Sukradusti kc013 udp

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EFFECT OF PUSHPADHANVA RASA IN THE MANAGEMENT OF SUKRA DUSTI W.S.R. TO OLIGOZOOSPERMIA, Magan Singh Shekhawat, 2006-2007, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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Sukradusti kc013 udp

  1. 1. EFFECT OF PUSHPADHANVA RASA IN THE MANAGEMENT OF SUKRA DUSTI W.S.R. TO OLIGOZOOSPERMIA By Dr. Magan Singh Shekhawat Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of Doctor of Medicine (M.D) In Department of Kayachikitsa Under the guidance of Dr. U.N.PRASAD M.D (AYU) Principal Co-Guide Dr. NIRANJAN RAO. M.D. (Ayu) Assistant Professor S. D. M. COLLEGE OF AYURVEDA, UDUPI 2006-2007
  2. 2. Rajiv Gandhi University of Health Sciences DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled “EFFECT PUSHPADHANVA RASA IN THE MANAGEMENT OF SUKRA DUSTI W.S.R. TO OLIGOZOOSPERMIA” is a bonafide and genuine research work carried out by me under the guidance Dr. U.N.PRASAD M.D. (Ayu), Principal, Department of Kayachikitsa Date: Signature of the candidate Place: Udupi Dr. Magan Singh Shekhawat
  3. 3. Rajiv Gandhi University of Health Sciences CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “EFFECT OF PUSHPADHANVA RASA IN THE MANAGEMENT OF SUKRA DUSTI W.S.R. TO OLIGOZOOSPERMIA” is a bonafide research work done by Dr. Magan Singh Shekhawat in partial fulfillment of the requirement for the degree of Doctor of Medicine (Ayu) Date: Signature of the Guide Place: Udupi Dr U.N.PRASAD M.D. (Ayu) Principal Department of Kayachikitsa
  4. 4. Rajiv Gandhi University of Health Sciences ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “EFFECT OF PUSHPADHANVA RASA IN THE MANAGEMENT OF SUKRA DUSTI W.S.R. TO OLIGOZOOSPERMIA” is a bonafide research work done by Dr. Magan Singh Shekhawat under the Guidance of Dr. U.N.PRASAD M.D. (Ayu) Principal, Department of Kayachikitsa. Dr. G. Shrinivasa Acharya Dr. U.N.Prasad HOD Principal Date: Date: Place: Udupi Place: Udupi
  5. 5. COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose. Date: Dr. Magan Singh Place: Udupi Signature of the Candidate © Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. Dedicated to My Beloved Parents
  7. 7. ACKNOWLEDGEMENTS With a bowed head, to the almighty; I express gratitude beyond words to my guide Dr U.N.Prasad M.D (AYU), Principal, S.D.M. College of Ayurveda for his encouragement, wholehearted support and helpful suggestion. I am extremely happy to express my deepest sense of gratitude to my beloved and respected Dr. Niranjan Rao, Asst professor Department of Kayachikitsa whose sympathetic scholarly suggestions and guidance at every step. I am extremely happy to express my deepest sense of gratitude to my beloved and respected H.O.D. Dr. G. Shrinivasa Acharya, for his valuable support and cooperation through out the thesis work. I express my deep sense of gratitude to Dr Jonah, Dr Shreelatha, Dr Lavanya, and Dr Veera Kumar for their valuable support. I also express my all hearted thanks to my most beloved friends Dr M.S.Thirunavukkarasu, Dr Mahesh patil, Dr Kuldeep patil, Dr Ramesh, Dr Ranjit Patil, Dr Shobha, Dr Deepthi, Dr Harish, Dr Sagar Shah, Dr Asha, and Dr Gautam. With lots of love and regards I am again thankful to my parents, Sister and my wife Dr (Mrs.) Santoshi Shekhawat and all my family for rejuvenating support, love and affection towards me, which kept me always going on. I am grateful to the librarian Mr. Harish Bhat, asst. librarian and to Mr. Kinni, digital library in charge for providing valuable books and internet services in time throughout my study. Place : Udupi Date : 15/09/2006 Dr. Magan Singh Shekhawat
  8. 8. ABBREVIATIONS A.H. Ashtanga Hridaya A.S. Ashtanga Sangraha AJOC American Journal of Obstetrics and Gynecology Am J Ep American Journal of Epidemiology BMJ British Medical Journal Br J Ur British Journal of Urology Bh.Pra.Ni. Bhavaprakasha Nighantu Bhi. Rat. Bhaishajya Ratnavali Br.U Brahma Upanishada C.S Charaka Samhita Chi. Chikitsa Sthana F St Fertility Sterility JCEM Journal of Clinical Endocrinology & Metabolism J Ur Journal of Urology J Adr Journal of Andrology J Ped Surg Journal of Pediatric Surgery Ga.pu Garuda Purana H.S Harita Samhita Hum Rep Human Reproduction Int Med Internal Medicine Kal Kalpasthana M.N. Madhava Nidana Ni. Nidana Sthana N.A. Nighantu Adarsha NEJM New England Journal of Medicine R.V Ruga veda S.S. Sushruta Samhita Sha. Shareera Sthana
  9. 9. Sha.S. Sharangadhara Samhita Su. Sutrasthana T.A Taittiraya Aranyaka T.B.M.P Text Book of Medical Physiology U Uttaratantra Vi Vimanasthana Y.R Yoga Ratnakara
  10. 10. ABSTRACT Male infertility is defined as the inability of a man to father a child after one year of regular unprotected intercourse. Although male infertility may be associated with impotence, many infertile men have perfectly normal and happy sexual relationships. About 8% to 10% of couples of reproductive age experience infertility, and in approximately 40% of these cases male infertility is the major factor. Another 40% of infertility problems are caused by abnormalities of the woman's reproductive system, and the remaining 20% involve couples who both suffer reproductive difficulties. Male factors appear to be increasingly recognized as a cause of infertility .Not all men with abnormal semen tests will have problems conceiving and in fact many men whose random tests are abnormal have an entirely normal fertility history. There is enormous variation from sample to sample and month to month in each of the parameters mentioned in study. What is important is what range the counts are in rather than what the absolute number is. For the management of sukradushti W.S.R to oligogozoospermia, pushpadhanva rasa was selected which is having Shukra vridikara and sukra dhatu utpatti properties and the dose fixed is 125mg twice daily with milk for 8 weeks. After 8 weeks of treatment the following results were obtained. It is single blind clinical study with pre test and post test design where minimum of 20 patients diagnosed with clinical condition shukrakshya were selected between age group of 25- 40 years of age. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  11. 11. Though the study was basically on oligozoospermia and observation shows that the sperm count was significantly increased by 54.34%. Other areas of improvement are as follows:- Volume (25.85% ↑), RLP motility (43.07% ↑), SLP motility (19.14 %↑), liquefaction time (13.07↓), pus cells (13.39 %↓), Orgasm (48.9 %↑), desire (40 %↑), erection (63.4 %↑). All this parameters shows statistically significant results. The study also reveals that it has also significant effect on pus cells, volume etc so it can be taken for further studies. After the treatment with Pushpadhanva rasa 20% patients able to impregnate their wives, where as 30% of patients attained normozoospermia. 40% of patients had marked improvement and 10% patients had no change in sperm count. KEY WORDS:- Infertility Sukra Sukradusti Sperm Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  12. 12. CONTENTS PART - I: INTRODUCTION 1-3 PART - II: OBJECTIVES OF THE STUDY 4 PART – III: REVIEW OF LITERATURE 5-70 Historical Review 5-7 Disease Review 9-27 Derivation of Sukra 9 Definition 9 Qualities of Sukra 10 Evolution of Sukra 11 Functions of Sukra 12 Sukradusti 14 Nidana 14 Bheda 47 Roopa 20 Samprapti 23 Chikitsa 24 Sadhyasadhyata 27 Upadrava 27 Pathya-Apathya 27 Modern Review 28-58 Drug Review 59-60 PART - IV: METHODOLOGY 61-64 PART – V: RESULTS 65-103 PART –VI: DISCUSSION 104-112 PART –VII: CONCLUSION 113-115 PART –VIII: SUMMARY 116 PART –IX: BIBILIOGRAPHY 117-125 PART –X: ANNEXURES 126-134
  13. 13. LIST OF TABLES Sr.No Titles of Table Page No 1 Drug review 60 2 Incidence of Age Group 65 3 Incidence of Religion 66 4 Incidence of Occupation 67 5 Incidence of Socio-economic status 68 6 Educational Status of Patients 69 7 Incidence of habitat 70 8 Incidence of satva 71 9 Incidence of sara 72 10 Incidence of samhanana 73 11 Incidence of satmya 74 12 Incidence of pachakagni 75 13 Incidence of koshta 76 14 Incidence of prakriti 77 15 Incidence of nidra 78 16 Incidence of diet 79 17 Incidence of addictions 80 18 Incidence of vyayama 81 19 Incidence of vaya 82 20 Incidence of main complaint 83 21 Incidence of marital life span 84 22 Incidence of relation with partner 85 23 Incidence of psychological status 86 24 Incidence of surgical intervention 87 25 Incidence of drug toxicity 88 26 Incidence of vericocele 89 27 Incidence of sukrakshya lakshana 90 28 Effect on sperm count 91 29 Effect on volume 92 30 Effect on RLP 93 31 Effect on SLP 94 32 Effect on liquification 95 33 Effect on pH 96 34 Effect on pus cells 97 35 Effect on orgasm 98 36 Effect on rigidity 99 37 Effect on ejaculation 100 38 Effect on desire 101 39 Effect on erection 102 40 Over all effect of treatment 103
  14. 14. LIST OF FIGURES Sr.No Titles of Table Page No 1 Types of sukradusti 19 2 Incidence of Age Group 65 3 Incidence of Religion 66 4 Incidence of Occupation 67 5 Incidence of Socio-economic status 68 6 Educational Status of Patients 69 7 Incidence of habitat 70 8 Incidence of satva 71 9 Incidence of sara 72 10 Incidence of samhanana 73 11 Incidence of satmya 74 12 Incidence of pachakagni 75 13 Incidence of koshta 76 14 Incidence of prakriti 77 15 Incidence of nidra 78 16 Incidence of diet 79 17 Incidence of addictions 80 18 Incidence of vyayama 81 19 Incidence of vaya 82 20 Incidence of main complaint 83 21 Incidence of marital life span 84 22 Incidence of relation with partner 85 23 Incidence of psychological status 86 24 Incidence of surgical intervention 87 25 Incidence of drug toxicity 88 26 Incidence of vericocele 89 27 Incidence of sukrakshya lakshana 90 28 Effect on sperm count 91 29 Effect on volume 92 30 Effect on RLP 93 31 Effect on SLP 94 32 Effect on liquification 95 33 Effect on pH 96 34 Effect on pus cells 97 35 Effect on orgasm 98 36 Effect on rigidity 99 37 Effect on ejaculation 100 38 Effect on desire 101 39 Effect on erection 102 40 Over all effect of treatment 103
  15. 15. INTRODUCTION 1 INTRODUCTION Infertility is the failure of a couple to become pregnant after one year of regular, unprotected intercourse. In both men and women the fertility process is complex. Even under ideal circumstances, the probability that a woman will get pregnant during a single menstrual cycle is only about 30% and when conception does occur, only 50% to 60% of pregnancies advance beyond week twenty. In many cases, infertility is caused by a combination of problems in both partners that conspire to prevent conception from occurring. About 8% to 10% of couples of reproductive age experience infertility, and in approximately 40% of these cases male infertility is the major factor. Another 40% of infertility problems are caused by abnormalities of the woman's reproductive system, and the remaining 20% involve couples who both suffer reproductive difficulties. Infertility affects one in 25 American men. More than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both. Oligozoospermia is one such condition for the cause of infertility, which is alone, is about 5% in India. Whether sperm counts are declining overall in industrialized countries is a controversial issue1 . It has been shown that reproductive potential of human population has a tendency to diminish. Approximately, 20% couples can be threatened by infertility out of those, male partners can be suspected for a leading reason of this disorder accounting for 40–60% cases. At the same time, modern techniques of assisted reproduction (ART) although quite aggressive, cannot exceed 1/3 part of couples who wish to be successful in procedures of in vitro fertilization. An increased sensitivity of males to spermatogenetic disorders became one of the hot issues, intensively studied throughout the world. The need for a wider range of methods of fertility regulation for men has been a consistent recommendation emanating from a number of international for over the past few years but still lacking in it for success. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  16. 16. INTRODUCTION 2 There is no doubt that modern medicine inspires awe. IVF laboratories and sophisticated ultrasound scanning machines appear very impressive and reassuring when you are infertile. However, paradoxically, even though the effectiveness of reproductive technology has improved dramatically, more infertile patients than ever before have become dissatisfied with their medical care today. This situation has resulted in a move towards “alternative medicine”, which has become increasingly popular all over the world. Even in the United States of America (the bastion of high-tech scientific medicine), more than 20 per cent of infertile couples have consulted an alternative medicine practitioner, mainly because they were unhappy with modern medical care2 . In Ayurveda, Vajikarana is the branch which deals with producing healthy progeny for the creation of a better society. A vaji is a horse or stallion. These are substances that give the power or vitality of a horse, particularly the horse's great capacity for sexual activity. More commonly, one could call them "aphrodisiacs". Though they are much more than superstitious love potions. Vajikaranas reinvigorate the body by reinvigorating the sexual organs. Hence, it deals with various diseases like infertility and conditions relating to weak shukra dhatu or the vital reproductive fluids of the body. Apart from prescribing a lot of effective formulations to provide nutrition to enhance the quality of these vital body fluids it specifically emphasized to lead a highly disciplined life. Charaka states the use of aphrodisiacs as mentioned in ayurvedic therapies enhance one's potency. Vajikarana means the medicine or therapy by which the man becomes capable of copulating with the woman. It also helps in nourishing the body of the person. The shukra dhatu has a direct link with ojas or the immunity of the body. Hence, Vajikarana prescribed the therapeutic use of various aphrodisiacs and tonic preparations for enhancing the vigor and reproductive capabilities of men that also strengthens other body tissues (dhatus) like muscles, fats, bones and blood. Vajikarana is mainly concerned Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  17. 17. INTRODUCTION 3 with therapies concerning specific remedies for male infertility and impotence as well as female infertility. They serve as good aphrodisiacs and induce an immediate sense of pleasurable excitement, along with increased fertile seminal secretions even in an ageing person3 . Vajikarana substances may be used either to improve sexual vitality and functioning, or to help direct sexual energy inwards for regeneration. Most of these are not simple aphrodisiacs - substances exciting sexual activity through irritation of the sexual organs. Many are tonics that actually nurture and give direct sustenance to the reproductive tissues. Others help promote the creative transformation of sexual energy for the benefit of the body-mind. By starting in the reproductive system, these herbs invigorate the entire system, just as a tree is invigorated from the roots. They have a strong revitalization action on the nerves and bone marrow, and increase the energy of the mind. Semen is the Soma of the body, which if catalyzed in the right way, by Rasayana and Vajikarana substances, brings about the renewal of the mind. In a similar way it helps strengthen the bones, muscles, ligaments and blood. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  18. 18. OBJECTIVE OF THE SRUDY 4 OBJECTIVE OF THE STUDY To evaluate therapeutic efficacy of Pushpadhanva Rasa in Oligozoospermia. Conceptual study of sukra dusti & its role in infertility Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  19. 19. REVIEW OF LITERATURE 5 HISTORICAL REVIEW VEDAS AND UPANISHDH:- Vedas ancient treaties of knowledge are having plenty of references about the “SUKRA” .The main contributing factor for male reproduction is considered as SUKRA. It has physical properties such as nirmala4 , subhra, sveta and sukla5 .Though many of the synonyms are used to denote the SUKRA. Putraeshana {desire for the progeny}, is one of the primary desire of the mankind. A very good description has been mentioned in Upanishad 6 . To have a better progeny various types of therapies has been explained and among them which are still followed is vajikarana and vrushya treatments. Same concept for better procreation has been explained at the time of Atharva Veda (4th and 8th khanda). To have a healthy baby is desire of every parent, for such many of the concept like garbhadhana, madhuvidhya, garbhadosh nivarana has been explained. But there are no A direct reference has been quoted about shukradushti and its various varieties. Only the excellancy of Ashwini kumars has been explained in infertility.7 In Taittiriya Aranyaka8 it has typically explained about the formation of the Garbha. In bradaryanyaka Upanishad pregnancy, sexology is disscused.9 ITIHAS AND PURANA A description of “Putrakameshti Yajna” is given in Valmiki Ramayana which again indicates that king Dashratha was suffering from one or other illness of sukradushti. From Mahabharata it may be assume that the total clan of the pandu, vidhura, kauravas was suffering from any of the sukra dushti. Yashodhara in his commentary on Kamasutra10 opines that the reproduction is impossible in the absence of sukra. Garudapurana described various recipes having spermatopoetic activity11 . Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  20. 20. REVIEW OF LITERATURE 6 SAMHITA CARAKA:- Caraka used the word Retas and sukra as synonyms and he used the word retas in sutrasthana and explained 8 varieties of retasdoshas12 where as in chikitsa sthana13 yonivyapda, the same 8 have been mentioned under title dusta sukra. 2nd chapter of chikitsa sthana is totally related to vajikarana drugs, diet, principle and different combinations. SUSHRUTA SAMHITA:- Retas word is used while describing 8 doshas; in the chapter Shukra shonita shuddhi14 .In sutra sthana the definition of the vajikarana has been mentioned15 .In chikitsa sthana named ksheena baliya vajikarana chikitsa, causes of shukra kshaya are described16 and some vajikaran drugs for its management have also been highlighted. He uses the word “Prajotpadane Na Samartha” while describing about sukra doshas. KASHYAPA SAMHITA:- 8 types of sukra dusti are mentioned17 . He has not given any description about its symptomology and treatment. ASTANGA SAMGRAHA:- He specifies the word Abeeja which said to be the cause of infertility and further divided into 8 types18 . SHARANGADHAR SAMHITA:- 5 types of punstava roga and 8 types of shukra doshas are also mentioned which are very much similar to Sushruta. BHELA SAMITHA:- Bhela mentioned only 7 varieties of sukradusti. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  21. 21. REVIEW OF LITERATURE 7 HARITA SAMITHA:- To avoid sukrakshaya various pathyapathya is described19 and 5 varieties of klaibya explained. MADHAVA NIDANA:- Sukradosha or retodosha are not dealt in this book, but upadmsa, sukadosha are dealt in detail. SARANGDHARA SAMITHA:- After enumerating 5 types of pumsavatrog, author told 8 types of sukradoshas. The 8 variety is called malabha due to the involvement of all three doshas20 . CHAKRADATTA:- There is no reference about sukrdosha or retodosa in this book, but categorization of drugs into sukravrddhikarana, sukrasurtikara, sukravrdhi srutikara has been explained. BHAVA PRAKASA:- There is no description of sukradushti in this book, but 7 types of klaibya its symptomology, treatment has been explained. In same context many “Retivarna Yogas” are described. YOGA RATNAKAR:- No specific description about sukradusti has been explained, but a separate chapter of Vajikarana has given. It includes Klaibya lakshanas, its treatment and various Vajikarana drugs21 . Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  22. 22. REVIEW OF LITERATURE 8 PREVIOUS WORK DONE Institute for Post graduate teaching and Research in Ayurveda, Jamnagar. Gujarat Ayurveda university, Jamnagar. 1997 Dr. Niranjan Rao A Clinical study on the role of sujrajanaka and sukrasodhana in the management of sukradusti SDM college of Ayurveda, Udupi. RGUHS, Bangalore. 2003 Dr.Ajit Kumar A pharmaceutical study of vanarigutika wsr to its therapeutic effect on shukra dusti vis –a-vis oligoasthenospermia 2004 Dr. Jeevan G A comprehensive pharmaco - therapeutic study of ksheera vidari in shukra dusti wsr oligoasthenospermia Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  23. 23. REVIEW OF LITERATURE 9 DISEASE REVIEW AYURVEDIC REVIEW:- The word sukra is derived from Sanskrit root“suk shocha” it means purity 22 and suc kleda23 which means moistness. The term also suggests the meaning like resplendent, white, shiny, etc. it is the 7th among the metamorphic chain of dhatus. DEFINITION:- The factors which is implanted for the formation of the embryo is known as sukra.It is mainly composed of vayu, agni, prithvi and jala mahabhoot and has their specific role in formation of garbha24. PARYAYA:- Numerous of synonyms have been explained by various authors like Amarkosh, Raj Nighantu and Dhanvantri Nighantu. From above such references some of them are as follows:- Majja samudbhava: - born out of majja dhatu Beeja: - one which has capacity to produce new generation. Punsava {virility}:- Masculinity of the body, Tejas {resplendent}:- which is shiny bright. Retas {ejaculate}:- which is ejaculated at the time of coitus. Veerya {potency}:- by virtue of which an action is manifested. Anand samudbhava: - which is excreted at the time of intense pleasure or Orgasm. Balam: - strength Charama dhatu: - last dhatu. Pourusham-Virility Pumsatva –Fertility Rupa Dravya-Which gives form of chetana Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  24. 24. REVIEW OF LITERATURE 10 PHYSICAL QUALITIES OF SUKRA:- ACCORDING TO CARAKA25 :- Snigdha Ghana Picchila Madhura Avidhae Shweta varna Sphatika ACCCORDING TO SUSHRUTA26 :- Drava Snigdha Madhura Madhugandhi like Sphatika like thin consistency of Tail like thick consistency of Madhu ACCORDING TO ASTANGA HRIDYA27 :- Shukla Guru Snigdha Madhura Bahala Bahu Like Gritha, Tail or Madhu Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  25. 25. REVIEW OF LITERATURE 11 ACCORDING TO ASTANGA SAMGRAHA28 :- Shukla Guru Snigdha Madhura Madhugandhi Pichila Bahalam Like Gritha, Tail or Madhu EVOLUTION OF THE SUKRA29 :- The evolution of the sukra can be explained in the following ways:- 1) Origin according to mahabhuta. 2) Produced from majja dhatu 3) From aahara rasa 1) Origin according to mahabhuta It is considered as soumya and kapha varga, as soma or jala mahabhuta is the one Principle from which kapha derives, it can be said that Sukra belongs to jala mahabhuta. 2) Production from Majja Dhatu:- Sukra being 7th in the order and produced through the evaluative metamorphosis of majja dhatu i.e. 6th and preceding one30 Sukra is produced from the essence of majja dhatu, vayu and akasha. Due to the porosity in asthi dhatu sukra ooze out like water from new earthen pitcher31 . 3) From Aahara Rasa:- Beginning from rasa dhatu upto sukra dhatu all the 7 dhatus are produced in fashion of progressive evaluative metamorphosis i.e. ksheera dadhi nyaya these means that previous dhatu is precursor for the next and higher. Thus from Anna Rasa, rasa dhatu is formed and from rasa dhatu rakta dhatu is formed and so on till majja is transformed into sukra dhatu.32,33 Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  26. 26. REVIEW OF LITERATURE 12 FUNCTIONS OF SUKRA34 :- So garbhoutpatti is considered as one of the important function of the sukra dhatu. Instead of this Acharya Sushruta has given some more other important functions of sukra, these are:- Dhairyam Chyavanam Priti Dehabalam Harsha Bijartham So from above various important functions explained by acharya sushruta it can be concluded that sukra not only having important role in fertilization but it helps in development of physical as well as mental health of the person. So many of the psychological factors may interfere in proper sukra formation and leads to infertility. DURATION FOR FORMATION OF SUKRA35 :- Though the explanation for the formation of sukra varies from author to author. One school of thought opines that it total required 7 days after the food intake, but some says about 15 days.Sushruta opines that this duration may differ from one month to instant formation of the sukra.He explained if person is only dependent on simple diet it requires near about 30 days for sukra formation but if same person consume sadhyo sukrakar, vrushya or vajikaran drug he may achieve at instant. PRAMANA36 :- Caraka explained its pramana as Ardhanjali SUKRA SAARA PURUSHA37 :- The person with excellence of sukra is known as sukra sara purusha, he is having soumya nature, having gentle look, eyes appearing as filled with milk, extremely happy, he is pleasant, unctuous, has good complexion and voice. His appearance is dazzling, he is Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  27. 27. REVIEW OF LITERATURE 13 loved by women {stree priya} endowed with prosperity, vigor, health, wealth, honor and apatya. STHANA OF SUKRA38 :- In classics seven kalas has been explained and the seventh kala is called “SUKRADHARAKALA” and Sushruta explained that it is present all over the body. Similar thoughts are shared by Acharya Caraka and Sushruta. By giving example Sushruta says that as grutha is there all over the milk, sugarcane juice in sugarcane.Same way sukra is present all over body. Caraka quote as tiltail is present all over the Tila same way sukra is present all over the body. SUKRA IN CO-ORELATION TO ANDROGENS:- The first and foremost important function explained by all Acharya’s about sukra is Garbhotpati. In addition to this many of the other functions explained by acharya sushruta like priti, chyavanam etc can be easily compare with the functions of the Androgens. The word chyavanam means proper physical development of the body structure either of male or female. If the functions of androgens are observed it may be opined that the FSH-follicle stimulating hormone and LH-leutinizing hormone helps in secretion of progesterone, oestrogen, and testosterone which helps in giving a proper physical development of the body structure in either sex. They play an important role by maintaining metabolic activities, maintaining internal environment or homeostasis of the body and various action on other systems. The word meaning of the “BIJA” can be taken for male and female gametes both of which have direct relation in fertilization. A Dalhana commentary on sushruta at sutrasthana 14th chapter gives a synonym arthava as sukra and its function for fertilization. In the 30th chapter of Chikitsha sthana caraka while giving explanation about retodushti he uses the word arthava as menstrual bleeding. So from the two different meaning of the word suggest that it arthava may consider as a gamete and its role in fertilization. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  28. 28. REVIEW OF LITERATURE 14 The word “PREETI” is acceptable for both the partners. It is an attraction towards opposite sex to which may be physical or mental. The cause of all this is the development of primary and secondary sex characteristics in both sex and all this is dependent upon the functions of Androgens. The word “DEHABALAM” means better strength to a person for his/her daily activities. This strengthening is possible by male from testosterone as it helps in anabolism of protein and similar function is done by oestrogen in female. Similar manner this entire concept can be explained on the basis of androgenic functions but a concept of homosexuality and formation of baby like a mass is not still not understood. SUKRADUSTI:- Sukra which is vitiated is called dushta sukra and the condition is sukra dushti. NIDANA OF SUKRADUSTI39 : Even though the descriptions regarding Sukra dusti are available in Sushurta Samhita & Astanga samgraha & Hridaya, the causative factors are not discussed. Description of Nidana is available only in Caraka Samhita and Madhava Nidana parishista. It may be described on the basis of:- AHARA VIHARA MANSIKA VAIDYAKRTA VYADHIKARSANA JANYA KSATA. AHARA:- Asatmya Ahara Sevana (Intake of unsuitable food), excessive intake of ruksa, tikta, kasaya, lavana, amla and usna dravyas Fascination with slimness and dietary control pervades a large segment of modern American society(including men ) and may have a role in the high incidence of reproductive failure (15%) experienced by American Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  29. 29. REVIEW OF LITERATURE 15 couples.(William, Bates 1993) Asatmya Sevana means that which is incompatible to the body. Here, we can put alcohol consumption etc. excessive consumption of alcohol (more than 60gms/day), tobacco, narcotics, leads to infertility. Alcohol consumption lowers plasma testosterone synthesis. Ethanol increases the metabolic clearance rate of testosterone, concomitant with an increase in hepatic 5-alphareductase activity and increased conversion of androgens into estrogen. VIHARA:- Excessive coitus, untimely coitus, coitus in other than vagina, abstinence, intercourse with an aroused partner, coitus in old age, excessive exercise, suppression of ejaculation. The physical effects of strenuous exercise on hypothalamic pituitary gonadal function in males have been established. Deceased testicular androgens (testosterone and dihydrotestosterone) and increased adrenal androgen have been noted in the plasma of highly trained male athletes compared with a control population. It is not undesirable to expect reproductive dysfunction in male athletes and under weight men (William, Bates 92.) Excessive intercourse , intercourse during improper time, intercourse in other than vagina/perverted sexual activities are all found in person who are having a very poor will power or satvabala. These persons will fall prey easily to such things and contact towards infection is also easy. These persons are prone to get sexually transmitted disease or simple genital tract infections. Now it is an established fact that the silent infection of semen also leads to male infertility.40 MANSIKA: Chinta (anxiety), shoka (grief), avisrambha (suspicion), bhaya (fear), krodha (anger). Low quality semen was found to be positively correlated with work related stress and stress within the family as well as with increased psychosomatic symptoms (Insler and Lunenfeld, 1993).The patients with stress reveal azoospermia, but it may be transient (Mary polan 1982). The key word here is emotional stress. The stress that comes from work, however, leaves the sperm free to run its reproductive race. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  30. 30. REVIEW OF LITERATURE 16 VAIDYAKRTA: Sastra, ksara, Agni vibhrama, leades to sukra dusti. The patients who have had an operation correction of the bladder neck along urethral reimplantation during childhood are highly unlike to be fertile. Because, the bladder neck surgery has ablated the internal sphincter. These individuals often experience retrograde ejaculation. This should be suspected in the patient who has a history of bladder surgery and ejaculate is less than 1ml in volume, oligospermic and abnormally alkaline. The diagnosis can be made by finding large numbers of sperm (at least 10 to 15 per HPF.) in the uncentrifuged, post ejaculation urine. Apart from surgery, many drugs may interfere with spermatogenesis either directly or through alteration in the endocrine system. Medication such as sulphasalazine, cimetidine, nitrofurontin, has also been implicated as gonadotoxic agents. The use of anabolic steroids, usually by athletes may also interfere with normal spermatogenesis. (Hammond and Tablert 92.).41 Some drugs are known to interfere with Leydig cell function. Spironolactone inhibits testosterone synthesis by reducing testicular cytochrome p450 and 17 alpha- hydroxylase activity. (Menard et al 78) VYADHIKARSANA JANYA: Atisara (Ma. Ni. Pa) but the review of andrological / urological literature as well as other literature pertaining to medicine gives many diseases which will ultimately leads to poor semen quality. Diabetes mellitus may cause peripheral neuropathy leading to retrograde ejaculation, loss of seminal emission, or erectile dysfunction (Kaplan et al, 1968). The Vas deferens or epididymis may be absent in cystic fibrosis (Kaplan et al 1968) kartagener’s syndrome (Situs inversus, chronic sinusitis and Bronchiectasis) possess ultra structural defects in both cilia and sperm tails resulting in immotile sperm.(Etiasson R. et al 1977) subnormal sperm densities are found in approximately 50% of testicular cancer patients prior to chemotherapy (Oroecklin H.R. et al 1973) sperm production and motility may be transiently affected by fever, viremia and elevations in environmental Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  31. 31. REVIEW OF LITERATURE 17 temperature(Lipshultz and Witt 92). Patients with a history of fibrocystic disease of pancreas may have congenital absence of vas deference (Lunenfeld, Insler, Glezerman 93)42 . KSATA. – Ksata or injury is the one cause which leads to the sukradusti. Here injury means to pelvic organ. Injury to the testes, testicular torsion may lead to atrophy of the testes and impaired fertility (Lunenfeld et al 93). TYPES OF SUKRADUSHTI:- ACCORDING TO CARAKA43 :- Phenil –vataja Tanu –vataja Ruksha –vataja Vivarna -pittaja Picchila -kaphaja Puti -pittaja Anyadhatu sanshrita- rudhranvita Avasadi -vataja ACCORDING TO SUSHRUTA44 :- Vataja Pittaja Kaphaja Kunapa- sonitaja Grantibhuta -sleshmaja Putipuya -pittasleshmaja Ksheena -pittavataja Mutragapurisha Gandhi Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  32. 32. REVIEW OF LITERATURE 18 ACCORDING TO ASTANGA SANGRAHA45 :- Vataja Pittaja Sleshmaja Kunapgandhi-sonitaja Granthibhuta-sleshmaja Puya -sleshmaja Ksheena -pittavataja Mutrapurisha Gandhi –sannipataja Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  33. 33. REVIEW OF LITERATURE 19 FIGURE 1 Phenila Picchila Vivarna Ruksa Tanu + PuyaPuti Anyadhatusamsrsta Avasadi Vita Nila / Pitta Pittaja Rakta Putipuya (P.K.) Kaphaja Vataja Other dhatus Mutra Purisagandhi (Sannipataja) Granthibhuta (K.V) Kunapagandhi A C C O R D I N G T O C A R A K A A C C O R D I N G T O S U S H R U T A Ksina (P.V) TYPES OF SUKRA DUSTI ACCORDING TO CARAKA, SUSRUTA AND VAGBHATA Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  34. 34. REVIEW OF LITERATURE 20 Sushruta explained in such a manner that’s look similar in number but on the basis of doshic vitiation it is totally counted as 8 in number. Both ashtang samgrah and ashtang hridya followed the pattern of sushrutha. Though mild difference of opinion in naming but totally it looks same. Kashyapa counted it as 8 in number. But he had not given invidividual description of the each variety, their characteristic for diagnosis and management. There are difference between school of caraka and school of sushruta while naming the type of sukradushti even though the total number is same. Even though caraka dealt doshic vitiations of sukradushti separately, he put stress on abnormal physical characteristics of semen. It mean phenile, tanu etc 8 characters mentioned by caraka are enlisted as 8 different types of sukradushti. Sushruta clubbed phenile tanu, ruksha together and labeled it vataja sukradushti. Caraka brought all the conditions of discoloration under vivarna where as sushruta dealt it separately under doshic variety .Overall sushruta incorporated all 8 types of caraka’s classification of sukradushti under 6 heading only.Furture sushruta added ksina and mutrapurishagandhi variety and made the total number 8. It seems that caraka classified on the basis of the characteristics of pathological semen or abnormal physical characteristics of the semen .but sushruta clubbed such factors together according to doshic vitiation ,where as caraka has mentioned doshic classification separately as described the treatment accordingly. Later sharangdhara followed the path of sushruta .he used the term “MALABHA” for sannipataja variety of sukrdushti. ROOPA OF SHUKRA DUSTI:- VAATAJA SUKRA DUSTI46 :- The sukra which is vitiated by vata dosha posses aruna or krushna varna , appears as phenil, tanu in consistency, rooksha in nature, alpa in quantity, there will be either delayed ejaculation or ejaculation with pain i.e. toda, bheda,. This sukra is having the quality of vicchinata & have no capacity to fertilize. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  35. 35. REVIEW OF LITERATURE 21 Vataja sukra dusti can be correlated clinically with hemorrhagic injury, severe oligospermia, and azoospermia, obstruction of the efferent ducts and chronic inflammation of accessory sex glands. PITTAJA SUKRA DUSTI47 :- The sukra which is vitiated by pitta dosha posses pita, neela Varna, hot in nature with putigandha, apicchila {not hyper viscous} and patient experiences daha, osha, chosa type of pain during ejaculation. This can be clinically co related with acute inflammatory condition of testis where semen may be yellow in colour having fetid smell due to presence of the pus cells.The hot nature of the semen and burning ejaculation indicate the acute state of inflammation acute bacterial prostitis, epididymitis etc. KAPHAJA SUKRA DUSTI48 :- It will be having sukla Varna, atipicchla in consistency, prabhuta in quantity, ejaculated with kandu mixed with majja dhat. This will be having visra gandha {unpleasant smell}, this morbid kapha also obstructs shukravaha srotas. The above mentioned features indicate increased viscosity of semen, commonly seen in chronic inflammation, presence of abnormal form in morphological seminal study. Above features also indicate chronic inflammatory condition. SHONITAJA {KUNAPAGANDHI} SUKRA DUSTI49 :- This is caused by excessive coitus, injury and wound and is due to affliction of rakta. The semen will posses smell of kunapa, quantity of semen is analpa or more. The patient experiences osha, chosha this reflects the condition called, haemaspermia along with acute inflammation caused by infection and injury to external genitals i.e. presence of RBS in semen, which can be seen in both vataja and shonitaja sukra dusti. In vataja sukra dusti few RBCs may be present, which gives aruna Varna, and blood clots may present which gives blackish Varna to the semen, but in shonitaja sukra dusti semen colour is rakta Varna and volume is high due to severe hemorrhage. In other words, this may be inferred as in case of vataja sukra dusti, the injury may be old one where as in raktaja sukra dusti, the injury will be recent origin and fresh blood can be seen. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  36. 36. REVIEW OF LITERATURE 22 GRANTHIBHUTA SUKRA DUSTI50 :- This is due to vitiation of morbid kapha and vata; hence the feature resembles kapha vataja dusti. Here due to suppression of the urge, the sukravaha srotas will be vitiated and obstructed by vata causing granthibhuta sukradusti, here patient will experience difficulty in ejaculation, the semen will be grathita, i.e. in form of coagulum, and clinically this can be compared to unliquifiable semen commonly found in prostatic dysfunction. This either does not contain liquefying enzyme or contains poor quantity causing failure in liquefying seminal coagulum. PUTI PUYA NIBHA SHUKRA DUST51 : - This is due to vitiation of pitta and kapha dosha, here the infected semen containing puya. This is commonly seen in the infection of genitor urinary tract. This condition may be seen in where abundance of leucocytes or positive culture findings i.e. pyobacteriospermia, chlamydial infection, this may be seen in urogenital inflammatory disease {Liunenfield & Mann 1993} KSHEENA SUKRA DUSTI52 :- The semen which is in little quantity or with subnormal parameters is called as kshina retas and is said to be vitiated by pitta and vata. Dalhana while commenting on this mentioned that the features told in ‘Dosa dhatu mala Vijnaniya’ in sutrasthana about Sukrakshaya should also be considered here in this context. Kshina retas also a variety under classification of sukrakshaya results due to acquired causes. Here, this particular variety denotes the same condition, but where the involved dosas are pitta and vata only. So decreased semen parameters resulted due to dosas other than pitta and vata should not be considered under this one. No specify features are quoted anywhere in classics, however, the characters explained for pitta and vata should be considered here. MUTRA PURISHA GANDHI SUKRA DUSTI53 :- The semen which posses the smell of urine or faeces is said to be vitiated by tridosha, however their is no such modern science explanation where semen is having smell of urine or fecal matter. It may be thought that recto genital urinary tract fistula may present Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  37. 37. REVIEW OF LITERATURE 23 with above said symptoms. ANYADHATU UPASAMSHRITA54 :- While enumerating 8 varieties of sukra dusti, Charaka has explained this condition but while explaining the treatment for this variety, he emphasized on involvement of dhatus and treatment aimed at treating vitiated doshas and dhatus. SAMPRAPTI55 The vitiated dosas singly or collectively having reached the retovahasira, cause defects in sukra. Further, sukra pervades in the entire body, so also vyanavayu. So, vyanavayuprakopa may also lead to sukradusti. In addition apanavata prakopa may also cause sukradusti as ejaculation of sukra is the function of apanavata, so by vaatkara nidanas 3 types of pathology may develop simultaneously. In apanavata dusti if we observe the apanavata function, this is mainly responsible for ejaculation of sukra. Because of the above said etiological factors vitiated, apanavata causing disturbance in sukravahastothas leads to kshina sukra i.e. both qualitatively and quantitatively. In sukravahastrothas apana vayu is undergoing avarna by vyanavayu leading to vitiation of sukradhatu. Due to that the produced sukra will be showing abnormalities like kshina sukra. In kaphaavruta apana this condition apanavayu undergoing avarna by kapha which leads to Gatisanga (obstruction) may be partially or completely associated with pain which leads to kshina sukra. In vitiated vata and pitta undergoing sthanasamsrya in sukravaha strothas leading to the vitiation of sukradhatu. Due to that produced sukra will be showing abnormalities. The other factors related to food like excess consumption of Katu, Tikta, Kashaya, Lavana Rasa, Ati Ushna Sevana and Manasika Karanas leads to vitiation of Doshas especially Vata and Pitta. Dosha Prakopa here can be interpreted as hormone imbalance. The Manasika Karana like Chinta, Bhaya lead to stress, which causes Vata Prakopa. According to modern view emotional stress may interfere with the GnRH Gonadotrophin releasing hormone, which initiates the release of LH and FSH from anterior Pituitary. FSH – Follicle Stimulating Hormone and LH – Lutinizing Hormone is responsible for Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  38. 38. REVIEW OF LITERATURE 24 spermatogenesis. Thus disturbance in GnRH secretion ultimately results in defective spermatogenesis. Pitta Prakopa can be taken as increased temperature due to thermal exposure, radiation, hot tubs etc., where elevated temperature directly applied to testis can impair spermatogenesis. Khavaigunya Karaka Nidana like Abhigata, Shastra, Kshara, Agni Karma Vibrama mentioned in the classics directly affects the Shukra Vaha Srotas especially testis and results in Shukra Kshaya. Any surgery or drugs (Sulphasalazine, Cimitedin, Alcohol), which are gonadotoxic agents, which affects spermatogenesis, can be considered here. CHIKITSHA56 Chikitsha of sukradusti is divided into 2 categories 1. Samanya Chikitsha 2. Vishesa Chikitsha Samanya Chikitsha comprises of management of the condition with purifactory modalities [sodhana Chikitsha]. In Vishesa Chikitsha certain drugs which are indicated in individual variety of sukradusti. SAMANYA CHIKITSHA:- This constitutes Snehana, Svedana followed by Panchakarmanusara Visodhana i.e.; Vamana, Virecana, Niruha basti, Anuvasana basti especially Uttara basti. Caraka says that before administration of any variety of treatment to shukradusti shashodana should be administrated to get a better efficacy in treatment .he quote an example that if a dirty cloth is not properly washed it not possible to give a colour over it, same way without a shashodana management drug efficacy is not so effective57 .. Though shanshodana has its important role in treatment aspect but still due to some reason if patient is unable to go this procedures the a second method of administration of shodhana should be accepted where acharaya’s has given importance to mala shudi which can be given on the basis of koshta of patient for 3,5, or 7 days58 . Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  39. 39. REVIEW OF LITERATURE 25 VISESA CHIKITSHA:- Here the treatment is aimed at the particular dosa or dosas, which get vitiated. After proper administration of shodana a physician can also think its line of management on two aspects59 :- • Shukrajana drugs • Shukrashodhana drugs Though the acharaya’s has explained various varities of sukradushti but this all can be easily classified in two types. Example a condition like kshina sukra can be taken as form of sukradushti where proper genesis is affected so in this condition drugs which acts as a sukrajanana can be used for fertilization. Similarly conditions like putipuya, anyadhatusamishra where drugs having shukrashodhana effect will be better effective. Vataja Sukra Dusti: The semen affected by Vata, Niruha vasti and Anuvasana vasti should be employed. According toAcharya.60 Sushruta, the first three varieties i.e. in Vataja, Pittaja and Kaphaja varieties, the treatment modalities such as Snehana ,Swedana ,Vamana,Virecana and Anuvasana ,Astapana and especially Uttara vasti should be employed ,and all the other pacifying measures according to doshas. Those vitiated by Vata and others 2 doshas should be treated with appropriate drugs. Ghritapana, Ashtapana, Anuvasana and Uttara vasti should be administered to treat the Vataja Sukra dusti. Pittaja Sukra Dusti:- Caraka advocates abhayamalaki rasayana61 . Vagbhata advocates ghrita prepared from kandeksu, gokshura, guduchi;Virechana with Trivrut choorna and ghee ;Astapana vasti with Sreeparni and Payasya ; Treatment with ksira ;Anuvasana –Uttara vasti with Taila prepared out of Madhuka and Mudgaparni. Kaphaja Sukra Dusti :62 In addition to samanya Chikitsa, Specifically Pippali rasayana, Amalaki rasaya are advisable in Kaphaja type .Treatment as sodhana involve snehana, Svedana, Vamana, Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  40. 40. REVIEW OF LITERATURE 26 Virecana, Astapana, Anuvasana and Uttarabasti Gritapana – Patina bheda, Ashmanataka, Amalaki are used for preparation of gritha for abhyantarasnehana, Madanaphala Kwatha for Vamana, Virecana with Danti & Vidanga coorna, Astapana Basti with decoction of Aragwadha, Madanaphala Anuvasana – Uttarabasti with taila of Madhuka and Pippali Kaphahara measures should be adopted for pacifying Kapha dosha in Kaphaja Sukra dusti. Kunapaganti Sukra Dusti Ghrita prepared out of Dhataki pushpa, Khadira, Arjuna and Dhadima are claimed beneficial63 . Also sarpi processed with Salasaradi gana or Asanadi gana is useful in the treatment of the same. Granti bhuta Sukra Dusti: In this condition Ghrita of Pashana bheda and Palasa kshara is advised. Ghrita prepared out of palasa khsara is also beneficial64 . Puya Sukra Dusti: Parusakadi gana and Vatadi gana drugs are used in the preparation of Ghrita, is said to be useful in puya variety of Sukra dusti65 . Kshina Sukra Dusti: Sva yoni vardhana dravyas, Sukra Kari karya kriyas are advised by Vagbhata, while Sushruta propounds the treatment in Ksina baliya adhyaya of Chikitsha stana66 The retas which got kshina avastha or decreased levels of sukra should be brought to normal state by means of upachaya. Mutra Purisa Gandhi Sukra Dusti: Ghrita made of Hingu, Useera Citric are claimed to be beneficial by Sushruta67 Dalhana concludes that Sodhana procedures are to be employed first accordingly Medications are started.68 Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  41. 41. REVIEW OF LITERATURE 27 Acharya Vagbhata expounds the use of Ghrita prepared out of Citric, Vitunnaka, Priyangu, Hingu, Samanga and Mrunala69 . Indukara says patients with severe vitiation are to be ignored, as this condition is Asadhya70 . Even though this variety is told to be Asadhya, to counteract the bad smell which is unbearable to the patients, treatment should be given74. In Dvandvaja variety of Sukra dusti sodhana should be done first and then corresponding Ghrita is given71 . In totality Sushruta advised to conduct Shodhana initially and then respective medication to be employed72 . According to Vagbhata Uttara vasti should be given repeatedly73 . SAADHYAASADHYATWA74 :- Retamsi abijani bhavanti, it means if sukra dusti is left untreated or not treated properly, then it will hamper the fertility aspect of the individual. Vataja pittaja kaphaja sukra dusti are said to be sadhya, kunapagandhi, putipuya and ksheen a variety are kruchra sadhya and sannipataja variety i.e. mutra purisha Gandhi is asadhya. UPADRAVA75 If the condition is left untreated then it may lead to infertility and sexual inadequacy or klebya. PATHYA Ghrita, dugdha, mansarasa, shali satika Sali, avoidance of the etiological factors also can be considered as Pathya76 . Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  42. 42. REVIEW OF LITERATURE 28 MODERN REVIEW Reproduction is the process by which new individuals of a species are produced and genetic material is passed from generation to generation. This maintains the constitution of the species. For the production of better progeny not only sperm have the important sole but all the anatomy of reproductive organ should have these proper functions. E.g. if accessory glands are unable to secrete properly it may effect the motility of the sperm and may effect the total count. So a proper knowledge of anatomical and physiological aspects of reproductive organs should be known77 . The reproductive organs can be grouped on their functions:- Gonads – production of sperm and hormones Ducts – helps in transport and storage Accessory glands – support gametes Supporting structure – penis GONADS: - Testis is considered as male gonads which have important functions in the formation of sperm and to secrete sex hormones. The testis or testicals are paired oval glands measuring about 5cm long and 2.5 cm in diameter. Each testis has a mass of 10 to 15 g. it mainly made up of 2 membranes outer one is called tunica vaginalis and the inner one as tunica albugenia a capsule composed of dense irregular tissue. Tunica albugenia extends inwards forming septa that divide the testis into a series of internal compartments called lobules. Each of the 200 to 300 lobules contains 1 to 350 coiled seminiferous tubules where sperm is produced the process by which the seminiferous tubules of the testis produce the sperm is called spermatogenesis. The seminiferous tubules contains 2 types of cells, spermatogenic cells the sperm producing cells and steroli cells which have several functions in supporting spermatogenesis. Steroli cells extend from the basement membrane to the lumen of the Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  43. 43. REVIEW OF LITERATURE 29 tubule .Internal to the basement membrane and spermatogonia tight junctios join neighboring steroli cells to one another. The junction forms an obstruction known as blood testis barrier because substances must firstly pass through the steroli cells. Before they can reach the developing sperm. Steroli cells support and protect developing spermatogenic cells in several ways. They nourish spermatocytes, spermatids and sperm; phagocytize exass spermatid cytoplasm as development proceeds and control movements of spermatogenesis cells and the release of sperm into the lumen of somniferous tubules. They also produce fluid for sperm transports secrete androgen binding protein and hormone inhibin and mediate the effect of testosterone and FSH. In the space between adjacent somniferous tubules are clustered of cells called leydig cells or interstitial endocrinocytes. These cells secrete testosterone, the most prevalent androgen. Although androgens are hormones that promote development of masculine characterstics. They also have other functions such as promoting libido (sexual desires) in both males and females. FUNCTIONS OF TESTOSTERONE78 :- PRENATAL DEVELOPMENT:- Before birth testosterone stimulates the male pattern of development of reproductive system ducts and the descent of the testes. Testosterone is also converted in the brain to estrogen (feminizing hormones), which may play a role in the development of certain regions of the brain in males. DEVLOPEMENT OF MALE SEXUAL CHARECTORSTICS:- At puberty testosterone is dihydrotestosterone bring about development of the male sex organs is the development of masculine secondary sexual characteristics. These includes muscular is skeletal growth that results in wide shoulders &narrow hips, pubic, axillary, facial& chest hairs, thickening of the skin, increased sebaceous gland secretion & enlargement of the voice. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  44. 44. REVIEW OF LITERATURE 30 DEVELOPMENT OF SEXUAL FUNCTIONS:- Androgens contributes to male sexual behavior is spermatogenesis is to sex drive in both males& females. PROTEIN ANABOLISM:- Androgens are anabolic hormones that is they stimulate protein synthesis. This effect is obvious in the heavier muscles and bone mass of most men as compared to women. SPERMATOGENESIS79 :- In humans, spermatogenesis takes 65-75 days. It begins in the spermotogonia, which contain the diploid (2n) chromosome number. Spermatogonia are stem cells because after they under go into mitosis at last they converted into primary spermatocytes. Primary spermatocyte, like spermatogonia are diploid that is they have 46 chromosomes. Each primary spermatocyte enlarges and then begins mitosis. In mitosis 1st the 2 cells formed is called secondary spermatocyte. Each spermatocyte has 23 chromosomes, the haploid number. Each chromosome with in a secondary spermatocyte, how ever is made up of two chromatids still attached by a Centro mere. In mitosis 2 few haploid cell results called spermatids. The final stage of spermatogenesis, spermiogenesis is the maturation of haploid spermatids into sperm. Because number of cell division occurs in spermiogenesis each spermatid develops into a single sperm cell. Spermatogenesis produces about 300 million sperm per day. Once ejaculated, must do not survive more than 24 hours with in the female reproductive tract. A sperm cell consists of 3 structures highly adapted for reaching and penetrating a secondary oocyte: a head, a mid piece and a tail. It contains an acrosome, a lysosome like vesicle and a nucleus that has the haploid number of chromosomes (23). Enzymes within the acrosome include hyaluronidase and protease, which aid penetration of the sperm into secondary oocyte. In the mid piece are many mitochondria, which provide ATP for locomotion. The tail a typical flagellum propels the sperm cell along its way. From head to tip of tail, human sperm about 70 micrometer in length. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  45. 45. REVIEW OF LITERATURE 31 The above function of testis is possible by supporting structure called scrotum, a sac consisting of loose skin and superficial fascia that hangs from the root of the penis muscle like Dartos have important role in maintenance of temperature making them 2-3 degree Celsius below the core temperature. The cremaster muscle, a small band of skeletal muscle in the spermatic cord that is the continuation of the internal oblique muscle, elevates the testis upon exposure to cold (and during sexual arousal). This action moves the testis closer to the pelvic cavity, where they can absorb body heat. DUCTS OF THE TESTIS:- The total structure is made from the combination of epididymus, vas deferens, ejaculatory duct and urethra. The epididymis is a comma-shaped organ about 4 cm long that lies along the posterior border of each border. it is site where sperm mature that is they acquire motility and the ability to fertilize an ovum. This occurs over 10-14 days of the period. The ductus epididymus also store sperm and helps propel them by peristaltic contraction of its smooth muscle into the ductus deferens. Within the tail of the epididymis, the ductus epididymus becomes less convoluted and its duct is known as ductus deferens or vas deferens. This act as storage of the sperm, which remain viable here for up to several months. The ductus deferens also conveys sperm from the epididymis toward the urethra by the peristaltic contraction of the muscular coat. ACCESORY SEX GLANDS:- This constitutes of seminal vesicles, prostate secretions and coupers gland. SEMINAL VESICLE:- Secretes alkaline, viscous fluid that helps neutralize acid in the female reproductive tract, provides fructose for ATP production by sperm, contributes to sperm motility and viability and helps semen coagulate after ejaculation. PROSTATE:- Secretes a milky, slight acidic fluid that helps semen coagulates after ejaculation and subsequently breaks down the clot. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  46. 46. REVIEW OF LITERATURE 32 BULBOURETHRAL (COWPERS) GLAND:- It secrets alkaline fluid that neutralizes the acidic environment of the urethra and mucus that lubricates the lining of the urethra and the tip of the penis during sexual intercourse. PENIS:- It acts as a supporting structure for the semen into the vagina. upon sexual stimulation, which may be visual, tactile, auditory, olfactory or imagined the arteries supplying the penis dilate and large quantities of blood enter the blood sinuses expansion of these spaces comprises the veins draining the penis, so blood outflow is slowed .this vascular changes, due to local release of nitric oxide is a parasympathetic reflex, results in erection, the enlargement and stiffing of the penis. The penis returns to in flaccid stage when the arteries constrict and the pressure on the vein is relieved. INFERTILITY:- Infertility is the inability of a couple to achieve a pregnancy after repeated intercourse without contraception for 1 year. Infertility affects about one of five couples in the United States. It is becoming increasingly common because people are waiting longer to marry and to have a child. Nevertheless, up to 60% of the couples who have not conceived after a year of trying do conceive eventually, with or without treatment. It is a common problem among young adults. About 15% of all couples are unable to conceive a child after 1 year of regular, unprotected intercourse. Infertility is one of the most difficult experiences that a couple may face together. The couple may have a sense of loss and a feeling of uncertainty. It is a time, however, when the couple must make certain key decisions. It is important that they work together as a team and avoid placing blame on one another. It often results from reproductive problems in both partners. Doctors now know that a male factor for infertility may be involved in roughly one half of all infertile couples. In 30-40% of these couples, the infertility involves both male and female factors. In about 20% of infertile couples, the inability to conceive is due entirely to a male factor. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  47. 47. REVIEW OF LITERATURE 33 In about 30-40% of infertile couples, the infertility is due to a female factor alone. In about 10% of couples, neither partner has a detectable abnormality. Infertility may be due to problems in one or both of the partners. An evaluation of both partners of an infertile couple should be performed at the same time. ETIOLOGY OF MALE INFERTILITY80 :- I. EXTERNAL CAUSES • conditions of semen collection • environmental factors • iatrogenic factors II. ACQUIRED DEFECTS OF THE TESTIS, PROSTATE AND SPERM • infection: prostatitis etc. • immunologic causes : antisperm antibodies • varicocele • testicular tumours III. DEVELOPMENTAL AND STRUCTURAL DEFECTS OF THE TESTIS OR SPERM • cryptorchism • genetic causes • `sertoli cell only syndrome • spermatogenetic arrest • anomalies of sperm structure IV. HORMONAL CAUSES AND ANDROGEN RESISTANCE • hypogonadotrophic hypogonadism (hh) • hyperprolactinaemia • congenital adrenal hyperplasia • androgen resistance syndrome Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  48. 48. REVIEW OF LITERATURE 34 V. SYSTEMIC DISEASES VI. IMPAIRMENT OF SPERM TRANSPORT: obstructive azoospermia VII. PROBLEMS OF EJACULATION • retrograde ejaculation • ejaculation failure VIII. SEXUAL DYSFUNCTION IX. IDIOPATHIC CAUSES EXTERNAL CAUSES :- 1. CONDITIONS OF SEMEN COLLECTION:- • incomplete sperm collection • use of condoms (spermicids),vaginal lubricants • duration of sexual abstinence: short – oligospermia, increased motility; long- asthenospermia 2. ENVIRONMENTAL FACTORS:-81 • occupational heat exposure • sauna, hot baths, tight underwear 82 • feverish states • Season: oligospermia in September (heat, photoperiodicity?) • toxic products: lead, cadmium83 • dibromochloropopane (DBPC), kepone • boric acid, vinyl chloride • aromatic solvents84 • drugs: heroine, methadone: FSH and LH ( marijuana: T and sperm mobility) • alcohol: inhibition of T synthesis and sperm capacitation, • reduced sperm quality in heavy drinkers85 • Cigarette smoking: in 11 studies the sperm density is 22% lower in smokers, the motility is lower; increased sperm disomy has been found. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  49. 49. REVIEW OF LITERATURE 35 3. IATROGENIC FACTORS:- Surgery: Hernioraphy in childhood (lesion of vasa), testicular torsion, orchidopexy • Radiotherapy • Chemotherapy DRUGS:- With anti androgenic action: spironolactone, cimetidine, ketoconazole, cyproterone acetate, tetracycline, phenytoin, carbamazepine86 • gonadotrophins: estrogens, androgens • sulfasalazyne, furodantoines, garamycine. • possible adverse effect: cotrimoxazol, antimalarials, amoebicides, tetracyclines - impotence or ejaculation disorders: neuroleptics, thioridazine, • clomipramine, alpha and beta adrenergic blocking drugs,clonidine, methyldopa, fibrates, anticholinergics etc, SSRI (fluoxetine,citalopram) • drugs without adverse effect on sperm: ranitidine, 5 -aminosalicylique, amitryptiline, enzyme conversion inhibitors (enalapril), AINS (diclofenac), quinolones (ciprofloxacine) II. ACQUIRED DEFECTS OF THE TESTIS, PROSTATE OR SPERM 1. INFECTION:- • Orchitis: mumps, echovirus, B arbovirus. Mumps: 75% of men witunilateral orchitis have a normal sperm within 1 to 2 years but only 30 % with a bilateral orchitis. Treatment with interferon 2B? • Epididymitis: Chlamydia, Gonococci, Tuberculosis: obstruction of epididymis: azoospermia + antisperm antibodies87 • Prostatitis: present in 25 to 30% of infertile compared to 10-15 % of fertile men. Controversial cause of asthenospermia and male infertility. Leukospermia and decreased seminal levels of zinc. Possible role of mycoplasma, chlamydia, capable of attaching to sperm. Induction of auto antibodies. Controversial effect of antibiotics. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  50. 50. REVIEW OF LITERATURE 36 • HIV: present in 10 to 30% of the sperm of seropositive men (in 87% by PCR). The virus is present in semen as cell-free or as cell-associated virus (mononuclear cells) (Kiessling, F St 58:667, 1992). Insemination with processed semen of HIV partners is still experimental and controversial. The virus is still present in seminal cells of patients receiving antiretroviral therapy88 . 2. IMMUNOLOGIC CAUSES:- Antisperm antibodies89 Antisperm antibodies have been detected in 5 to 10% of infertile men and in 2% of fertile men. Antibodies against spermatozoa can reduce fertility by decreasing the binding of sperms to the zona pellucida, by interfering with capacitation or acrosome reaction or by immobilizing sperms in cervical mucus. Antibodies directed against the sperm head are deleterious. The presence of antisperm antibodies is determined by the attachment of a labeled antihuman immunoglobulin specific for the class of human Ig to be essayed, to the sperm-associated antibody. The label can be an erythrocyte (MAR test), a polycramid bead (immunobead essay) an enzyme (ELISA), a fluorescent molecule or a radioisotope. a) Male autoimmunization - Antisperm auto antibodies in semen:- They induce no specific abnormality in sperms but could decrease the mobility and can be detected by MAR test or immunobead essay (IgG or IgA). The cause is unknown: possible cross reactivity between sperm internal antigens and certain microorganisms? An increased incidence has been found in the case of associated Prostatitis. Antisperm antibodies are also present after vaso-vasostomy, inversely related to sperm motility90 . Antibodies (Ab) have a high affinity for sperm surface antigens and they cannot be removed by washing (even 18 times). Ab could be added by exposure to seminal plasma and ejaculation into buffer can be useful to decrease antibody-bound sperm by dilution91 . IVF is possible except in case of antibodies directed against sperm head or acrosine), ICSI is preferred in the latter situation. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  51. 51. REVIEW OF LITERATURE 37 b) Circulating antisperm auto antibodies Unbound antibodies can be measured by the tray agglutination test (serial dilutions of serum are able to agglutinate donor spermatozoa) or by the indirect immunobead test (antisperm antibodies in the serum will bind to donor sperm free of antibody). Ab can be produced because of disruption of the blood testis barrier that isolate sperm antigens from the male's immunological system (testis biopsy, torsion). Leakage of sperm due to sperm degeneration in the epididymis could be responsible for the occurrence of circulating antibodies in unilateral or bilateral obstruction of the male genital tract (e.g. antibodies are present in 50 to 80 % of cases after vasectomy) . Genetic factors (HLA A28) could play a role. The roles of the circulating ab in infertile couple and in the persistent infertility after vaso-vasostomy as well as the utility of prednisone treatment are controversial 92 c) Auto antibodies in the testis: Auto antibodies directed against testicular basement membrane and against steroid cells (Leydig cells) have been described in rare cases of hypogonadic men with multiple endocrine autoimmune diseases93 3. VARICOCELE The incidence is 10-15% in the male population and 20 to 30% in infertile patients. Varicoceles are associated with impaired seminal and hormonal parameters. It is a classical cause of secondary infertility. Adverse effects could result from increased scrotal temperature, reflux from the adrenal gland or adrenal metabolites (left internal spermatic vein enters the left renal vein). A review of 509 publications comprising 5471 patients shows that surgical ligation of the spermatic vein results in an average pregnancy rate94 of 36%. However the benefit of surgery has not been proved in a randomized study controlling for female factors (29% pregnancy in the treatment group and 25% in the non- treatment group (n=125). Practically, varicocelectomy can be recommended in order to prevent a further deterioration of the sperm if the following criteria are fulfilled95 : Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  52. 52. REVIEW OF LITERATURE 38 1. infertility for 1 year 2. Valsalva-positive varicocele documented by doppler and US 3. smaller testicular volume on the varicocele side 4. subnormal seminal parameters 5. FSH not elevated 6. normal or treatable female reproductive functions 7. no other causes of male infertility (prostatitis, autoimmunity etc) High surgical ligation (by laparoscopy!) and angiographic embolization give similar results. 4.TESTICULAR TUMORS:- Testicular tumors affect 2-3/100.000 men per year and are responsible for 1% of cancer deaths. Men with cryptorchidism have a fivefold increased risk (3/4 are seminoma= tumors arising from the germinal epithelium). Tumors of adrenal cell rests dependent on ACTH have been described in 21-hydroxylase deficiency and can decrease after corticoid treatment. About 50% of men with germ cell tumors have initial low sperm count96. III. DEVELOPMENTAL AND STRUCTURAL DEFECTS OF THE TESTIS OR SPERM 1. CRYPTORCHISM :- Cryptorchism exists in 0, 7-0, and 8% of adult men and in 2-3% in newborns and is present in 6% of infertile patients. Maldescent occurs in more than 40 human congenital defects including cases of hypogonadism and lack of androgen synthesis or action. It is associated with HLA-A11 and A-25. The lack of descent after HCG occurs in 40% of HLA-A11 and 70% of HLA-DR5. It is not clear whether the testis functions poorly because of the maldescent (heat etc.) or it fails to descent because it is initially abnormal. Spermatogenesis is also abnormal in the descended testis. Deleterious changes in the ultra structure of the cryptorchid testis are observed in the first year of life. Therefore it has been suggested to operate the cryptorchid testis in the first year in case of lack of response to GnRH or HCG. However, operation may not ameliorate the fertility potential Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  53. 53. REVIEW OF LITERATURE 39 in cases of bilateral cryptorchism. In case of unilateral cryptorchism surgery in early puberty has been advised by some authors. In bilateral cryptorchism 42% of treated patients are azoospermic and 31% are oligospermic. In untreated cases 75% are azoospermic. In unilateral cases 14% of treated patients are azoospermic and 31% are oligospermic (the results are not different for treated cases) 97 2.GENETIC CAUSES98 Karyotype abnormalities have been observed in 15 to 23% of azoospermic and in 5-6% of oligospermic patients99 . Klinefelter syndrome (XXY): Frequency: 1 in 500 males. It is the most common form of hypogonadism in men (1,6% of infertile men) and occurs due to meiotic non-dysjunction during gametogenesis. Patients present with small firms testes (2-10 ml), gynecomastia, increased height, azoospermia and elevated levels of gonadotrophins. Due to increased estradiol and increased TBG, T levels may be normal although the production is reduced. 10% of the cases are mosaic forms 46 XY/ 47 XXY (due to mitotic non- dysjunction after fertilization of the zygote). Sometimes the mosaicism can be present only in the testes. Azoospermia is present only in 50% and some patients can be fertile. 3. SERTOLI CELL ONLY SYNDROME It accounts for 1/10 to 1/3 of azoospermic patients. Histological findings are characterised by a complete absence of germinal elements occuring in patients with a normal male phenotype and normal caryotype. It can be the result from several etiologies: viral orchitis, cryptorchidism, androgen resistance, familial syndrome. FSH values are usually high, sometimes normal Y microdeletions can be detected in 50% of cases. 4. SPERMATOGENETIC ARREST: This is observed in 4 to 30% of azoospermic patients. Interruption of germ cell differentiation resulting in oligospermia (partial arrest) or azoospermia (complete arrest). It generally occurs in normal patients with normal testicular volume and gonadotropin Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  54. 54. REVIEW OF LITERATURE 40 levels. Most cases are due to genetic abnormalities occurring in the prophase of the first meiotic division (zygoten and pachyten phase). Acquired cases can be due to hormonal, thermic or toxic factors. 5. ANOMALIES OF SPERM STRUCTURE: a) Immotile cilia syndrome: Inherited as an autosomal recessive trait. Results in chronic sinusitis and bronchiectasis. The Kartagener syndrome is associated with situs inversus. Due to missing or very short dynein arms, missing central tubules or displacement of one of the nine doublets. In normal subjects 10% of sperms have an incorrect number of microt. Doublets and 7% have fewer than 9 doublets. Asthenospermia can also be due to mid-pieces abnormalities of mitochondria and to deficiency in protein carboxyl methylase100 . Among 400 patients with absent sperm motility 3% had dynein arm deficiency and 23% were necrospermic. b) Necrospermia: can be distinguished from immotile sperm. Syndrome by supravital dyes. Degenerative changes involve all sperm components c) Teratospermia: agenesis of the acrosome results in round headed spermatozoa. Familial, polygenic mode of inheritance.Monomorphic round head teratozoospermia is probably of genetic origin whereas testicular factors could be responsible for the amorphous head. Teratospermia has been associated with autosomal translocations. IV: HORMONAL CAUSES AND ANDROGEN RESISTANCE The incidence of primary endocrine defects in infertile men is less than 2% 1. HYPOGONADOTROPHIC HYPOGONADISM (HH) Patients with HH show decreased levels of gonadotrophins and T. If it occurs before puberty, signs of eunuchoidism are present: arm span 5 cm greater than height, decreased hair and muscular development, infantile genitalia. If anosmia is present: Kallmann syndrome (frequency: 1/10000 to 1 /60000). Absence of neurons secreting GnRH. X linked inheritance or autosomal-dominant or recessive (role of KALIG 1 locus on short Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  55. 55. REVIEW OF LITERATURE 41 arm of chromosome X which encodes for a protein that could be responsible for neuronal migration (GnRH neurons arise in olfactory placode and migrate along the cranial nerve I to the preoptic area)101 . Acquired form of HH occurs in patients with normal pubertal development with a recent history of decreased sexual function and fertility. Partial defect in gonadotrophin secretion (low LH and normal FSH) can lead to fertile eunuch syndrome. Hemochromatose must be ruled out by dosage of ferritine. HH can also be due to pituitary lesions (prolactinoma, Cushing disease) or infiltrative diseases and a IRM of the pituitary is always indicated in case of HH, as well as a dosage of prolactin in case of impotence (cf infra). These conditions can be treated with HCG (3 x 2000 U and HMG 3 x 75-150 U /week) or by pulsatile GnRH if fertility is desired .Cryptorchism has a bad prognosis102 . 2. HYPERPROLACTINAEMIA Micro- or macroadenoma of the pituitary secreting prolactin can induce hypogonadism either by impairing GnRH release or by destruction of the pituitary. It causes loss of libido, visual abnormalities and galactorrhea in 15-30% of cases. Fertility and potency can be recovered after surgical or medical treatment. 3. CONGENITAL ADRENAL HYPERPLASIA In mild forms of 21-hydroxylase deficiency high ACTH levels stimulate the synthesis of androgenic steroids by the adrenal cortex (androstenedione and 17 OH P) resulting in precocious puberty and abnormal phallic enlargement. Gonadotrophins are suppressed resulting in some cases in oligospermia. Fertility can be restored by glucocorticoid treatment 4. ANDROGEN RESISTANCE SYNDROME Quantitative or qualitative defects of testosterone binding to the androgen receptor due to mutations in the receptor result in a spectrum of disease ranging from complete testicular feminisation to infertile male syndrome. Androgen receptor deficiency has been observed in 0 to 19% of men with idiopathic oligospermia and normal phenotype. LH levels are Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  56. 56. REVIEW OF LITERATURE 42 slightly increased and T levels are normal. The LH (UI) x Testo (ng/ml) product is increased above 200, but could be normal (100) in some cases. Increased LH x T products have also been reported in coeliac disease and in hyperthyroidism (with increased estradiol levels in the latter). The androgen receptor has been shown to contain trinucleotid repeat loci. An increased length of these repeats has been associated with androgen resistance and defective spermatogenesis103 . V. SYSTEMIC DISEASES:- 1. Renal failure:- Renal failure leads to decreased T levels and increased gonadotrophins and prolactin in 25% of cases. Improvement of sperm after zinc administration104 . Fertility can be restored by kidney transplantation but not by dialysis105. 2. Cirrhosis of the liver Gynaecomastia and impotence are present in half of the cases, estradiol and TBG are increased. Gonadotrophins are slightly increased. Testicular atrophy and hypospermatogenesis are described. 3. Sickle cell anaemia: Testicular atrophy occurs in 1/3, maturation arrest of sperms. Hypoxaemia and zinc deficiency might play a role106 4. Gastrointestinal diseases: In coeliac disease, a decreased mobility and teratospermy has been observed as well as an increased T x LH ratio. In Crohn's disease oligospermia has been observed in 6/13 patients. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  57. 57. REVIEW OF LITERATURE 43 5. Hodgkin disease: Asthenoteratospermia has been observed in 50% of the cases, oligospermia in 25% (35 patients) and low T levels. 6. Neurological diseases: a) Myotonic dystrophy: small testes, low T and high gonadotrophins b) Spinal cord lesions: moderate oligospermia and most of the time asthenospermia is observed in paraplegics. Multifactorial causes: retrograde ejaculation, urinary tract infection. Not due to hormonal problem or infrequent ejaculations. Semen collection by rectal probe electrostimulation or vibrator. 7. Psychological factors: Infertile men do not present a special psychopathological profile and compared to a control group of fertile men they do not present differences in personality profile and coping strategies. No sperm alteration has been observed in male marathon runners and in depressed patients107 . However, the stress due to IVF procedure and the stress due to the loss of a close parent or due to earthquake but not the stress at work could decrease slightly semen quality. VI. IMPAIRMENT OF SPERM TRANSPORT: OBSTRUCTIVE AZOOSPERMIA Genital duct obstruction is found in 5 to 7% of infertile patients. Obstruction may occur at any level of the genital tract. It can be congenital or acquired, secondary to infection (bilateral epididymitis), stricture or vasectomy. Most of the patients present with azoospermia, normal size testes and normal gonadotrophin levels. In congenital absence of the vas there is usually an associated absence of the seminal vesicles and ampulla. The semen volume is low, acid and fructose negative. Incomplete or unilateral obstruction of the male genital tract can be responsible for oligospermia and is associated with circulating antisperm antibodies. A trial with an anti- inflammatory treatment such as diclofenac could be useful Investigations and treatment will be discussed by Dr de Boccard Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  58. 58. REVIEW OF LITERATURE 44 VII. PROBLEMS OF EJACULATION 1. Retrograde ejaculation: It can be suspected in case of "dry" ejaculation or small volume of the ejaculate. It may follow transurethral resection of the prostate, bladder neck surgery, retroperitoneal lymph node dissection or pelvic surgery (rectum). It occurs in diabetes with peripheral neuropathy, multiple sclerosis, paraplegia and alpha-adrenolytic drugs. Sperm can be recovered in the urine after alkalinisation (650 mg of bicarbonate 4 x /d 48 h prior to collection). Imipramine (25-50 mg/d) can be tried to re-establish antegrade ejaculation. 2. Ejaculation failure: A complete absence of antegrade ejaculation can be due to sympathetic denervation, autonomic medications or psychogenic problems. Retarded ejaculation can be a milder form of this condition. Treatment includes vibratory stimulation, electro ejaculation and psychotherapy. VIII. SEXUAL DYSFUNCTION Impotence and premature ejaculations. Discussed by Prof. Ruedi. IX. IDIOPATHIC CAUSES In 30 to 50% of cases (if we include cases with no sperm improvement after varicocele repair or prostatitis treatment) no aetiology can be identified to explain abnormal semen or infertility. Abnormalities of all semen parameters are usually observed. Slight increase of FSH values may result from injury of the testis due to viral, toxic or congenital factor. In 1/3 of the cases of idiopathic infertility with apparently normal sperm, there is a decreased rate or a lack of oocyte fertilisation with IVF. A decreased binding to zona pellucida has been observed in 28% of cases and an absence of sperm hyperactivation induced by follicular fluid in another 39% (from 18 patients). In these patients (with idiopathic infertility), reactive oxygen species generation was not different from the control group (semen samples producing high rate of free oxygen radicals are characterized by a loss of sperm function) 107 . Ultrastructural defects of sperm head or tail or defects of acrosine reaction could also be responsible for some cases of lack of IVF. Immunological factors could be responsible for another 10% of cases (by decreasing Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  59. 59. REVIEW OF LITERATURE 45 sperm binding to the zona pellucida). Androgen receptor deficiency is under diagnosed although the prevalence rate is much lower than the 40% rate observed by Aiman. Genetic diseases are also under diagnosed in case of chromosomal anomalies present exclusively in germ cells. Reduced LH pulse frequency has been observed in oligospermic patients with high FSH levels, which were decreased by GnRH pulsatile administration. However, there is no sperm improvement after GnRH treatment. Aromatase inhibitors could improve the sperm count. EXAMINATION OF THE INFERTILE MALE: Ideally the patient should be naked, so that the physician can obtain a general impression of possible endocrine stigmata. The presence of Cushing’s disease, hypogonadism or hypothyroidism may become obvious by observing the body habits, the amount and distribution of body hair, the presence or absence of gynaecomastia and the pattern of fat distribution. Height, weight, blood pressure, any unusual length of extremities and general nutritional status are noted. A test for anosmia is important in patients with hypogonadism in order to rule out Kallamans syndrome. If hyperprolactinemia is present a space occupying lesion in the fossa turcica should be ruled out (visual fields, CT scan). The thyroid gland is carefully palpated and the breasts are carefully examined for gynaecomastia. Abdominal palpation may reveal liver enlargement. Operative scars in the inguino genital areas are noted. The examination room should be warm so that the scrotal dartos reflex will be relaxed facilitating the examination of the genitalia. Urogenital examination includes inspection of the penis and the location of the urethral opening. Any abnormality concerning the prepuce should be noted. Palpation of the scrotal content provides information about localization, consistency and possible tenderness of the testes. The size of the testes should be measured with orchidometer. Men who have small and firm testes (volume less than 6 ml) may have Klinefelter’s syndrome. Testes volume more than 15 ml is considered as normal. The epididymis and vas deferens are carefully palpated in search of cystic formations, tenderness or thickening which could confirm past, present or chronic inflammatory Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  60. 60. REVIEW OF LITERATURE 46 disease resulting in infertility. The presence of scrotal swelling due to hernia orhydrocele is noted, with the patient standing upright, occurrence of varicocele or of spermatic venous reflex during valsalva manoeuver is investigated and graded as follows: Grade-I: No varicocele on inspection and palpatation but palpable filling of the pampiniform plexus during valsalva manoeuver. Grade-II: No varicocele on inspection but detectable varicocele by palpation. Grade-III: Varicocele clearly visible. Other means for diagnosis of a varicocele are scrotal thermography, Doppler echography, venous scintigraphy and retrograde venography. Then the groins are examined for lymphadenopathy, surgical or other scars. Finally, prostate and seminal vesicles are examined. The prostate should be symmetrical, of firm consistency, normal in size and non tender to palpation. A prostate gland that is enlarged and boggy in consistency is often congested, infected or both. ENDOCRINE EVALUATION: Testosterone levels should be determined in patients with history or signs of deficient development of the secondary sex characteristics and in men with sexual impotency. Some times the only sign of androgen deficiency may be deficient sperm motility or abnormal sperm output as a consequence of impaired epididymal sperm maturation. To determine the functional quality of the Leydig cells, the HCG stimulation test should be performed: An increase in plasma testosterone without an increase in the concentrations of the physiological markers in the ejaculate indicates a mechanical block, dysfunction or agenesis of the respective secondary sex gland. FSH determination is indicated in patients with a sperm concentration of less than 5 million per ml. Elevated levels indicate germinal cell insufficiency. In azoospermic men, high FSH levels indicate primary germinal cell failure, only Sertolicell syndrome, or genetic conditions such as Klinefelter’s syndrome. If elevated FSH levels are accompanied by elevated LH levels and subnormal testosterone, this indicates primary testicular failure or andropause (Lunenfeld et al 1982) Elevated levels of LH in the presence of relative low values of testosterone is sign of Leydig cell insufficiency. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  61. 61. REVIEW OF LITERATURE 47 An elevated prolactin levels may be a symptom of hypothalamic inability to secrete the prolactin inhibiting factor or may be an early sign of pituitary adenoma. SEMEN ANALYSIS:-108 Spermatozoa were first described by Leeuwenhoek in the 17th century but it was not until 1928 that the sperm count was found to be associated with fertility potential. Since that time a variety of sperm tests and semen parameters have been developed with the hope of clarifying whether or not a man could impregnate his partner. MacLeod (1942), MacLeod and Gold (1953), Eliasson (1971) and Hellinga (1949, 1976) have led the scientific basis of conventional analysis of spermatozoa and the techniques recommended by them are still considered the reference for more advanced methods. Semen analysis comprises a set of descriptive measurements of spermatozoa and seminal fluid parameters that help to estimate semen quality. Conventional semen analysis includes measurement of particular aspects of spermatozoa such as concentration, motility and morphology and of seminal plasma. Quantification and identification of non-spermatozoidal cells and detection of antisperm antibodies are also part of basic semen analysis. Normal values of semen parameters issued by the World Health Organization (WHO) in 1992 are generally used as reference values. Ideally, each laboratory should set its own normal values, reflecting the specific population analyzed. SAMPLE COLLECTION AND DELIVERY:- The following instructions for sample collection and delivery are based on WHO recommendations. The subject should be provided with clearly written or oral instructions concerning the collection and, if required, transport of the semen sample. The sample should be collected after a minimum of 48 hours and no longer than 7 days of sexual abstinence. The name of the man, period of abstinence, date and time of collection should be recorded. The time interval between the last ejaculation and sample collection should be well defined and preferentially as constant as possible in order to allow a reliable interpretation of the results of, in particular, sperm concentration and motility. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  62. 62. REVIEW OF LITERATURE 48 When the duration of abstinence is more than 7 days, sperm motility, i.e. the proportion of spermatozoa with rapid progressive motility, may decline. If the duration of abstinence is <48h, sperm concentration may be reduced, but motility will probably not be affected . Two semen samples should be collected for initial evaluation. The interval of time between the collections will depend on local circumstances but should not be less than 7 days or more than 3 months apart. If the results of these assessments are remarkably different, additional semen samples should be tested because marked variations in sperm output may occur within the same individual. Analysis of multiple semen specimens provides a reliable screen in the evaluation of male factor infertility. Information and support are important since semen analysis cause a moderate amount of stress. Ideally the sample should be collected in the privacy of a room near the laboratory. If not, it should be delivered to the laboratory within 1h after collection. The sample should be obtained by masturbation and ejaculated into a clean, wide- mouthed glass or plastic container. If plastic is used, it should be checked for lack of toxic effects on spermatozoa. The container should be warm to minimize the risk of cold shock. Ordinary condoms must not be used for semen collection because they may interfere with the viability of spermatozoa. In cases in which masturbation is not possible or against an individual’s values, the specimen can be collected in a non-spermicidal condom following intercourse. It has been shown that semen samples collected during intercourse using a special plastic condom or a silastic collection device tend to have better parameters. Other authors, referring to their experience, hold the view that the quality of the specimen when collected in this way is generally compromised. This way of collection should be considered for a second sample if the first one shows a relatively low volume. Coitus interrupts is not acceptable as a means of collection because it is possible that the first portion of the ejaculate, which contains the highest concentration of spermatozoa, will be lost. Moreover, there will be cellular and bacteriological contamination of the sample and the acid pH of the vaginal fluid will adversely affect sperm motility. Incomplete samples should be not analyzed, particularly if the first portion of the ejaculate is lost. The sample should be protected from extremes of temperature (not less Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  63. 63. REVIEW OF LITERATURE 49 than 20°c and not more than 40°c) during transport to the laboratory. The sample should be examined immediately after liquefaction and certainly within 1h of ejaculation. Laboratory technicians should be aware that semen samples may contain harmful viruses (e.g., HIV and viruses causing hepatitis and herpes) and should therefore be handled with due care. MACROSCOPIC EVALUATION:- Appearance The semen sample is first evaluated by simple inspection. A normal sample has a grey- opalescent appearance, is homogenous and liquefies within 60min at room temperature under the influence of enzymes of prostatic origin. In some cases, liquefaction does not occur within the normal time period and this fact should be recorded, as it may suggest functional disturbance of the prostate. Normal semen samples may contain jelly-like grains which do not liquefy. The sample may appear clear if the sperm concentration is too low. It may also appear brown when red blood cells are present in the ejaculate (haematospermia). The presence of mucous streaks may interfere with the counting procedure and suggests inflammation or abnormal liquefaction. Samples which do not liquefy need additional treatment such as exposure to bromelin, to make the sample amenable to analysis. The sample should be well mixed in the original container. Incomplete mixing is probably a major contributor to errors in determining sperm concentration. Consistency The consistency, also called viscosity, of the liquefied sample can be estimated by gentle aspiration into a 5-ml pipette and then allowing the semen to drop by gravity and observing the length of the thread formed. A normal sample leaves the needle as small discrete drops, while in cases of abnormal consistency the drop will form a thread of >2 cm (6, 25). Another method to estimate consistency does not use needles and is performed by introducing a glass rod into the sample and observing the thread that forms on withdrawal of the rod. Again the thread should not exceed 2 cm. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  64. 64. REVIEW OF LITERATURE 50 Increased consistency has the same clinical meaning as abnormal liquefaction, and may be related to prostate dysfunction resulting from chronic inflammation.Very viscous specimens can impair the availability of fertile sperm at the site of fertilization. Volume The major component of the ejaculate volume is made up of secretions from the accessory glands. The bulk of the volume is secreted by the seminal vesicles and between 0.5 and 1 ml originates from the prostate. The volume of the ejaculate should be measured either with a graduated cylinder or by aspirating the whole sample into a wide- mouthed pipette by means of a mechanical device. The sample volume can also be determined directly in the collection tube by weighing, assuming 1ml equals 1g.. Thereby, loss of volume associated with transfer from the collection tube to either another tube or a pipette can be avoided. A low ejaculate volume can reflect abnormalities in accessory sex gland fluid synthesis or secretion. It can also be indicative of a physical obstruction somewhere in the reproductive tract, or may occur in cases of incomplete or (partially) retrograde ejaculation. Large volumes are sometimes found in association with varicocele or after relatively long periods of sexual abstinence. pH The pH is determined by acidic secretions of the prostate and alkaline secretions of the seminal vesicles. It should normally be in the range of 7.2-8.0. Recently, one author has shown that the mean pH values are consistently well above 8.0 regardless of the method of analysis and the time of examination and has suggested that the range of normal values needs to be revised further. To test pH, pH paper range 6.1 to 10.0 is used. Whatever type of pH paper is used for this analysis, its accuracy should be checked against known standards before the use in routine semen analysis. If the pH exceeds 8.0, infection should be suspected with decreased secretion of acidic products by the prostate, such as citric acid. Abnormal pH may also be recorded in cases Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia
  65. 65. REVIEW OF LITERATURE 51 of incomplete ejaculation. Extremely acidic pH (<6.5) is found in cases of agenesis (or occlusion) of the seminal vesicles. Initial microscopic investigation During the initial microscopic investigation of the sample, estimation of motility and concentration of spermatozoa is performed. The presence of cells other than spermatozoa and of agglutination of spermatozoa is determined. Motility In recent years, a number of techniques for objective assessment of movement characteristics of human spermatozoa have been introduced by using computer-assisted semen analysis (CASA) systems. For the purpose of conventional analysis, a simple classification system which provides the best possible assessment of sperm motility without resorting to complex equipment is recommended. A fixed volume of semen (not more than 10 m l ) is delivered onto a clean glass slide and covered with a 22x22 mm cover slip. It is important that the volume of semen and the dimension of the cover slip are standardized so that the analyses are always carried out in a preparation with fixed depth (i.e., 20m l). This depth allows full expression of the rotating movement of normal spermatozoa. The preparation is then examined at a magnification of x400-600. An ordinary light microscope can be used for unstained preparations, particularly if the condenser is lowered to disperse the light. However, a phase-contrast microscope is preferable. The weight of the cover slip spreads the sample for optimal viewing. The freshly made, wet preparation is left to stabilize for approximately one minute. Motility estimation can conveniently be carried out at a room temperature between 18 and 24°c. At temperatures outside this range, some alteration in sperm motility will occur and this must be standardized in the laboratory. Effect Of Pushpadhanva Rasa In The Management Of Shukra Dusti WSR To Oligozoospermia

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