Introduction

Now a days, Infertility is a major issue due to changes in lifestyle, unhealthy diet, anxiety leading to hormonal imbalance, ovulation failure, failure of implantation and embryonic growth. Infertility causes great personal suffering and distress. According to Ayurveda, Infertility refers to biological inability of woman of reproductive age to contribute to conception and also the state of a woman who is unable to carry pregnancy to full term1. Ayurveda has its own way to handle any health issue, it focus on treatment of infertility holistically with an aim of improving overall health and quality of life of an individual. Ayurveda is an ancient medical science and has a solution for this situation in the form of Panchakarma. As stress and busy lifestyle cause the vitiation of vata. Among Panchkarma especially Basti which is very effective in maintaining our healthy life because Basti maintains the proper function of Vata, When Vata has maintained properly then the normal physiological body function runs properly and decrease the chances of disease2. In many disorders Ayurveda management is very useful and satisfactory because of its long-lasting effects and multisystemic regenerative actions without any harm3. Panchkarma is a comprehensive system of knowledge and practice to purify the body from degenerative influence of toxins and restore it to balance with natural laws. In Ayurveda, there are two types of karmas Shaman karma and Shodhan karma. In Shodhan karma there are five types of karma such as Vaman, Virechan, Basti, Nasya and Raktmokshan. Among the Shodhan karma, Bastikarma is considered as prime as it can provide relief in koshtgata, Dhatugata, Marmagata and sarvsharirgatavikara4. Basti is one of the major treatment modality that comes under Yuktivyapashraya chikitsa. As Vata is considered for disjunction and conjunction of faeces, urine bile etc. with their receptacles, there is no remedy other than Basti for the pacification of Vata when it is aggravated severely. Hence Basti is said as half medicine or even whole medicine by Acharyas. The rectal absorption can prove the good alternative route of drug administration as it provides portal avoidance of first portal pass metabolism. It has been demonstrated that the rectal route is more efficient than the intravenous route5,6. In Ayurveda Vata is considered to be the root cause behind all the disorders related to the female reproductive system including female infertility. So Gudabasti is a Karma for the management of Vata. This article clarifies the effect of Gudabsti in female infertility.

Aim: To study Ayurveda view on Female Infertility and its management w.s.r. to role of Gudabasti

Objective: 1. To study Female Infertility.

2. To study role of Gudabasti in female infertility.

Material and Methods: Ayurvrdic classical text such as Charak Samhita, Sushruta Samhita, Ashtanghridaya, Harita Samhita, Bhela Samhita etc. and other literature were reviewed critically and scientifically to compile the article. Further, data available data on web-based sources and article published on internet were compiled.

Female Infertility: Failure to achieve conception by a couple of mature age, having normal coitus, during appropriate period of menstrual cycle, regularly, at least for one year is termed as infertility7. It develops due to fault in either of the partner or both of them. However, here etiopathogenesis, classification and treatment of only female partner would be discussed. One does not find unequivocal description of this entity in any of the ayurvedika classic referred in this book, except Harita samhita. Harita has defined bandhyatwa(infertility) as failure to achieve a child rather than pregnancy, because, he has included garbhasravi (having repeated abortions) and m?itavatsa (having repeated stillbirths) also under the classification. This definition is not acceptable today. In spite of normal coitus, the woman does not conceive during childhood, old age, puerperium and to certain extent during lactation, but this is not considered infertility. Infertility is not an independent disease, rather a cardinal feature of so many diseases. Other ayuvedika classics have not used word bandhyatwa, but its the only symptom i.e. failure to achieve pregnancy has been referred under various conditions i.e. coitus with an old, young or diseased woman, coitus in abnormal posture, due to diseases of yoni (reproductive system) and abnormalities of artava. Kashyapa says that the couple having number of children with proper growth and development due to effect of nature or their own deeds are fortunate, otherwise (having failed to achieve pregnancy) should be treated8. In Sushruta samhita etc. one disease named vandhya9 is included among twenty gynaecologic disorders. Charaka and Vagbhata have referred vandhya10 due to abnormality of bijamsha. Both these references do not give complete picture of bandhyatwa (infertility). Under the description of jataharinis, Kashyapa has mentioned one puspaghni having useless puspa or menstruation (no conception) and certain others characterized with repeated expulsions of foetus of different gestational periods11. Since in these conditions also the woman fails to get a child, thus, can be included under infertility.

Hetu:- Failure to achieve conception is infertility. Among the important factors or constituents of garbha (zygote/embryo/fetus), authors have included rtu (season or fertile period), k?etra or healthy yoni, uterus and passage (reproductive organs), bija or shukra and shonita (sperms and ovum), ambu or proper nutrient fluid, clarity or normalcy of hridaya or psychology, properly functioning vayu (normal nervous system) and ?adbhawas (mother, father, atma, satwa, satmya and rasa)12. Abnormality in any one of these can cause infertility. Charaka, while answering the question about causes of failure in achieving a child, says that abnormality of any one out of these ?a?bhawas will cause the failure to get a pregnancy. Coitus with a woman who is very young, old, chronically ill, hungry, sorrow- striken and afflicted with other psychological abnormalities, or in hump-back or lateral posture is futile; semen falling over samira?a nadi or in outer part of yoni also fails to impregnate the woman. Due to non -acceptance of bija (sperms) or garbha (zygote/embryo) by vitiated yoni in various yonivyapad (gynaecologic disorders) and destruction of bija in artava dustis (menstrual disorders) the conception does not take place, similarly due to destruction of artava as a complication of yonyarsa also conception will not occur or in other words yonivyapad (gynaecologic disorders), diseases of artava and yonyarsa can be included in the etiology of infertility. Bhela says that due to abnormalities of bija of mother and father, non-consumption of congenial rasas, suppression of natural urges and disorders of yoni, the woman either delivers abnormal child or becomes infertile. He further writes that causes of failure to become pregnant are only two i.e. affliction with various diseases of vata and abnormalities of yoni (reproductive organs). Aggravated vayu expells the shukra (sperms) from the uterus, destroys the raja (ovum), thus the woman becomes infertile. No male or female is infertile from birth. Due to coldness of asaya (gabhashaya or uterus) and dryness of indirya (shishnendriya or penis) the infertility occures. Kashyapa says that girl or boy passing urine with quivering or flopping stream (sphalita mutratwa) are also infertile. Infertility is included among eighty diseases of vata. He says that if excessive medicines for emesis or purgation are given to a person of mridu ko?tha (soft bowel) even after proper oleation and sudation, then due to bleeding, the vayu gets vitiated; this aggravated vayu causes destruction of bija (sperms and ovum) and puspa (menstruation); in such condition infertility will always develop. While describing the classification, Harita has included childhood, garbhakosabhanga (injury to the uterus or prolapse of uterus), loss of dhatus and constriction of uterus and vulva due to coitus having been done with the girl before her menarche also in the causes of infertility. Infertility has been included in the clinical features of injury to artavavahasrotas by Sushruta. Abnormalities of yoni, psychology, shukra, asrk, diet and mode of life, coitus at improper time and loss of bala have been included in the causes of delay in achieving conception by an otherwise fertile or sapraja woman by Charaka. The woman suffering from diseases of vata, if copulates with husband, then also she does not conceive. Normalcy of psychology has been given highest importance for achieving conception.

Under the etiology described by Caraka for delay in achievement of conception in otherwise fertile woman, all the cause described else-where in Caraka as well as other classics are included except abnormalities of atma, satwa and fate given by Charaka and curses of god or fate along with affliction by jataharini given in other classics.

All are discussed hereunder-

1.Yoniprado?a or abnormalities of reproductive organs:- The word yoni refers to entire reproductive system, thus, under this heading congenital or acquired diseases of anatomic components of reproductive organs i.e. vagina, cervix, uterus, endometrium and fallopian tubes can be included. Description of normal or healthy state of k?etra (uterus or passage) also indicates importance of healthy condition of reproductive system. Subject matter to be considered under yoniprado?a available in different classics can be grouped in following way-

1. 1. Yonivyapad or gynecologic disorders
   2. Injury to artavavaha
   3. Yonyarsh
   4. Garbhakoshabhanga or injury to the uterus
   5. Bhaga sankoca or constriction of vulva and vagina
   6. Sphalita mutratwa or passage of urine with quivering or flopping stream
2. Psychological abnormalities:- Normal psychology of the couple is said to be very important for achievement of pregnancy. Clarity or happiness of heart, as a factor for pregnancy and failure of impregnation in afraid, sorrow-stricken, etc. woman denote importance of psychology.
3. Abnormalities of sukra:- Abnormalities of sperms along with spermatic fluid cause infertility. Pitrja bhawas described under six factors are carried to the embryo through sperms. Importance of sperms for pregnancy and infertility due to abnormalities of these has been mentioned in unequivocal words in all the classics.
4. Abnormalities of asrk:- Word asrk refers to ovum, menstrual blood and ovarian hormones). Ovum caries matrjabhawas one of the six factors to the embryo. Abnormalities of ovum and ovarian hormones produce infertility. Artava vitiated by different dosas produces infertility due to destruction of its bija or the ovum.
5. Abnormalities of diet:- For maintenance of normal health the balanced diet is essential. Dietetic abnormalities influence nourishment of the body or cause loss of dhatus which influences normal secretion of hormones resulting into failure to achieve pregnancy. Abnormal diet is one of the important cause of vitiation of do?as, which if vitiated, influence fertilization by producing gynecologic disorders, diseases of vata, chronic illness and udavarta etc. The fertilized egg is nourished by the exudates of epithelial lining of fallopian tubes and endometrium, these exudates are derived from the rasa dhatu formed from maternal diet; for

implantation of zygot, the endometrium is prepared by the hormones, which are also formed with the help of maternal diet, if fertilized egg is not nourished properly, then either fails to develop or after getting implanted in endometrium may get discharged with menstrual blood and the woman will never know that she ever conceived and consider herself as infertile.

1. Abnormalities of mode of life:- Abnormal mode of life and suppression of natural urges aggravate dosas, which influence impregnation by producing various gynecologic abnormalities.. In short, abnormalities of mode of life also produce infertility in two ways i.e.

(1) by vitiating do?as, thus, causing gynecologic disorders and (2) by preventing proper entry of sperms due to faulty deposition of seminal ejaculate.

1. Akala yoga or coitus in improper time:- Word kala (time or period) refers to period of age and rtukala both. In young or old ladies due to premenarche and menopausal stage respectively and before or after rtukala due to absence or destruction of ovum respectively conception does not take place.
2. Loss of bala or strength:- Bala or strength refers to physical strength and capacity to become pregnant. Physical strength depends upon dhatus, which has already been discussed under diet. Here probably bala refers to capacity to achieve conception.
3. Abnormalities of atma and satwa:-This heading includes infertility due to influence of misdeeds done by the couple in their previous life as well as abnormalities of atma descending in this pregnancy.
4. Affliction by Jataharinis :- Affliction by jataharini refers to idiopathic cause of infertility. On the basis of clinical features, the pushpaghni jatahari?i (having infertility as cardinal symptom) seems to be infertility due to inadequate level of hormones.
5. Curses of god or fate

This also refers to idiopathic causes of infertility.

Considering all these references together infertility can be classified in three types according to Charaka.

1. 1. Vandhya or absolute sterility:- Vandhya due to congenital absence of uterus and/or artava is referred earlier
   2. Apraja:- Infertility in which woman conceives after treatment or primary infertility.
   3. Sapraja:- Sapraja is a condition in which a woman in her active reproductive age does not conceive after giving birth to one or more children or it refers to secondary infertility.

Harita has described classification and etiology together. Vandhya is of six types.

1. 1. 1. Kakavandhya (one child sterility),
      2. Anapatya (no child or primary infertility),
      3. Garbhasravi(repeated abortions),
      4. Mrtavatsa (repeated stillbirths)
      5. Due to balak?aya (loss of strength).
      6. If the coitus is done with a girl before her menarche, then it results in constriction of uterus and bhaga (perineum and vaginal canal) and this woman does not conceive or (even after treatment) conceives quite late with great difficulty.

Vandhya described by Caraka is a congenital disease, in which the part of bija responsible for development of uterus and artava is absent or the woman has congenital absence of uterus and artava, this is incurable. Apraja and sapraja described by Caraka and puspaghni, andaghni, durdhara and kalaratri jataharinis described in Kashyapa Samhita are curable. Nakini jataharini is yapya (relapsable), and vasya jataharini is incurable. Anapatya etc. five types described by Harita are curable. Infertility of woman who has coitus before her menarche gets cured with difficulty. Anapatya gets cured with treatment, then neither she remains anapatya (no child) nor kakavandhya(only one child), rather gets so may children. Infertility due to loss of dhatus is also curable.

1. Treatment of specific causes responsible for infertility such as treatment of all the gynecologic disorders including injury to the uterus or its prolapse, diseases of sukra and ärtava and yonyarsa etc. (described in preceding pages) should be done. Authors have mentioned unequivocally that pregnancy occurs only in healthy reproductive organs.
2. Forsaking other etiological factors such as abnormal diet and mode of life,coitus before or after rtuk?la, psychological trouble etc.
3. Use of strength producing and brmhana articles to compensate loss of bala and dh?tus.
4. After using oleation, sudation, emesis, purgation, asthapana (cleansing) and anuwasana (nutritive) enema in consecutive order, the man should be given milk and ghrta medicated with sweet drugs and the woman, oil with m??a etc., is opinion of few authors. K??yapa says that after using cleansing measures, both should be prescribed congenial diet. The infertile woman should be prescribed emesis, purgation and asthapana enema, with the use of these the woman conceives positively and delivers normally. Use of enema in infertility due to diseases of v?ta is highly beneficial. Infertility gets cured by use of purgation. Niruhabasti is like a nectar to an infertile woman. The woman having infertility due to abnormality of either of the partner conceives after anuwasana basti. The woman having amenorrhoea, scanty menstruation, non ovulation or useless ovulation (ovum with minimal or absence of capacity of fertilization) etc. causes of infertility should be prescribed anuwasana enema. By use of basti the yoni becomes healthy, even sterile woman conceive. The basti is beneficial to the women having repeated abortions, short lived and weak children, who are delicate and indulge daily in coitus. Yapana bastis perform both the actions i.e. cleansing of niruha and oleation of anuwasana. By use of these, the infertile couple gets progeny.
5. The drugs prescribed for pumsawanakarma can also be use.

Literary review of Basti

Basti karma means enema which is medicated. In this process, medicated decoctions and oils are administered via anus in the body with the aid of instruments specially designed for the process of Basti. Basti karma's place of action is Pakwashaya which is Vata Dosha's main site. Hence it is the major treatment modality for Vata Dosha. Vata is considered as the cause of all type of movements of the body and is the main etiological factor in the pathogenesis of various diseases. Apan Vayu is responsible for the elimination and retention of faeces, urine and other excreta. Vata is mainly located in the large intestine. Basti sustains the age, improves strength, digestive fire, intellect, voice, and complexion and provides a happy life. The body performs all its functions smoothly. 14 It is very beneficial for all age groups. The bioavailability of the drug i.e. the part of the drug increases when given as Basti. According to Acharya Sushrut, Basti works as plant watered at its root and then root circulate it in all branches. 15 It has also been described as Ardha Chikitsa i.e. half treatment for the management of diseases.

Classification of Basti

According to the consistency of the drugs, Basti is broadly divided into two types

1. Niruha Basti (Aasthaapana)
2. Anuvasan Basti

1. Niruha Basti/ Aasthaapana Basti,- Decoction of medicinal plants is the major content of this Basti, other ingredients like honey, Saindhava, Sneha, Kalka, Prakshepa Dravya are also included to form a suspension. Niruha means to eliminate. This Basti eliminates morbid Doshas from the body. It is also known as Asthapan which means to establish life span and sustains age. 17 12 Prasuta i.e. approximately 1200ml is the quantity of Niruha Basti for administration. The quantity of Sneha to be added depends upon the dominance of Dosha.

Vata dominance- 6 Pala i.e. 1/4th of Niruha Bastidravya Pitta dominance- 4 Pala i.e. 1/6h of Niruha Bastidravya Kapha dominance- 3 Pala i.e. 1/8h of Niruha Bastidravya

1. Sneha Basti/Anuvasan - In this type medicated Sneha in the form of Oil/ Ghee, lipids are administered. Anuvasan means to stay, the administrated medicines stay inside for a longer period, without causing any harm. It can be given daily. Sneha Basti again subdivided according to the quantity of Sneha(oil) into two types.
   1. Anuvasana Basti- 1/4th of the quantity of Niruhabasti
   2. Matra Basti- 1/2th of the quantity of Anuvasanabasti

The number of Basti to be given according to the need of the patient, Basti is divided into 20 Karma -30 Basti

Kala -16 Basti

Yog -8 Basti

Anuvasana and Niruha Basti are given alternately. Rasayana and Burhan Basti can be given to the geriatric person. Dosha shaman Basti is preferred for the young person as metabolic activities are at its peak level. Varnya Basti is preferred for the people who are more beauty conscious. Lekhan Basti can be given to the obese person or who want to be loose their extra fats. Vrushya Basti can be given in infertility. Burhan Basti can be given to the children for their normal growth and development. The person who is habituated with heavy work or heavy exercise can undergo Matra Basti. Matra Basti has an advantage as the person does not need to follow any special Pathya.

Bastikala (Time factor for Basti)-According to various authors, Basti in a healthy person can be given in Varsharitu. Varsharutu is the best time for Basti because in this season Vataprakopa is present in the body as well as in the environment. 21 Usually, Niruha Basti is given in the morning because evening time is the period of Vataprakopaka and Niruha Basti causes Vataprakopa. This is the reason why snehadravya is added to NiruhaBasti. AnuvasanaBasti can be given in the evening. Basti can also be given according to age, Rutu, Kala, etc.

Indications - Vatajvikara(hemiplegia, muscular dystrophy, sciatica, parkinsonism, cerebral palsy), diseases related to muscles and bone, Rheumatic diseases, Vibandha(constipation), abdominal distension, delayed mild stone in children, Ashmari(kidney stone, bladder stone),Jeerna Jwara(chronic fever), Niramaatisar(chronic diarrhoea).

Contraindication- Krusha(very emaciated), Amatisara(Acute diarrhea), Chhardi (vomiting), Kasa(cough), Shwas (asthma), Madhumeha (Diabetes), Shoona-payu (inflamed anus), Kritahara (immediately after taking food) Table 1.

Bastikarmukata (Stepwise Mode of Action of Basti)-

Before starting Basti Chikitsa some Purvakarmas(pre-treatment) are to be carried out to achieve better results.

Amapachana- It clears the obstruction in Srotas caused by Ama. Amapachana is done with the Deepana, Pachana Dravyas such as Trikatu Churna or Panchkola Churna. When Amapachana is achieved, the Srotomukh becomes clear and Srotas become ready to carry vitiated Doshas from Shakha back to Koshtha.

Snehana (oleation of the body)- Sneha enters the body through tiny pores of the skin by its Anupravana Prabhava. After entering the Srotas, it causes Vishyandana and softness in the body and destroys obstruction in srotas. 27 It also pacifies Vata as Sneha is Vatashamaka.

Swedana- After proper Snehana, Swedana is done to liquefy the Doshas which obstruct the minute channels.28 Thus with the help of these three procedures, Amapachana, Snehana and Swedana Dosha move from Shakha towards Koshtha.

Basti- Any substance present in the body which is not conducive to health is considered as mala. 29. In healthy and empty rectum the absorption is more and in diseased condition and the presence of stool delays absorption 30 Hence proper excretion of Mala is very essential which is done by Basti. Bastidravya given through rectal route reaches Pakwashaya which is considered as the main site Vata. As Vata is pacified the disease itself get cured because it is a major causative factor in the disease. Other two Doshas do not have existed without Vata.

VataSthana and so it can alleviate the Vataat. According to Ayurveda, water given at the root of the plant gives nutrition to the whole plant similarly the Basti functions. 31 Guda (rectum) is considered as the Moola of Sharira. It has rich blood and lymph supply. The Bastidravya cross the rectal mucosa and absorption of unionized and lipid-soluble substances from the rectum takes place through the rectal venous plexus. The absorption of the drug from the rectum is according to the laws of transfer of molecules across the biological membrane. It is known as diffusion. Diffusion is the transport of molecules from a region of higher concentration to a region of lower concentration. The concentration of Bastidravya is more in the lumen of the rectum and lower in the cells adjacent to the rectum. Thus the molecules of Basti move from the rectum to surrounding cells. Many factors such as physical status of Bastidravya, ingredients of Basti and their solubility, temperature, size of molecules, pH of gastrointestinal fluid, ionization, the surface area of absorption, vascularity influence the rate of diffusion and absorption. The constituents of Basti reach up to the small intestine and get absorbed through the gut wall, dispersed in the body and thus exert systemic effects. 32 The intestine is enclosed by 4 layers viz. Muscular, Submucosal, Serosa land mucosal layer. When Basti is administered, initially Bastidravya comes in contact with the mucosal layer which is most superficial. The layers of the intestine and the villi get the nutrition thereby improving the absorption of micronutrients. These micronutrients enter the circulation and finally reach up to the target organ. These all things would be possible only when the intestine gets purified regularly. The mucous membrane of the intestine can easily absorb the lipid-soluble content and finally thrusts into circulation. Thus drug may deliver to the target tissues and Basti proves effective in curing many diseases. Furthermore, in Niruhabasti the contents of Basti are Makshika, Saindhava, Sneha, Kalka. Saindhava by its Sukshma. Teekshna and Vyavayiguna spread in the minute channel of the body. 33 The other Dravyas used to prepare Basti different properties, some are water-soluble and some are fat-soluble and get absorbed accordingly. Sushrut explained how the Basti eliminate the Doshas from the body, Virya of Bastidravya extracts the morbid Doshas from all parts of the body to the Pakwashaya just like the sun which resides in the sky and evaporates the water from the earth surface. Similarly, by its Ushna, Tikshnaguna, Basti not only eliminate the Mala and Apana Vayu but also vitiated Doshas present inside the body along with Bastidravya. 34

Discussion

Vata is considered to be the cause of all type of movements of the body and plays a major role in the pathogenesis of many diseases. Basti administered in the Pakvashaya affects the whole body by its Virya. Basti administered through Guda (rectal route) normalizes Apana Vayu leading to Vatanulomana and improves physiological functioning of Vata. Moreover, Bastidravya spreads all over the body, pacifies the aggravated Dosha along with Vyana Vayu leads to Samyaka Rasa Raktadi Dhatu Nirmana. Samyak Rasa Dhatu leads to the formation of Samyak Rakta, Mamsa and Uttarottar Dhatu. It strengthens the muscle power of the body and promotes tissue regeneration. It improves the function of the bladder, uterus, fallopian tube,and ovary. Basti is effective on Asthivaha and Majjavaha Srotas also. Purishadhara Kala, the colon membrane, is considered as Asthidhara Kala, the membrane of the bone tissue. 41 Asthi is important sites of Vata Dosha. Hence, medications are given rectally affect all the tissues up to bone tissue. A significant increase in serum calcium was seen after the course of Basti. Though serum calcium decreased after 90 days, it was still higher than the baseline level.

Basti in Infertility- When the channels of the body are cleaned by Niruha Basti it provides complexion and strength. Anuvasana Basti destroys roughness, lightness and coldness of Vata. Basti provides clarity of mind, energy, and strength to the body. 44 All the Dhatus gets nourished by Basti enhancing the body's Dhatwagni to maintain Dhatusamya (homeostasis) and increase the immunity of the body towards the invasion of the disease. As Vata dosha is the cause for female infertility and Basti is the best Panchakarma for Vatavyadhi. Gudabasti plays an important role in management of female infertility.

Conclusion

Basti is one of the most important and useful treatments for a diseased and healthy person. There are so many types of Basti according to diseases, Rutu, Bala, Kala. So we can consider these factors while adopting the Basti in any person. Basti is not only curative but also disease preventive and health promotive. Basti helps to maintain the equilibrium of Vata dosha in our body. It increases Shukra(potency), Oja (vital energy) and Agni (digestive fire). In this modern era, Infertility is pretty common, and it has the need of hour to find a solution which is having fewer complications. So Gudabasti is very effective in the management Female infertility.