Comparative Critical Analysis of Charakokta Yoga and Vagbhatokta Yoga for Vamini Yonivyapath with Special Reference to Luteal Phase Defect

Introduction

Vamini Yonivyapath is one of the twenty Yonivyapaths discussed in Ayurveda classics with very limited description about symptomatology, pathology and treatment. If the Shukra gets expelled out from the Garbhashaya after six to seven days of its entry into the Garbhashaya, the woman is said to be suffering from Vamini Yonivyapath. The concept of seminum effluvium or the post coital semen expulsion from the vagina is obsolete, as it is now understood that very limited amount of the semen is sucked into the uterus after the coitus and rest is expelled. So, a pathology which occurs six to seven days post ovulation with failed conception should be considered to fit the description of Vamini Yonivyapath. Luteal phase defect (LPD) is one such predominantly recognised pathology which shifts the implantation window in post ovulatory phase of the cycle leading to negative outcome of the pregnancy. LPD is the inevitable stage in most of the assisted reproductive techniques. The present manuscript discusses if Yogas told in the context of Vamini Yonivyapth can be proposed for LPD in clinical practice.

Methods

Literary data was collected from Brihatrayis and its commentaries, compiled books of Dravya Guna, and contemporary allopathic text books. Web sources were searched using MeSH words like uterine peristalsis, progesterone, ovulation, luteal phase defect, and endometrial receptivity. Experimental studies, clinical trials, systematic analysis, abstracts and review articles were considered. The collected data was critically analysed and interpreted.

Literary review

Vamini Yonivyapad

Vamini Yonivyapath is one of twenty Yonivyapaths explained by Acharyas. Charaka stated that, ‘the disorder in which Shukra is expelled out, with or without pain, within six to seven days of its entry into the Yoni is called as Vamini’.¹ Vagbhata I and II have followed Charaka; however, rather than Vata being expelled with Bija and Raja, they held Vata responsible for the expulsion of Shukra.^2,3 Indu commented that, ‘there is Shukra Vamana and Vamana means expulsion’.⁴ He mentioned that due to the presence of Vata in Garbhashaya, the ejaculated Shukra gets expelled out with or without pain.

Sushruta stated that, ‘Yoni which vomits or expels Bija and Raja along with Vata, and associated with features of Pittadushti like, Osha, Chosha is known as Vamini’.⁵ Sushruta has not mentioned the time of expulsion of Bija. Dalhana commented that Bija implicates Shukra, Udgireth means ‘Vameth or being vomited’,

Rajasaayutha means ‘mixed with Artava’.⁶ It can be understood that, due to Pittadushti, Shukra gets expelled along with Artava. Here Artava can be considered as shedding endometrium. Madhavakara stated that, even though Shukra is Shuddha, it is vomited out.⁷

According to Charaka and both Vagbhata I and II, the involved Doshas are Vata Pitta.^8,2,3 According to Sushruta, it is Pitta. Vagbhata listed Vamini in Vataja Yonivyapath group. But explanation is similar to Charaka, hence Dosha involvement can be considered as Vata Pitta.

Chikitsa

Samanya Chikitsa

-  Yonivyapath Samanya Chikitsa.

Vishishta Chikitsa

The principles of treatment are -

-  Sneha Swedadi Krama, Snehapichu, Santharpana⁹

-  Swedana followed by Tharpana, Sneha Pichudharana and Vatanashaka Ahara Prayoga¹⁰

Two preparations mentioned in the texts are as follows:

1. Yoni Dharana with Uthkarika or Samyaava (tampon form) prepared from the Kalka of Shatahwa, Yava, Godhuma, Kinva, Priyangu, Bala, Akhukarni and Shrayahva. Chakrapani says that, this Yoga acts as Bijadharana Karaka.¹¹ 
2. Shallaki, Jingini, Jambu, and Dhava Twak and Panchavalkala Kashaya Sidda Snehapichu Dharana.¹⁰

Observation

The Rasapanchaka of Charakokta Yoga and Vagbhatokta Yoga were analysed and descriptive statistics were generated.

Descriptive Statistics

Rasa

Charakokta Yoga- 33% of drugs have Madhura Rasa and 28% of drugs have Kashaya and Tikta Rasa.

Vagbhatokta Yoga - 43% of drugs have Kashaya Rasa and 35% drugs have Madhura Rasa.

Guna

Charakokta Yoga- 22% of drugs exhibit Laghu and Snigdha Guna and 17% of drugs have Ruksha Guna.

Vagbhatokta Yoga - 43% of drugs have Ruksha Guna and 24% drugs have Laghu Guna and 19% have Guru Guna.

Virya

Charakokta Yoga - 86% of drugs have Sheeta Virya.

Vagbhatokta Yoga - 80% of drugs have Sheeta Virya.

Vipaka

Charakokta Yoga - 71% drugs have Madhura Vipaka.

Vagbhatokta Yoga - 100% drugs have Katu Vipaka.

Doshagnatha

Charakokta Yoga - 47% drugs have Vatahara property and 40% drugs have Kaphahara property.

Vagbhatokta Yoga - 50% drugs have Kaphahara property and 44% drugs have Pittahara property.

Discussion

Discussion contains three parts:

1. Vamini Yonivyapath and Luteal phase defect.

2. Samprapti Vighatana of Vamini Yonivyapath.

3. Drug delivery of vaginal preparations.

Discussion on Vamini Yonivyapth

a) Vamini as Yonivyapath

While explaining Vamini Yonivyapath, Madhavakara mentioned that, the Bija gets expelled even though it is Shudda.⁷ In the commentary, Bija is considered as Shukra.⁷ Most of very early pregnancy wastages are due to chromosomal anomalies of gametes. When Shudda Bija is mentioned, all chromosomal anomalies of both gametes causing non fertilization and early pregnancy wastage are ruled out. So, Vamini refers only to the Kshetra dushti and not Bija dushti.

b) Vamini Yonivyapath

Dalhana commentary⁶ on Sushruta Samhita states that, Shukra gets expelled mixed with Artava. But the time of expulsion is not mentioned. If we consider the time stated by other Acharyas, which is around six to seven days after ovulation, the woman should get Artava srava by six to seven days after ovulation. Along with that, Shukra also gets expelled if the couple indulges in coitus.

Samprapti Ghataka

Dosha, - Vata Pitta,⁸ Pitta,⁵ Vata/Vatapitta^2,3

Dushya - Artava

Srotas - Artavavaha Srotas

Srotodushti Prakara - Atipravritti

Udbhavastaana - Pakvashaya

Sanchara staana - Abhyantara Rogamarga

Vyakta staana - Garbhashaya

Purvarupa - Avyakta

Rupa - Saruja, Niruja, Shukra Vamana with Raja on Shat or Sapta Ratra, Osha, Choshadi Pitta Lakshana

Upadrava - Na Shukram Dharayathi, Na Garbham Grahnathi.¹²

Deficient progesterone response is called as ‘Luteal phase defect’ (LPD). Here, early luteolysis leads to premature withdrawal of progesterone support due to which the woman would have menstruation by D20 or D21 of menstrual cycle which is six to seven days post ovulation. This is called ‘epimenorrhoea’. Even though there is coital activity, the sperm is thrown out and woman gets the cycle early due to deficient progesterone leading to premature endometrial breakdown.

Vamini Yonivyapath as a cause of infertility

In Vamini Yonivyapath, due to vitiated Doshas, Shukra that has entered Yoni is expelled out with or without pain within 6 to 7 days, which means, it is a stage in which the conception itself would not take place.

Uterine peristalsis, secretory phase of the endometrium, endometrial receptivity, and early embryonic development are progesterone dependent. Progesterone deficiency in LPD leads to hyperactive uterus. Uterine dysperistalsis or hyperperistalsis can cause impaired transportation of the sperms into the fallopian tube,¹³ as well as impaired embryo migration, thereby adversely affecting the chances of pregnancy.¹⁴ Patients with uterine peristalsis rate less than 4 wave/min before embryo transfer had a higher chance of successful implantation and pregnancy compared with those with higher uterine contraction frequencies.¹⁵

Defective peristalsis of uterus leads to dysmenorrhea, i.e., painful menstrual cycle.¹⁶ Progesterone controls prostaglandin production. High oestrogen level and low progesterone level triggers prostaglandin production leading to painful cycle.¹⁷

The time of expulsion of Shukra is said to be six or seven days after Rutukala. Progesterone is responsible for well-developed vascular architecture within endometrium and nutrient rich uterine secretions which are needed for early growth of zygote.¹⁸ These changes are at their peak at six to seven days post ovulation i.e., at 20 to 21st day of menstrual cycle.  This is called ‘Implantation window’ which is progesterone dependent. LPD leads to improper secretory changes of endometrium¹⁹ and shifting of implantation window. The zygote cannot develop due to inadequate secretory changes of endometrium. Shifting of implantation window culminates in failed implantation due to non synchronized materno-foetal dialogue.²⁰

Physiologic continuity between the developing follicle and corpus luteum is very essential for proper progesterone secretion. LPD is perpetuated to be a result of insufficient progesterone response to maintain a normal secretory endometrium and allow for normal embryo implantation and nidation.²¹ LPD is not considered as an independent entity for infertility, but it is positively correlated with recurrent implantation failures and administration of progesterone is found to be beneficial in such conditions.²¹

Accordingly, LPD can occur in two scenarios:

1.  Defective follicular phase

i. Inadequate Follicle Stimulating Hormone (FSH) stimulation followed by lower FSH:LH ratio during follicular phase is associated with short luteal phases.

ii. Increased Luteinizing hormone (LH) pulse frequency during follicular phase is associated with LPD.

2.  Defective luteal phase

i. Decreased LH levels lead to decreased progesterone levels. Stress, exercise may influence metabolic clearance of progesterone distribution leading to LPD.

ii. Intrinsic secretory endometrium defects like progesterone receptor deficiency or progesterone receptor resistance will lead to LPD.

Patients of LPD presents with epimenorrhoea, implantation failure, dysmenorrhea and early pregnancy wastage. All these symptoms are also seen in Vamini Yonivyapath.

Understanding Vamini Yonivyapath on the Dosha predominance

a) Role of Vata - Apana Vata is responsible for Garbha and Arthava Nishkramana. Defective peristalsis of uterus, dysmenorrhea and epimenorrhea can be attributed to Vatadushti. Defective uterine peristalsis can hamper sperm and zygote transportation.

b) Role of Pitta – Pitta is considered as a causative factor for the secretory changes including implantation window in Rutuvyathitha Kala. For the impaired secretory endometrium, Pitta vitiation could be considered as the attributing factor.

According to Charaka and Vagbhata, involved Doshas are Vatapitta. So, their description of Vamini Yonivyapth seems to be including dysperistalsis and defective secretory endometrium of LPD which can be attributed to Vata Pitta. Sushruta has considered it as Pittaja type Yonivyapath, which can be attributed to defective secretory endometrium without impaired uterine peristalsis. So, he has not included Ruja as the symptom.

Comparison between Vamini Yonivyapath and Luteal phase defect

Nidana / Etiology

Vamini Yonivyapath occurs due to Vatapittakara aharaviharas like excessive physical and psychological stress and excessive consumption of Ati Ushna Teekshna Vidahi Ahara, etc.

LPD manifests due to inadequate progesterone response which may occur due to defective follicular or secretory phase. Excessive exercise, stress, weight loss, assisted reproductive techniques, aging, tobacco, are some of the factors leading to LPD.

Lakshana / Symptoms

Vamini Yonivyapath - Symptoms are expulsion of Shukra or Bija on 7th or 8th day, along with or without pain and subsequent infertility.

Luteal phase defect - Symptoms of LPD would be premenstrual spotting, epimenorrhoea, implantation failure, infertility and recurrent early pregnancy wastage.

Samprapti / Pathogenesis

Vamini Yonivyapath - Due to Swanidanas, increased Vata or Vatapitta take Sthaana Samshraya in Garbhashaya. The Prakupita Vata present in the Garbhashaya expels Shukra out along with Raja on 6th or 7th day with or without pain.

Luteal phase defect - Inadequate concentration of progesterone or inadequate endometrial response to progesterone causes early endometrial shedding, dysmenorrhea, implantation failure or repeated early pregnancy wastage.

Vatapitta Prakopa during follicular phase might cause impaired folliculo-genesis and subsequent LPD due to Ruksha Guna of Vata and Ushna, Teekshna Guna of Pitta. Vatapitta Prakopa during secretory phase leads to LPD due to Ruksha, Laghu and Chala Guna of Vata and Ushna and Teekshna Guna of Pitta culminates in defective secretory changes, shifting of implantation window, epimenorrhoea and dysmenorrhoea.

Time period of symptoms

Vamini Yonivyapath - 6th or 7th day

Luteal phase defect - 6th or 7th day post ovulation

Chikitsa / Treatment

Vamini Yonivyapath - Snehana, Swedana followed by Pichudhara of Vatapittahara, Garbhada Dravyas are indicated.

Luteal phase defect - Oral or vaginal progesterone, oestrogen, Human Chorionic Gonadotropin hormone (hCG), Luteinizing hormone (LH) are advised.

Mode of action of treatment

Vamini Yonivyapath - The treatment would act as Vatapittahara, Bijadharana, Garbhastapana.

Luteal phase defect - The treatment would improve endometrial receptivity, imparts quiescent-ness of the uterus and stability of early pregnancy.

Discussion on Yogas in Samprapti Vighatana

Probable mode of action of Charakokta Yoga

Vamini Yonivyapath is due to Vatapitta Doshas according to Charaka. Most of the drugs have Madhura, Tikta, Kashaya Rasa, Sheeta Virya and Madhura Vipaka. The Yoga ideally acts as Vatapittahara, Godhuma, Bala, and Shatahwa act as Santharpana and Balya, and might help during folliculogenesis and improve subsequent LPD. Bala acts as uterotonic. Due to Shulagna and Vatanuloma property, uterine peristalsis is regularised. Priyangu, Bala, Shatahwa, Padma and Bilwa might act on defective secretory endometrium due to Vatapittahara and Stambhana Guna. The Prabhava of Yoga is Bija Dharaka. This Yoga might help to retain Shukra and aid in fertilization and implantation. Madhura Rasa, Sheeta Virya and Madhura Vipaka is also ideal for the Garbha, if pregnancy occurs. The Yoga probably improves follicular phase along with subsequent LPD.

Kinva (SuraBija), a form of Shukta Kalpana initiates fermentation and formation of lactic acid, congenial for the maintenance of Lactobacillus and thus the pH of vagina is maintained acidic. Ideal vaginal pH helps in survival of sperm and its transportation into uterus through cervical canal.

Probable mode of action of Vagbhatokta Yoga

The drugs told in the Vagbhatokta Yoga belong to Kashaya Skanda and act on Apana Kshetra. Most of the drugs have Garbhasthapaka property.

Except Jambu and Dhava - all seven drugs i.e., Shallaki, Jingini and Panchavalkala act as Yonishodhaka, Pradarahara and Raktadoshahara. Due to Kashaya Rasa and Sheeta Virya Pradhanata, the Yoga might help in retaining pregnancy by stabilizing the endometrium during secretory phase. Panchavalkala is well known for Pittahara property which might be acting on defective luteal phase and normalising secretory endometrium. Shallaki is a well-known analgesic and useful in dysmenorrhoea.

The drugs of Panchavalkala also have Garbhasthapana Guna and could help during the process of implanta- tion. They are also indicated in Garbhasrava as Stambhaka Dravya. So, the Yoga probably acts on vitiated Doshas locally, rendering Garbhasthapana effect in LPD, especially in secretory phase.

Panchavalkala drugs are known as Yonidoshahara, thus help to maintain healthy vagina thereby enhancing sperm survival. The comparison of Charakokta Yoga and Vagbhatokta Yoga with respect to their Rasapan- chaka, Doshagnatha, probable mode of action on female genital system along with their effect on LPD is shown in Table 2.

Drug delivery of vaginal preparations

Sthanika Chikitsa i.e. drug administration through vaginal route is given utmost importance in Yonivyapath Chikitsa. Both Charakokta and Vagbhatokta Yogas are vaginal preparations.

Charaka has advised Snehana and Swedana prior to administration of Uthkarika to pacify Vataprakopa as Uthkarika is devoid of Sneha. Vagbhata has advised insertion of Snehapichu after Swedana. Snehana and Swedana pacify vitiated Vata. Sneha along with Kashaya Rasa and Sheeta Virya pacifies Vatapitta. It maintains normal integrity of vaginal mucosa.

Swedana increases local blood congestion temporarily and helps in better absorption of vaginal preparations. Uthkarika and Snehapichu probably act on vagina by direct effect as well as on uterus due to first pass effect.

Spreading and retention of formulation and drug absorption, release, dissolution in vagina depends on properties of vaginal environment like pH, discharge, microflora, total surface area, vascularization and specific microbiota.²² Lamina propria and tunica adventitia of vagina contain large plexus of blood vessels and lymphatics. Vaginal vascular system anastomosis with uterine vascular system leads to accumulation of drug in uterus and endometrium through first pass effect. This route avoids the gut and hepatic first pass metabolism due to which gastrointestinal and hepatic complications are avoided. Swedana temporarily increases vascularity of vaginal surface and might help to increase concentration of the drug in uterus and endometrium through first pass effect.

Both Yogas have phytoconstituents of hydrophilic and lipophilic nature which get dissolved in vaginal secretions, and absorbed through vaginal vasculature. Snehana advised as Purvakarma might help in absorption of lipophilic molecules. Snehapichu probably releases lipophilic molecules in vaginal secretions.

Surabija of Charakokta Yoga helps to maintain vaginal pH. Panchavalkala of Vagbhatokta Yoga is an efficient Yonidoshahara and Krimighna. Both preparations maintain normal environment of vagina.

Conclusions

LPD is characterized with inadequate secretory changes in endometrium along with epimenorrhoea with or without dysmenorrhoea due to progesterone inadequacy. Symptoms of Vamini Yonivyapath explained in the classics resemble that of LPD. Dysperistalsis in uterus causes Saruja Rajodarshana. Inadequate secretory changes resulting in shifting of implantation window leads to Shukra Vamana along with Raja on sixth or seventh day after ovulation. So, the viable pregnancy fails to occur in spite of healthy gametes. LPD is an inevitable phenomenon in the Assisted Reproductive Technology.

Uthkarika devoid of Sneha after local Snehana Swedana and Snehapichu after Swedana is advised by Charaka and Vagbhata, respectively. Local Snehana and Swedana increase the vascularity in vaginal plexus and helps in better drug absorption. Both preparations have hydrophilic and lipophilic phytoconstituents which might get absorbed into vaginal plexus.

Analysis of Rasapanchaka indicates that vaginal drug administration of Charakokta Uthkarika might be useful during follicular phase there by improving LPD. Vagbhatokta Vartiprayoga appears to be having the effect during secretory phase, thus improving the LPD. Both Yogas probably act during periconceptional period due to Garbhasthapana property which might help to retain the Shukra and Garbha. So, they might offer a safe replacement for the systemic hormones used in LPD.

Furthermore, randomised clinical trials are needed to confirm impact of both the Yogas in Luteal phase defect. It is equally important to ascertain the drug delivery capacity of the Uthkarika and Varti through vaginal route, and the specification of vaginal drug delivery carriers.

Conflict of Interest

None