honey, taila, kalka, kasaya, adi 1. Mix until a liquid consistency 10-15 2. Mix in for 5 mins mins maha masa taila 80-100ml Saindhava 5g Maduka 80g 3. Pre mix into a bolus with kasya (total 4. Add 250ml kseera 25g); add and mix in for 2-3 minutes mustadi kshira paka 30g Mustadi rajayapana kalka 1 pala each: mustā uśīra balā śata-puṣpā madhuka kuṭaja phala āragvadha rāsnā mañjiṣṭhā kaṭu- rasāñjana priyaṅgu saindhava rohiṇī trāyamānā purnarnavā Plus bibhītaka guḍūcī śāla-parṇī bṝhatī aswagandha kaṇṭakārī gokṣura madana bala Milk 250ml Water 1000ml (slowly evaporate water) Reduced to 1/4th 5. Add 100ml goat mamsa soup 100g goat meat Water 400ml Reduce to ¼ volume Success Indicators Application no separation of oil and liquid General rule for Niruha basti Whole volume, luke warm, for max 48min retention. If retained longer induce removal with virechana suppository© Chris St. Clair Gribble 96
    • 8.17 Traditional Chinese Medicine (Male Infertility)What is the TCM treatment response to the problem of male sub-fertility?Just as an overview of the allopathic response has been outlined, in the same fashion abrief overview of the TCM approach is outlined to provide a wider context to analysis ofthe ayurvedic literature.Chinese medicine is an important energetic based form of medicine that is widelypractised across the world. The following summary on the TCM treatment approach isderived from “Treatment of infertility with Chinese medicine” (Lyttleton, 2004).Sperm which constitutes about 1% of the ejaculate is dynamic, fast moving andrepresents Yang energy, whilst the seminal fluid which is moistening and nourishingrepresents Yin energy. Both these aspects are considered in the treatment of maleinfertility.In Chinese medicine, male reproduction is governed by kidney function. In over 60% ofcases, male infertility is diagnosed as a deficiency of Kidney Yin or kidney Yang. Dampheat and blood stagnation seen as secondary causes behind male infertility are regardedas complications of kidney deficiency.A kidney Yang deficiency is considered the fundamental disorder of male reproductionwhich is evidenced by poor sperm manufacture and loss of sexual function. Patientsreport loss of libido, impotence, lethargy, cold intolerance, a pale coated tongue, and asoft slow pulse. Associated kidney symptoms are frequent copious pale urine, slightincontinence, lower back and knee pain. Sperm tests usually show both reduced spermcount and motility.A kidney Yin deficiency raises body temperature impacting sperm production, dryingseminal fluid, and sometimes is associated with inflammation of the prostrate gland.Patients report restlessness, a thin wiry body, hot at night, thirst, red face, red tongueand a rapid pulse. Often there is high libido and premature ejaculation. Associatedkidney symptoms are increased urination, dark scanty urine, poor urine flow, and© Chris St. Clair Gribble 97
    • tinnitus and heel pain. Sperm tests usually show high sperm count with reducedmorphology, motility and oocyte penetration.Damp heat is evidenced by abnormal discharge from the penis, is indicative of aninfection, and usually associated by painful urination or tenderness of the testes. Thistype of low grade infection is rare in developed countries where antibiotics areprescribed for GUI infections. Where damp heat is a complication of a kidney deficiency,damp heat is always treated first.Qi and blood stagnation includes all conditions that obstruct the passage of sperm orblood circulation. Varicocele would be included in this category and is treated with bloodmoving formulas.A guiding formula, Bu Shen Yi Jing Fang, to treat male infertility is included in theappendices. This formula is adjusted according to the relative Yin or Yang deficiency.There is some clinical evidence to support the effectiveness of this formula. One studyinvolved 16 childless couples where the problem was diagnosed as male sub-fertility andall went on to produce children (Hui, 1996).Bu Shen Yi Jing FangThe following base formula addresses most factors in kidney related male infertility: Polygonum Chinese blood tonic He Shou Wu (root) multiflorum Polygonaceae knotweed (> semen) Rehmannia Chinese Shu Di (root) glutinosa Scrophulariaceae foxglove root kidney yin wolfberry tree Gou Qi Zi (fruit) Lycium chinense Solanaceae fruit kidney yin Shan Yao (root) Dioscorea opposita Dioscoreaceae Chinese yam Invigorate Qi Shan Zhu Zu Japanese (fruit) Cornus officinalis Cornaceae cornel fruit kidney yin Tu Si Zi (seed) Semen Cuscutae Convolvulaceae Dodder Seed kidney yang Chinese Fu Pen Zi (fruit) Rubus chingii Rosaceae Raspberry kidney yang Nu Zhen Zi (fruit) Ligustri Lucidi Oleaceae Privet fruit kidney yin Chinese peony Bai Shao (root) Paeonia lactiflora Paeoniaceae root blood tonic Mu Dan Pi (bark) Moutan Radicis Ramunculaceae Moutan bark Cools blood© Chris St. Clair Gribble 98
    • Codonopsis Codonopsis Dang Shen (root) Pilosulae Campanulaceae Root Invigorate Qi Astragalus Huang Qi (root) membranaceus Leguminosae Milkvetch Root Invigorate Qi Epimedium Yin Yang Huo brevicornum Epimedium (herb) Maxim Berberidaceae Herb kidney yang Rou Cong Rong Cistanche Desertliving (herb) deserticola Orobanchaceae Cistanche kidney yang morindae Ba Ji Tian (root) officinalis Rubiaceae Morinda Root kidney yang Suo Yang (Fleshy Cynomorium Cynomorium Stem) songaricum Cynomoriaceae Herb kidney yang Regulates Salvia miltiorrhiza blood, calms Dan Shen (root) Bge Labiatae Red Sage Root mind Deer Horn Lu Jiao Pian Deer Horn (Antler) none (Antler) kidney yang kidney yin heat Han Lian Cao Ecliptae Prostratae Asteraceae Eclipta alba deficiency Asparagus asparagus kidney yin heat Tian Dong (tuber) cochinchinensis Asparagaceae tuber deficiency Phellodendron Phellodendron kidney yin heat Huang Bai (bark) amurense Rutaceae Bark deficiencyIf Yin deficiency is marked or there is Yin deficiency heat then add: Regulates Chuan Xiong (root) Ligustici Wallichii berberidaceae Chuānxiōng blood Regulates Tao Ren (seed) Prunus persica Rosaceae Peach Seed blood Regulates San Qi (root) Panax notoginseng Araliaceae san qi bloodAnd remove Yin Yang Huo, Suo Yang and reduce Ba Ji Tian and Rou Cong RongIf yang is marked with signs of cold then add: Cinnamomum cassia-bark Rou Gui (bark) cassia Lauraceae tree kidney yang Aconitum (Zhi) Fu Zi (root) charmichaeli Ranunculaceae Aconite kidney yang© Chris St. Clair Gribble 99
    • 8.18 Glossary (Ayurvedic Terms) Ayurvedic Term Translation Agnikarma Cauterization Alpa retas Low seminal volume Anuvasana Oil enema through anal route Anya-dhātu-saṁṣṣṭa Semen mixed with other tissue elements Avasādi Semen sinking in water Bījopaghātaja klaibya Impotence caused by seminal diminution Dhvajabhaṅgaja klaibya Impotence caused by a non erectile phallus Doshas 3 body energetics, vata (air), pitta (fire), kapha (water) Granthi Semen which is vitiated by vata is knotty through suppression of sex Jarāja klaibya Impotence caused by old age Kapha Bio-energy dominant in water Klaibya Impotence or infertility Kṣāra Alkalis Panca karma 5 radical purification techniques through nose administration, therapeutic vomiting, therapeutic purgation, medicated enemas, and blood letting Phenila Frothy semen Piccila Slimy semen Pitta Bio-energy dominant in fire Pūti Semen with putrid smell Rūkṣa Ununctous semen Shamana Pacification and balancing the bio energies through medication and various treatments as distinct from shodana Shodana Radical expulsion of imbalanced energies and bio toxins Śukra Sperm, seminal fluid and seminal tissue Śukra kashaya Reduced semen, seminal fluid, compromised seminal tissue Śukra pravartana Increasing flow, fluidity and volume of semen. The coordinating function that eases of expulsion of seminal fluid Śukra shodana Sperm purification i.e. increases semen quality Śukradharakala Seventh layer of the body producing semen Sukrajanna Sperm promoting substances Śukra-kṣayaja klaibya Impotence caused by excessive loss of semen through sexual intercourse or masturbation Sukrala Encompasses vrsha , śukra jannana, and śukra pravartana Śukravardhaka Sperm increasing Tanu Thin semen Uttaravasti Decoction enema through urethral injections Vājīkaraṇa Reproductive capacity encompassing functional capacity and sexual arousal at the level of the brain Vata Bio-energy dominant in air Viśuska retas Azoospermia Vivarṇa Discoloured semen Vrsha Aphrodisiac substances© Chris St. Clair Gribble 100