Secondary Infertility

Brief Medical History

Presenting Complaints with unable to conceive after earlier 2 pregnancy failures
1. Secondary Infertility High severity more than 5 years
2. Scanty menstrual flow High severity more than 4 months
Associated complaints: 3.Bony overgrowth in right wrist with pain high severity 2 years

Brief Relevant Medical History (Onset, Duration, Ag/Rel Factors, OTT, Prior Confirmed Diagnoses if applicable):

Married life since 6 years G2 P2 A2 L0
First pregnancy 5 years back due to congenital cardiac anomaly (Mitral valve dysplasia and TR)Termination done vaginaly at 5th month
Operative hysteroscopy+Laproscopy done-Adhesiolysis+Fulgralton of endometrial cysts.
Second pregnancy-Ectopic pregnancy october 2011 -laproscopic surgery done(In november 2011 Left ectopic rupture.Left salpingectomy done.
Right F.Tube is patent
One cycle of IUI in jan 2013 and 2nd march 2014 not succesful,Patient was reffered for IVF
Husbands age:33years,Healthy, no unhealthy habits
First Consultation at AVHD on 3/9/14

History of past illness:
K/C/O: Hypothyrodism Family historty: DM MotherCurrent medication: Thyronorm 25 mg

Integrated Summary

Clinical Status

Allopathy

Ayurveda

Vital Parameters

• BP:100/70mm of hg
• Pulse:68 per min
• Weight:52.8 kg
• BMI:21.42

Asta Sthana Pariksha

• Malam:Niraama
• Mutra:Normal
• Jihva:Liptha
• Shabda:Sadharanam
• Sparsha:Anushna seetha
• Drik:Prakrutha
• Akruti:Madhyama

Examinations

• GC:Fair
• CVS:NAD
• CNS:NAD
• RS:NAD
• PA:NAD

Dasa Vidha Pariksha

• Prakriti:Vatha pitha
• Vikriti:Vatha
• Sara:Raktha sara
• Samhanana:Madhyama
• Pramana:Madhyama
• Satmya:Rooksha,Katu
• Satva:Alpa
• Aharashakti:Abyavaharana sakthi and jarana sakthi madhyama
• Vyayam Shakti:Madhyama
• Vaya:Yowana
• Desha:Jangala
• Kala:duration-5 years

Nityaka-Varsha
Avastika-Upadrava(Tubal blockage)

Rogi Bala- Madhyamam

Roga bala-Pravara

Nidana Panchaka

• Nidana:Mithya aahara vihara(Ushna,Thiktha,Katu aahara,Jala kreeda,Athi chinthana,Rooksha aahara)
• Purvaroopa:Garba srava
• Roopa:Kruchrarthavam,Anapathya
• Updrava:Tubal blockage
• Samprapti

Dosha:Vatha Pitha
Dushya:Rasaadi shuklathwam
Agni:Sama
Ama:Niraama
Srotas:Arthava vaha,Rasa vaha-Shukla vaha
Sroto Dushti Prakara:sanga

Lab Tests:

• Roga Samprapti Flow Chart

Vatha pitha vardhaka aahara vihaara+Jalakreeda----------------Vatha pitha vrudhi-----------------Arthava vaha srotho rodha -------------------------Garbhasaya------Anapathya

Lab Findings	Last Recorded Value	Lab Findings	Last Recorded Value
Prolactin levels (Normal range:4.79 to 23.3 )	8/8/14 22.26ng/ml 14/6/14 57.63ng/ml 22/1/14 27.50 ng/ml	TSH Normal range:0.27 -4.2)	5/9/14 2.48 8/8/14 3.72ulU/mL 14/6/14 2.90 22/1/14 5.39
Free testosterone (Normal range:<4.1pg/ml)	8/8/14 3.20	Testosteron total (Normal range 0.06 to 0.82)	8/8/14 0.516ng/ml
FBS (Normal range(<110mg/dl)	5/9/14 80.7 8/8/14 82.8mg/dl	Vit B12 Normal range:180-914)	425.8 pg/ml
T3 (Normal range 0.80-2.0 ng/ml)	5/9/14 1.52 8/8/14 1.31 ng/ml	Anti mullerian Hormone	1.4ng/ml Low fertility
T4 (Normal range 5.1-14.1 uIU/mL)	5/9/14 8.15 8/8/14 9.61ug/dl	Total chol Upto 200mg/dl desirable	161.3
HDL (Normal:40-59)	47.3mg/dl	Triglycerides Normal Upto 150 mg/dl	64.9
LDL (Optimal:<100mg/dl Near optimal:100-129)	101.0 mg/dl	ESR (Normal 0-12)	20mm /1st hour
HB (Normal 11.5-15)	12.7	Total count (Norma:4000-1100/cumm)	4700/cumm

USG abdomen:
Impression: Small anterior wall intra mural uterine fibroid

Husband semen analysis:
90million/ml
80% motile

Differential Diagnosis with reasoning

Secondary infertility

Puthragni yonivyapath:

''Roukshyathaayuryadha garbha
jatham jatham vinasayeth
Dushta sonithajam narya: puthragni
saa matha//(Charaka.chi30)

''Shitham sthitham hanti garbha
puthragni raktha samsravath
Chathasrushvapi chaadhyasu pitha
lingochrayo bhaveth// ''(su.sa)

Charaka says that vayu aggravated due
to predominance of rooksha properties
in the body repeatedly destroys the
fetuses conceived with vitiated sonitha (Abnormalities of sonitha by vayu).

Susrutha says that in this condition, the
fetuses after attaining stability are
repeatedly destroyed due to bleeding,
besides there are other clinical features
of disordered pitha.

Anapathya

Vandhya-

”Vandhyam nashtarthavam
vidhyath.......//''

Evidence Based Diagnosis with References

Secondary infertility

Evidence Based Diagnosis with References

Puthragni

Chikitsa Vivechana:

Details of Allopathy medicine if continued

Tab. Thyronorm

''Sarva: vyapannayonim thu karmabhirvamanaadibhi:
Mrudhubhi: panchabhirnaareem snigdhaswinnaamupaachareth/
Sarvatha: suvisudhaayaa: sesham karma vidheeyathe//''
Yaccha vathavikaraanaam karmoktham thaccha karayeth//''

In all these gynecological disorders after proper oleation and sudation,emesis etc. all five purifying measures should be used. Only after proper cleansing of doshas through upper and lower passages other medications should be given. These emesis etc cleansing measures cure gynecologic disorders in the same way as they cure the diseases of other systems.

''Basthou rogeshu naareenaam yoni garbhaasayeshu cha/ Dwisthrayasthaapana sudhebhyo vidhadhyadwasthimutharam''

Type – IPT+Internal medications

Duration –

Pathyam-Thaila,Masha,Madhura rasa

Apathyam-Katu aahara,Dadhi,Lavana,Thiktha

Primary Treatments-
Udwarthanam(For preparing body for receiving snehana)
Snehapaanam

Main Treatments-
Shodhana-
Virechanam-Vathanulomana,Amashaya sodhana. After the very next periods.
Yogavasthy (after 2 ruthukala.)
(Uthara vasthy was also planned on next ruthukala after yogavasthy programme ,not done as she got conceived shortly after Yogavasthy)

• From 3/9/14 ( first consultation) to 15/9/14
Internal Medicines:
Lakshmanaaristam 3-3-3 tsp after food with water
Balathailam 10 drops with milk morning empty stomach and evening 6 pm.
• Patient got her periods on 11/9/14.Patient observed good Menstrual flow.
• Treatment start date-15/9/14
Internal medicines (15.9.14 to 19.9.14 ):
Lakshmanaaristam 3-3 -3 tsp after food with water

During snehapana no internal medications were given.

From date	To Date	Procedure	Treatment Medicines
15/9/14	19/9/14	Udwarthanam	Ellumnisaadi choornam
20/9/14	23/9/14	Snehapanam	Sukumara ghrutham+Bala thailam 20/09/14=20ml+10 ml 21/12/14=40ml+20ml 22/09/14=60ml+40ml 23/09/14=80ml+40ml
24/9/14	25/9/14	Virechana Sneha	Sukumara ghrutham
24/9/14	26/9/14	Abhyanga+Bashpasweda	Dhanwantharam thailam
26/9/14		Virechanam	Gandharva hasthadi Eranda thailam 60 ml with hot milk at 6 AM

Internal medicines after Virechana programme Pulimkuzhambu 1 tsp with hot water before food(11 am a7.30 pm)

Gandha thailam 10 drops with warm milk on empty stomach(6 am)(for bone growth and pain in fingers??)

Draksharistam+Kumaryasavam 15ml+15ml thrice daily after food

Sahacharadi thailam for application on body before bath

Review on 7/10/14
Weight-51.9kg ,BP:100/60 mm of hg
Appetite-Improved
Bowels- clear
Sleep-Good

Medicines:
Lakshmanaaristam 3-3 -3 tsp after food with water

Phalsasarpis 1-0-1 tsp with warm milk on empty stomach

Balathailam 10 drops with ghee in the morning

Review on 8/11/14
LMP :6/11/14
Appetite-good
Bowels-clear
Sleep-Good

Review on 6/12/14
LMP-5/12/14
Weight:52 kg
BP:110/74 mm of hg
Advised Yogavasthy programme.
Treatment start date:11/12/14

From date	To Date	Procedure	Treatment Medicines
11/12/14	18/12/114	Yogavasthy	Mathra vasthy with pancha thiktha ghrutha 50 ml+Dhanwantharam Mezhupakam- 50 ml Kashaya vasthy-Eranda mooladi Kashaya-800 ml+Honey-100ml+Shathapushpa-30 g Saindhava-10 gm Panchathikthakan ghrutha-50 ml Dhanwanthara Mezhupaka-50 ml

Suggested to come back for utharavasthy (if not conceiving in that cycle) .

16/01/15-
Early fetal scan report
Pregnant 6 weeks
Single intra uterine gestation ,Estimated gestational age-6 weeks one day
Medication suggested for Garbha raksha:
Phalasarpis 1 tsp with milk twice daily after food
Mahadhanwantharam Tablet 1-0-1 for 3 months.
Pathya-Milk and ghee

Phala sarpis:Ashtanga sangraha uthara sthana Indi:Yoni sukla doshas “Phala sarpirithi khyatham pushpe peetham phala yath// Mriyamaanaprajaanam cha poojitham//''

Lakshmanaristam-indi:sthree roga Bhaishajya rathnavali,sthree roga,pradara chikithsa.

Balathailam:indicated in Vatha vyadhi,Sahasra yogam

Pulimkuzhambu indi;Asta vidha gulma,shoola,Antra vrudhi,Pandu

Draksharistam:indi:Bala krith,Mala shodhanam.Saranga dhara samhitha,madhyama khanda,Sandhana kalpana.

Kumaryasvam:indi:Vrushyam,Bala varna agni deepanam,Bruhmanam,Sukla dosha,Raktha pitha. Sahasra yogam

Sahacharadi thailam-indi: yoni roga,Gulma,Sosha,Astanga hrudayam-chi-vathavyadhi

Outcome

• Samyak Lakshanas
Samyak snigdha lakshanas were observed on 25/6/14.
Samyak virechana lakshanas were seen with 8 vegas on 26/09/14.
Basthi samyak lakshanas were achieved duely.

• Other outcomes as per following table to be duly filled

#	Outcome Parameters \| Date-Time:	TSD	T	T	TED
#	Outcome Parameters \| Date-Time:	11/2/15	17/2/15	23/2/15	25/2
1	Appetite (Agni)	Sama	Nirama	Nirama	Nirama
2	Urination (Mutra)	1-2/ N	1/N	1/N	1/N
3	Stress (Manas)	Fair	Fair	Good	Good
4	Vitality (Ojus)	Fair	Good	Good	Good
5	Wellbeing (0-10)	3	5	7	8
6	BP	140/90	130/90	140/90	120/86
7	Pulse	70	70	72	68
8	Weight, Kg	64	64	64	64
9	W-U, cm
10	Diet (Ahara)	Mixed	Veg	Veg	Veg
11	Exercise (Vyayama)	No	No	No	No
12	Low back pain (Lt side) (0-10) VAS	9	7	2	1
13	Radiating pain to Lt leg (0-10) VAS	8	6	1	3
14	Ability to sit in minutes	< 1min	15min	1hr	> 1hr

Patient’s Outcome Scale

#	Presenting Complaint	Weightage	Status 15-9-14	Status 25-9-14	Status 11/12/14	Status 17-1-15	Status_6 Months
1	Secondary infertility/Inability to conceive	100%	1	1	1	Conceived 5
WEIGHTED AVERAGE SCORE----->		-	-	-	-	-
IMPROVEMENT SCORE----->			0.0	-2.0	-2.0	-2.0
IMPROVEMENT %ge----->			0%	-100%	-100%	-100%

Adverse Incident Report (Drug or Treatment):Not reported.

	Date	At the start of Treatment	During the Treatment	Post treatment
Images/ Details of the site				16/01/15- Early fetal scan report Pregnant 6 weeks Single intra uterine gestation ,Estimated gestational age-6 weeks one day

Conclusion

''Evam yonishu suddheesu garbha vindhanthi yoshitha:
Adhushte praakruthe beeje jeevopakramano sathi//''(Cha.Chi 30)

After achievement of healthy state of yoni(Reproductive system) with the help of treatment. Conception occurs with the union of healthy seed(Sukra or sperms and sonitha or ovum)possessing all its normal qualities

Disclaimer: * Outcomes may vary from person to person

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