Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1343 - 1349 Full Version

A Clinical Round up of the Female Infertility Therapy Amongst Indians


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2486
Princy Louis Palatty, Pratibha S. Kamble, Meera Shirke, Sanjay Kamble, Manohar Revankar, Vijaya M. Revankari

1. Professor, Department of Pharmacology, Father Muller Medical College, Mangalore, India. 2. Lecturer, Department of Pharmacology, Father Muller Medical College, Mangalore, India. 3. Consultant Ayurvedic Practitioner, Sanjeevani Chikistalaya, Mangalore, India. 4. Assistant Professor, Department of Radiotherapy, Father Muller Medical College, Mangalore, India. 5. Tutor Cum PG., Department of Pharmacology, Father Muller Medical College, Mangalore, India. 6. Associate Professor, Department of Obstetrics & Gynaecology, Kasturba Medical College, Mangalore, India.

Correspondence Address :
Dr. Princy Louis Palatty (MBBS, MD)
Professor, Department of Pharmacology,
Father Muller Medical College,Mangalore -575002,
Karnataka, India.
Phone: 09686578701
E-mail: drprincylouispalaty@yahoo.com

Abstract

Background: Infertility varies across the regions of the world and it has been estimated to affect 8 to 12% couples worldwide. It tends to be the highest in countries with high fertility rates. The WHO has estimated the overall prevalence of primary infertility in India to be between 3.9 and 16.8%. Moreover, the prevalence of primary infertility has also been shown to vary across the tribes and castes within the same region in India.

Area focussed: Some common medicines which are used to treat infertility in women include—Clomiphene citrate, Human Menopausal Gonadotropin or hMG, FSH, the Gn-RH analog, Metformin, Bromocriptine, etc. Some modern technologies which assist conception include-assisted reproductive technology (ART), In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian transfer (GIFT), Intracytoplasmic sperm injection (ICSI) and intrauterine insemination (IUI). Other options like surrogacy and gestational carriers are also there.

Conclusion: Female infertility is a challenging issue despite the high fertility rates. ART gives reprieve in 41% of the cases, but the most commonly tried methods are pharmacotherapy, ayurvedic preparations and faith healing.

Keywords

Female infertility, Invitro Fertilisation, Assisted Reproductive Technology, Clomiphene Citrate, Intracytoplasmic Sperm Injection, Faith healing, Ayurveda, Pumsavana karma

Introduction
The recent census shows a steady rise in the population, which is the direct evidence of the increased fertility in the population, yet there are cases of infertility that need to be addressed too. This review plans to compile the causes and the therapy which is afforded in such cases. This review focuses particularly on female infertility. The fertility rate of the human race is impressive but infertility is yet, a cause for concern. Infertility is the state of being unable to get pregnant or to remain pregnant upto the full term. To deliver a healthy baby, after trying for approximately 1 year. A lack of uniform definitions has compromised the research on infertility. It has been accepted that the terms infertility, childlessness or sterility, all refer to the incapacity of couples in conceiving or in bearing children when it is desired. The WHO definition which was drawn up by the Scientific Group on the Epidemiology of Infertility has used a two-year reference period: Primary infertility: In the present study, the infertility was labelled as primary if the couple had never conceived despite cohabitation and exposure to the risk of pregnancy (absence of contraception) for a period of 2 years.

Secondary infertility: In the present study, the infertility was labelled as secondary if the couple had failed to conceive following a previous pregnancy, despite cohabitation and exposure to the risk of pregnancy (in the absence of contraception, breastfeeding or postpartum amenorrhoea) for a period of 2 years (1). Due to the small study population, the primary and secondary infertility cases were analyzed together. This review was aimed at determining the medications and the interventions for femaleRevankarinfertility and at analyzing the causes and the factors which led to it.

Material and Methods

A compilation on the treatment and the causes for female infertility was looked for in various Indian journals and in Indian reports in international journals over the past 5 years. Comparisons were made with the earlier study practices. The Indian scenario patients had a strong belief in Ayurveda and hence, noting the prescribing pattern of the Ayurvedic drugs that were often used along with the drugs from the modern system of medicine was required. Our methodology did not analyze statistically as is the usual practice in Evidence Based Medicine, but it only put forth relevant data on the promising treatment options.

Discussion

A. The burden of female infertility: A report states that in India, 13% of the ever-married women who were aged 15-49 years were childless in 1981 (rural 13.4% and urban 11.3%), which had increased to 16% in 2001 (rural 15.6% and urban 16.1%). Over half of the married women who were aged 15-19 years were childless in 1981, which had increased to 70% in 2001 (2). Infertility affects females in a one third proportion as males, but unknown and combined factors comprise the final third of this proportion. The infertility statistics quote 10% of women in the U.S. ie 6.1 million. B. The aetiology of female infertility: In India, the primary infertility cases are 3.9% (age-standardized to 25-49 years) and 16.8% (age-standardized to 15-49 years), which were found by using the “age but no birth”, which was put forthby the WHO. In Mysore, India, the prevalence of primary infertility in one study on young women was found to be 12.6%, which was within the range which was reported by the WHO. Their analysis revealed that the HSV-2 seropositivity was significantly associated with primary infertility in that group of young, reproductive-age women. The prevalence of the HSV-2 infection was 11.5%, and many of these women had the concurrent T. vaginalis infection and BV, as was also reported in other studies. Primary infertility was not associated with the Candida infection, the T. vaginalis infection, and BV24 (3). According to the National Family Health Survey (NFHS) 2007, some states in India show low fertility rates, ie. Tamil Nadu -1.8, Himachal Pradesh -1.9, Punjab -2 and Karnataka -2.1, while some other states show high fertility rates i.e., Madhya Pradesh- 3.1, Jharkhand -3.3, Uttar Pradesh -3.8 and Bihar -4 (4). Studies which were conducted in Kanyakumari and Thiruvananthapuram showed the maximum infertility between 25-30 years of age, ie. 43.80% and 36.26% respectively. The%age of the infertile females was more in the urban than in the rural areas in both the districts. Infertility in females has been reported in all the religious groups like Hinduism, Islam, Christianity, etc. In Kanyakumari, 76.64% of the infertile females were unemployed and 23.36% were employed, while in Thiruvananthapuram, the infertility rate was 70.18% in unemployed women. This infertility was significantly correlated with a family history of infertility as well as with menstrual irregularities (40%, 44.11%) (5). In the U.S., the pregnancy rates by the age of the woman were the highest in 1990 and 2005 for women in their twenties, they were intermediate at the ages of 18–19 and 30–34 years, and they were lowest at the ages of under 18 years and 35 years and older (6). The infertility in the UK (2010) can equally be attributed to males and females, with both being responsible in 30% of the cases. Combined issues account for 10% and unexplained problems account for as much as 25% of the fertility cases (7). The female infertility is difficult to diagnose, but it abounds in therapeutic options. Usually, a history of ectopic pregnancy, irregular periods, pelvic inflammatory disease and thyroid disease reflect infertility. The increased risk factors for the female infertility are advancing age, sexually transmitted diseases, weight problems, endocannabinoid discrepency, radiation and chemotherapy insults and substance abuse, especially smoking and alcohol use. The ultimate cause of the female infertility translates to the anovulatory cycles, blocked fallopian tubes and uterine and ova malformations. Acquired and genetic factors have an equal share in the aetiology of infertility. Mutations, spontaneous and environmental, indeed are also responsible- BMP15, CBX2, FEF8, EMRF, KISIR, etc.

The prevalence of obesity is low in India as compared to that in the western countries like England and the US. It affects the fertility and the fertility treatments. A high BMI reduces the chances of conception in ovulatory women and it also affects the outcome of the ovulation induction treatment. Obesity is associated with a lower fertilization rate, poor quality embryos and higher miscarriage rates. The obese also need higher doses of gonadotropins if they are using the IVF technology. These women also respond poorly to the ovarian stimulation and have fewer oocytes harvested (8). The diagnosis may be done both by examination and imaging and it can be confirmed by laboratory tests. The prevention is effected by maintaining a healthy lifestyle, treatment and by preventing diseases and an undelayed parenthood. C. The therapeutic modalities for female infertility: The therapeutic options vary between pharmacotherapy and intervention. Pharmacotherapy is first tried, with the drug of choice being Clomiphene citrate- an ovulation inducer. Clomiphene citrate is a drug of considerable pharmacologic potency. It has been demonstrated to be a useful therapy for anovulatory patients who desire pregnancy. The available data have suggested that both the oestrogenic and the antioestrogenic properties of Clomiphene may participate in the initiation of ovulation. The two Clomiphene isomers have been found to have mixed oestrogenic and antioestrogenic effects which may vary from one species to another. Some data have suggested that zuClomiphene has a greater oestrogenic activity than enClomiphene. Clomiphene citrate has no apparent progestational, androgenic, or antiandrogenic effects and it does not appear to interfere with the pituitary-adrenal or the pituitary-thyroid functions. Clomiphene citrate increases the spermatogenesis by the maturation of the spermatogonia in males. Clomiphene citrate alone can be used as the first-line therapy for the treatment of infertility in women with the polycystic ovary syndrome. There is no significant benefit of combination therapy with clomiphene and metformin over clomiphene alone with respect to the live-birth rate (9). The Follicle Stimulating Hormone (FSH), the human menopausal gonadotropin, the gonadotropin releasing hormone, Metformin and Bromocriptine are also used in combination or alone. The FSH test is usually done to diagnose the problems with the sexual development, menstruation, and fertility. This test is used to diagnose or to evaluate menopause, polycystic ovary syndrome, ovarian cysts, irregular vaginal bleeding, or infertility. It is also done in children who start sexual development at a very young age and in men who have infertility, who do not have testicles or whose testicles are underdeveloped. The normal FSH levels will differ, depending on a person’s age and gender. In males, a normal FSH level of 0–5.0 mIU/mlis seen before puberty, during puberty, it is 0.3–10.0 mIU/ml and in adults, it is 1.5–12.4 mIU/ml, while in females, before puberty, it is 0–4.0 mIU/ml, during puberty, it is 0.3–10.0 mIU/ml, in menstruating women, it is 4.7–21.5 mIU/ml and in postmenopausal women, it is 25.8 - 134.8 mIU/ml ( mIU/ml = milli international units per millilitre). Sometimes, abnormal FSH results can be seen in some clinical conditions like hypopituitarism, Klinefelter’s syndrome, polycystic ovary disease, Turner’s syndrome, ovarian failure (ovarian hypofunction), ovarian or adrenal cancers, precocious puberty in girls and boys, anorexia, etc. [10-12]. In India, generally we give an FSH and an LH recombinant rather than FSH and LH alone (LH alone is not used in India). The Gonadotropin-releasing hormone analogue (GnRH -a) therapy has been approved for the treatment of endometriosis and uterine fibroids. The GnRH-a therapy may be used for dysfunctional uterine bleeding or ovarian cysts and endometriosis and when an ultrasound has confirmed that uterine fibroids are present and that they cause significant symptoms. The GnRH-a therapy decreases the production of the hormone, oestrogen, to the levels that women have after menopause. This decreases • ovulation and stops menstrual periods (but it does not provide a dependable pregnancy prevention). • the growth and the size of the endometriosis sites (implants). • the uterine size. • uterine fibroid growth and it promotes fibroid shrinkage [13,14].

The side effects of this GnRH therapy includes hot flashes, mood swings, vaginal dryness, a decreased sexual interest, increased LDL (low-density lipoprotein) cholesterol levels, decreased HDL (high-density lipoprotein) cholesterol levels, insomnia and headache. The GnRH analogues are goserelin acetate, leuprolide acetate, nafarelin acetate. These GnRH analogues are given by the parenteral route. Nasal sprays are not used in India. The human Menopausal Gonadotropin (hMG) and the recombinant human Follicle-Stimulating Hormone (rFSH) are gonadotropin fertility drugs. • MG contains natural FSH and LH which are purified and obtained from the urine of postmenopausal women. (After menopause, women produce high levels of gonadotropins which are excreted in their urine.) • FSH is genetically synthesized in the laboratory. The combination human menopausal gonadotropin (hMG)/human chorionic gonadotropin (hCG) or recombinant human follicle-stimulating hormone (rFSH)/hCG treatment can consistently stimulate the ovulation. It results in pregnancies in 60% of the women who fail to ovulate. But among such pregnancies, up to 35% end in miscarriages (15). Metformin is an antihyperglycaemic agent which improves the glucose tolerance in the patients with type 2 diabetes, lowering both the basal and the postprandial plasma glucose levels. The use of metformin, an insulin-sensitizing agent, in PCOS patients who undergo IVF or ovulation induction has been extensively researched, but with divergent results. Now,

a new study has reported that metformin significantly reduces the incidence of the Ovarian Hyperstimulation Syndrome (OHSS) and miscarriage, while positively affecting the oocyte and the embryo quality in CC-resistant PCOS women who undergo IVF. The results of the randomized controlled study have been published in the Journal of Obstetrics and Gynecology (16). On the contrary, a recent review which was written by Tso et al (Cochrane Database of Systemic Review, 2009) concluded that metformin administration prior to and during the ART cycles did not increase the pregnancy and the live birth rates in PCOS women (17). Bromocriptine has been the most widely used prolactin-lowering agent since its introduction in 1972. Bromocriptine is highly effective for normalizing or reducing the prolactin levels in hyperprolactinaemic patients, and it restores the normal gonadal function in approximately 70-90% of the patients. A new dopaminergic ergoline derivative, cabergoline, has been found to suppress the serum prolactin levels in hyperprolactinaemic patients and several reports concerning women have been published (18). These results have shown the better efficacy of cabergoline, both in pregnancy and in lowering the serum level of prolactin. In addition, most of the side effects had a significantly lower incidence among the patients who received cabergoline than those who were administered bromocriptine. Multiple pregnancy is the main downside of this option. Mostly, anovulatory cycles and infertililty, despite the normal reports, are amenable to the drug therapy and they achieve a success rate of 50%. An interventional approach in the form of Assisted Reproductive Technology (ART) is commonly tried in those who are without financial problems. ART, which includes in vitro fertilization, gamete in vitro fertilization, zygote intra fallopian tube and intrauterine insemination have been tried although they are expensive ventures with substantial success. Surrogacy uses the ovum of the surrogate and the fertilized embryo is allowed to grow. It is handed over to the concerned parent at the birth of the offspring. Gestational carriers are used in cases of uterine malformations in the women who thus require the hiring of a womb till the offspring is delivered. One hospital in Mumbai, India, made success in assisting the birth of over 2300 babies through the IVF technology since October 1990 till now. Assisted Reproductive Technology (ART ART): According to the 2009 CDC fertility clinic success rates (U.S.), the average%age of the ART cycles that led to a live birth were: • 41% in women who were younger than 35 years of age • 32% in women who were aged 35–37 years • 22% in women who were aged 38–40 years • 12% in women who were aged 41–42 years and • 5% in women who were aged 43–44 years In the Indian system of Ayurveda, the approach to the female infertility is entirely different. The modern system of medicine, as we have seen, is only successful in 17% of all the infertility cases. Assisted reproductive technology and pharmacotherapy have been the most fruitful methods. The inadvertent loose of medication in infertility has not very successful due to ambigues aetiology. The patients in Indiawho have exposure to an array of alternative systems of medicine, impatiently resort to one of these systems; folklore medicine, Ayurveda, Pranayama, Siddha and Unani.

The Ayurvedic Preventions which are Commonly Used
In ayurveda, we compare the human body to the miniature universe. There is a sun–pitta, moon–kapha and vayu-vata in our body, which is the same as compared to the universe. As a sprout comes out as a result of the combination of the season, soil, water and seed, conception takes place positively if these 4 factors are combined properly. In the human body, the fertility factor depends on the Rutu-ovulation period, the kshetra-uterus, the ambu–pervading rasa dhatu which is formed by the digested food, the bija- ovum and the sperm. (Su Sharira ch.2: 33). If there is any impairment in the above 4 factors, conception will not take place. In Ayurveda, 20 types of pathologies which are related to the genital organs have been discussed as yoni vyapath. These are caused by the wrong regimen, menstrual morbidity, genetic defects and as a result of evil actions which were done in the previous life (Daiva ). [Charak, chikitsa sthana chapter 30] When the reproductive system is afflicted by any of this yoni rogas, a woman becomes incapable of retaining or receiving the semen, as a result of which she does not conceive.

Yoni Vyapath 1. Vatika yoni Roga: If a woman has a vata constitution (Prakriti) and if she resorts to food and regimens which aggravate the vayu, then the aggravated vayu gets located in the reproductive organs and produces pain, ache, stiffness, a tingling sensation, dryness, numbness, fatigue, etc and she gets an untimely menstrual discharge which is frothy, thin and dry, which is associated with sound and pain. 2. Paithika yoni roga: It is caused by the intake of pungent, sour, salty, alkaline and similar other types of food. The woman suffers from a burning sensation, suppuration and fever. The menstrual discharge becomes heavy, blue, yellow or black in colour and it has an offensive smell. 3. Kaphaja yoni roga: With the intake of abhishyandi (which obstructs the channels ) food, the aggravated kapha vitiates the reproductive system and causes itching, sliminess, mild pain and pallor of the genital organs. Her menstrual discharge will be pale and slimy. 4. Sannipatika Yoni roga: If the woman indulges in samashana ( intake of good and bad food which has all tastes together), then all the 3 doshas which are located in the genital tract and the uterus get vitiated and they cause the signs and symptoms of all the 3 doshas. 5. Rakta yoni, Asradgdhara (D.U.B): If the woman resorts to food and regimens which increase the rakta and pitta, then her blood gets vitiated by the excess flow of the pitta through the genital tract. The blood flow does not stop even when he woman becomes pregnant. The pregnancy does not continue because of the excess blood flow. 6. Arajaska (Amenorrhoea): If the pitta is located in the vagina and the uterus, this vitiates the blood and there will be no menstruation. There will be extreme emaciation and discolouration of the skin. In Astanga samgraha, Vagbhata explains this as Lohita kshaya, which is manifested by the aggravation of vata and pitta, which causes a decrease orloss of the menstrual fluid, which is accompanied by a burning sensation, emaciation and discolouration of the vagina (A.S. uttara. 38) (20) 7. Achrana: If hygiene is not maintained, micro organisms grow in the genital tract and cause itching. 8. Aticharana: Because of excessive sexual acts , the aggravated vayu causes swelling , numbness and severe pain. 9. Udavartini (dysmenorrhea): If a woman controls her bowel movements, flatus and the urge for urination, the vayu gets aggravated and causes severe pain. The pain stops immediately after the menstrual flow starts. 10. Putraghni: The aggravated vata pollutes the ovum and the formed embryo gets destroyed. Vagbhata describes Jaataghni (astanga sangraha uttarasthana ch. 38) which is of similar symptoms. 11. Mahayoni: The openings of the uterus and the vagina remain dilated after intercourse. There will be pain and the discharge of frothy blood. There will be protuberance of the muscles and pricking pain in the joints and the groins. Then, there is Prak chrana in puberty, Upapluta in pregnancy and Paripluta (due to the suppression of natural urges like sneeze, etc, the vata gets aggravated , causing oedema, tenderness and pain in the genital tract.) , Karnini (polyp), Antarmukhi yoni roga (distortion of the cervix), Suchimukhi yoniroga (Pin hole os), Shushka yoni (dryness of the vagina), Vamini (Semen is thrown out after 6-7 nights) and Shandi (female impotency).

Rtukala After the pathology of the uterus, one should consider about the season of the conception. As per Sushrutha, it is 12 days after the commencement of the menstruation. (Su Sharira 3: 6) On even days (6,8,10 and so on), the arthava ( ovum) will be less and on odd days (5,7 and9 ) it will be more. So, the copulation on these days will lead to male and female babies respectively. (A.S. sharira.1) (21). Pumsavana Karma: Once the lady has conceived , before the signs of the pregnancy manifest clearly, pumsavana (a rite which is done to beget a male child ) should be done on the Pushya stellar constellation. Milk which is prepared by using herbs like Lakshmana (Solanum surrattense) and the sprouts of Vata (Ficus bengalensis Linn), is put into the right nostril of the woman if she desires a male child and into her left nostril if she desires a female child. The milk should be swallowed. (A.S sharira 2).

Line of Treatment For the diseases which are caused by vata, the patient should give oleation, fomentation, enema, and such other therapies which alleviate the vayu. Her body should be massaged with oil which is mixed with rock salt and she should be then given fomentation. After the fomentation, her body should be sprinkled with warm water and she should drink meat soup which is prepared by using vayu alleviating drugs. The affusion (decotion of Triphala [Terminalia chebula, Terminalia belerica, Phylanthus embilica] or Guduchi (Tinospora cardifolia), massage and Pichu kriya (insertion of tampons’ soaked in medicated oils in the genital tract). Oils like Guduchyadi taila, Saindhavadi taila and Sukumara taila are used. The paste of Himsra (Capparis sepiaria pessary) is kept in the vagina. In case of the ailments which are caused by Pitta, cooling therapies which are curative of rakta and pitta are administered. The pasteof Panchavalkala [(the bark of Nyagrodha (Ficus bengaenesis, Udumbara (Ficus glomerata), Ashvatha (Ficus religiosa), Parisha (Thespesiap populanea Soland ex correa) Plaksha (Ficus lacor)] is applied inside the vagina. Affusion, massage and pichu kriya (insertion of tampons which are soaked in ghee or oil in the genitalia) with the pitta pacifying drugs are also effective. For eg. Shatavari (Asperagus recemosus). In case of Kapha aggravation, pessaries which are prepared by using barley flour, rock salt and the latex of Arka (Calatropis gigantea) should be kept in the vagina for a short period. Then the genital tract is cleansed with a douche of luke warm water. If there is stenosis, the dilation is done after the administration of oleation and fomentation. A pessary ( varti) which is of the shape and size of the index finger should be prepared out of Pippali (Piper longum), Maricha (Piper nigrum), etc and it should be inserted in the genital tract. It cleanses the genitalia. Douching the female genital organs with a decoction of Nimba (Azadirachta indica ) , Jambu (Eugenia jumbolaana ), Vasa (Adathoda vasica) Triphala, Amra(Mangifera idica ), Arjuna (Terminalia arjuna), Palasa (Butea monosperm) and Karanja ( Pongamia pinnata ) cures the morbid vaginal discharges. Enemas which are given according to the dosha predominance is useful. For eg, in vatika type oil, pittika type medicated milk, in kaphaja decoction of pungent drugs.

Rakta yoni, Asrgdara (Menorrhagia) The intake of yogurt which is mixed with sugar, honey, Yasstimadhu (glycyrrhiza glabra) and Nagara (zinzeber officinalis) is useful. The paste of the root of Thanduliyaka (Amaranthus spinosus Linn) which is mixed with honey should be taken along with rice water. Ghee which is cooked with a decoction of Kashmarya (Gmelia arboria) and Kutaja (Holerrhena antidysentrica) should be used as a douche. Vasa ghrita and maha tiktaka ghrita are given internally. In Udavartha yoni roga, anuvasan enema and a douche which is made with ghee, oil or enema with milk which is boiled with Dasa mula ( roots of Bilva (Aegle marmelos), Agnimantha (Premna mucronata), Shyonaka (Oroxylum indicum), Gambhari (Gmelina arborea), Patala (Stereospermum suaveolens), Gokshura (Trebulus terrestris), shalaparni (Desmodium gangaticum), Prashnaparni (Uraria picta), Brihati (Solanum indicum) and Kantakari (Solanum xanthocarpum) are useful.

The Treatment for Leucorrhea The paste of Amalaki (Phylanthus embelica) which is mixed with sugar and honey with water. Vaginal pessaries which are made of Plaksha (Ficus lacor), Lodra (Symplocos recemosus) or Thriphala and Eugenia jambolana, samanga ( Mimosa pudica) are inserted to dry the exudation . Also, the decoction of the same can be used as a douche. A tampon which is soaked in Udumbara tail (the oil which is prepared from Ficus glomerata) is inserted in the genital tract. Thereafter, a douche which is prepared with the cold decoction of the same drugs is given. When the genital organs get cleaned by the aforesaid measures, the woman becomes capable of conception, provided the sperm and the ovum ( beeja) are unpolluted. T he medicines for ovulation are as follows: the powdered roots of Solanum surrattense which are taken with milk or ghee in the fertile period with Kumari (Aloe vera) juice. Milk which is processed with a decoction of Asvagandha (Withania somnifera), to whichghee is added, is given on the 4th day of the menstrual period. A combination of Pippali ( Piper logum) ,Sunti ( Zinzeber officinalis), Maricha (Piper nigrum) , Nagakeshara (Mesua ferrea) – should be taken with ghee. (Chakradatta ch. 62:27, 28, 29). The chraka mentions the Prajasthapana (procreants ) drugs which eliminate the doshas which cause obstruction to the conception.(Ch. Su 4).

Mode of Action Amalaki (Phylanthus embilica), Shatavari (Asperagus recemosus), etc give strength to the uterus and nourish the foetus by their madhura rasa vipaka (sweet taste and metabolite), sheeta (cold) and snigdha (oily) characteristics. The uterus is made up of blood and muscle tissue. The uterus becomes weak due to mamsa (muscle), meda (fat) – kapha vitiation leading to the accumulation of kleda (exudation). Brahmi (Bacopa monnieri), Katuki( picrorhiza kurroa), Doorva (Cynodon dactylon), Patala(Stereospermum suaveolens) and Haritaki (Terminalia chebula), by their katu (pungent)– tiktha (bitter) – kashaya (astringent) taste, laghu (light) and rooksha (dry) qualities dry the exudation, stimulate the circulation and nourish the foetus. For a better progeny, drugs like Brahmi (Bacopa monnieri), Lakshmana (Solanum surretense), Amalki (Phylanthus embelica), Haritaki (Terminalia chebula), Shatavari (Asperagus recemosus), etc be consumed by the mother before and after the conception. (Dravya Guna Vignana 19) (22) In modern times, because of stress and wrong food habits and life styles, more cases of infertility are being observed. Along with the problems which are mentioned in the ancient classic texts, new problems like polycystic ovarian disease, chocolate cysts, simple cysts, and endometriosis are the reasons which cause infertility. Consuming too much of chicken, cocoa products, spicy and oily food and working late at nights are the causes for above said pathology.

As the first and fore most line of treatment, we ask the women to avoid these foods and lifestyles. The drug of choice for female infertility is Ashoka ( Saraca asoca Roxb De Wilde) – by its astringent taste and cold potency, it strengthens the uterus. It stops the bleeding by contracting the uterine blood vessels and promoting uterine muscular contraction. It stimulates the uterine function by stimulating the decidual and the ovarian functions. Kumari (Aloe vera ): It improves the blood flow to the decidual membrane and it stimulates the uterine musculature to contract. It thus improves the menstrual flow. It should not be given during pregnancy as may cause abortion. It is useful in inducing ovulation. Shatavari (Asperagus recemosus): It nourishes the uterus and gives strength to the muscles and the rakta dhatu which is associated with it. It induces ovulation and it also prevents abortion or miscarriage. Ashokarista (fermented medicine which is prepared by using Saraca asoca and other herbs) is most commonly used to regulate the menstrual cycle, improve the endometrium and to stimulate ovulation. From the 4th day of the menstruation, Ashokarista, in combination with Kumaryasava (fermented medicine which is made by using Aloe vera and other herbs) should be given. I usually combine this with Aloes compound [a tablet which is made by using Aloe vera, Manjista (Rubia cardifolia), etc], Rajapravrtinivati (asafoetida, etc) to induce ovulation. From the 14th day, Ashokarista with Ashvagandharista ( Withania somnifera, etc ) or Punarnavasava ( fermented medicine which is made by using Boerhvia diffusa and other herbs) should be given to maintain the embryo. Along with this, Laptaden (a tablet which is made by using Jeevanti [Leptadinia reticulate, etc) and Garbhapala rasa which helps in sustaining the pregnancy should be given. It normalizes the environment which is required for the conception. In case of the women with high prolactin levels, Chandraprabha vati (shilajit etc.) is given. When there is heavy menstruation, shatavari (Asperagus recemosus) is the drug of choice to control the bleeding and to strengthen the uterus. When there is too much of hormonal imbalance or amenorrhea for a long duration and in spite of consuming all types of emmenagogue herbs, when there is no menstruation, we have to opt for Panchakarma treatments like Virechana (removing the toxins by purgation) and Basti chikitsa (introducing the medicine through the anus to remove the toxins in the pelvic region, to strengthen the genital organs and also to pacify the vata ). When there is leucorrhoea, the vaginal media becomes acidic, which is not favourable for sperms. Giving a vaginal douche of Udumbara (Ficus glomerata) is very beneficial in such cases. Phala sarpi (Ghee which is prepared with Manjista (Rubia cardifolia), Bala (Sida cardifolia), etc) is another drug of choice for infertility. It is highly effective for all diseases of the reproductary system and also the best for Pumsavana. It is especially useful in cases of threatened abortion and for pregnant women. (A. S. Uttara 39). The traditional medicine which is being used over the centuries is Ayurveda, which is being held in high esteem and trust. In the event of infertility, couples turn to ayurveda and modern medicine for succour. Indians are known to visit religious places and to take vows and penance for success. Faith healing is integral to the Indians, as their religious fervour runs deep. The ayurvedic concepts are precisely outlined in this review (24).

Conclusion

The incidence of infertility in females is definitely an issue of concern, although it affects only a small%age of the total population. The options which are available, range from ART, despite it being an expensive alternative. Pharmacotherapy is the initial approach for most of the women. The patients look forward to the alternative systems of medicine and faith healing for a quick and successful outcome. Ayurvedic preparations have been reported to be effective in correcting the female infertility.

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DOI and Others

ID: JCDR/2012/4204:2486

Date of Submission: Feb 29, 2012
Date of Peer Review: Mar 22, 2012
Date of Acceptance: Jul 22, 2012
Date of Publishing: Sep 30, 2012

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