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Introduction

Infertility is one of the major diseases in society causing a great amount of stress to the couples. It is a cardinal feature of underlying diseases rather than a separate entity. The incidence of infertility in any community varies in between 5 to 15 %. One of the major causes of infertility is tubal block. Tubal abnormalities account between 25% and 50 % of female infertility.[1] Tubal damage usually occurs through pelvic infection and  pelvic inflammatory diseases. The block may be due to occlusion of the tube in cornua, isthamus, infundibulum or fimbrial end. Ovum pick up, ovum transport, Sperm transport, fertilization, embryo transport and  early development are processes essential for reproduction which occur within the normal tube.[2] Tubal block possesses a good challenge to the gynecologists. No doubt, there are various modern methods to investigate and  treat the tubal block but they are quite expensive and  complicated. In modern system of medicine ‘Tuboplasty’ is the only solution for tubal block.[3] Keeping this view in mind an attempt has been made in the present study for assessing the efficacy of kshar-tail+Til-tail uttarbsti in tubal block. The clinical study was conducted on 60 patients at R.A.Podar Ayurved Medical College and Hospital, Worli, Mumbai during the year 2004 to 2007. Tubal block which is challenging to modern system of medicine can be solved with Kshar-tail+Til-tail Uttarbasti.

OBJECTIVES:

To determine the efficacy of the uttarbasti by Kshar-tail with Til-tail in tubal block.

Primary Outcome:

1. To remove flimsy adhesions, to improve the function of tubal cilia.
2. To avoid intra-abdominal and intra tubal adhesions by providing conservative atraumatic treatment.

MATERIALS AND  METHODS:

Type of Study: Open randomized uncontrolled study

Study Centre: R.A.Podar Ayurved Hospital, Mumbai

Drug: Kshar-Tail+Til-tail (Seasamum oil)

Duration: 6 cycles

Follow-up : Every cycle after menstrual bleeding is over

Dose: 5cc to Avg. 15 cc

No of Patients: 60 Patients

Criteria of Selection

Inclusion criteria

1. Age between 21-45 Years
2. Tubal block with hydrosalphinx, chronic P.I.D
3. Tubal due to chronic abdominal Koch's treated with AKT.

Exclusion criteria

1. Malignancy of genital organs, Surgically damaged tubes, Endometriosis
2. Active vaginal or cervical infections, Cervical erosion, Acute Pelvic inflammatory diseases

Investigations:

1. H.S.G before and  after treatment(Done in post menstrual phase)
2. Laparoscopy in some patients
3. U.S.G where ever necessary

Concept of Uttarbasti: Uttarbasti means basti which is given in upper passage, i.e., urinary or vaginal passage than the usual anal passage or basti which is superior in quality. There are two types of basti viz. Mutramargagata (By urethral route) and Yonimargagat (By Vaginal or intrauterine route). The ideal period for the intervention of uttarbasti is during the Ritukal) or after menstrual bleeding stops completely up to 16th day of menses.[4,5]

Uttarbasti Matra (Quantity)

1. Unilateral tubal block: starting from 5 cc with gradual increase of 1 cc/day up to 10 cc.for 5 days.
2. Bilateral tubal block: starting from 5 cc with gradual increase of 1 cc/day up to 15 cc. for 10 days.

Instruments for Uttarbasti:

1. Swab holding forceps
2. Sim’s speculum
3. Anterior vaginal wall retractor
4. Vullsellum or Allis forceps
5. Uterine sound
6. Artificial insemination canula
7. 5 cc & 10 cc Plastic syringe
8. Antiseptic solution

Procedure of Uttarbasti-Preparation :

              Five milliliters of Uttar Basti for six cycles, with the consent of the patient. The patient was admitted for Uttar Basti, a day after cessation of menstruation. Snehana (oleation) of Bala Taila.[6] on the lower abdomen, back, and lower limbs followed by Nadi Sveda (fomentation) with water steam on the lower abdomen and back was given to patients before each Uttar Basti.[7] Yoni Prakshalana with normal saline was performed to sterilize the peri vaginal part. The procedure was carried out in the Minor Operation Theater/Uttarbasti Room under all aseptic conditions. The oil and instruments were autoclaved. The patient was placed on the operation table in a dorsal lithotomy position and then inj. Atropine 0.6 mg IM given. The private part (already shaved) was cleaned with antiseptic solution. The vagina and cervix were visualized with the help of the Sim's speculum and an anterior vaginal wall retractor. The anterior lip of the cervix was held with the help of the Allis’/Vullsellum forceps.[8] Uterine sounding was done and then Uttar Basti cannula, already attached with 5 mL syringe filled with Kshar Taila + Til tail was passed into the uterine cavity after making a head low position. The drug was pushed above the level of the internal os with constant force, but quickly to make the drug reached up to the tubes. The patient was sent to bed and the bed was kept with head low for two hours. The lower abdomen was fomented with hot water bag.

Possible Complications:

I) Procedure Faults

1. Cervical and  Endometrial trauma
2. Bleeding
3. Endometriosis
4. Lower abdominal spasmodic pain
5. Giddiness
6. Shock

OBSERVATIONS AND  RESULTS:

              In the present study, the effect of Kshar-tail+Til-tail in the patients of blocked fallopian tubes were observed. Patients were randomly selected and  grouped according to the site of tubal block with the help of H.S.G findings. Uttarbasti is a instill and  drainage type of procedure which shows immediate return of the 2/3 of instilled oil. After instillation of oil complications were noted, not a single pt. was observed for non return of instilled oil. Some Patients of peritoneal irritation were immediately treated with anti-biotics and anti-spasmodic. Among 60 patients, 63.33% Patients were having unilateral tubal block and 36.67% having bilateral tubal block. Among the total no. of patients 25% Patients were of corneal block, 45% mid-tubal block, 30% fimbrial block Patients. The blocked tubes opened after giving Kshar-tail+Til-tail uttarbasti for 6 cycles with dose starting from 5cc upto 15 cc averagely. Success rate is 53.33%.Percentage of opened unilateral tubal block is 55.26% and in bilateral tubal block is 50.00%. Partial opening of tubes observed in 20% Patients of unilateral mid-tubal block and 20% Patients of bilateral tubal block.37.50% patient is conceived after treatment successfully.

Discussion

DISCUSSION:

              The intervention given in Uttarbasti was kshar tail and til tail having ingredient like Mulak, Shunthi, Hingu, Shatpushpa, Vacha, Kustha, Daruharidra, Shigru, Rasanjan, Sourwachal, Yawa, Saindhav, Madhu, matulung etc which having properties like vatahar, tridoshnashak.[9,10] Til tail by Tikshna, Ushna guna, it acts as Kaphaghna. 11,12] properties like Vikasi, Sara, Preenana, Snigdha, Ushna guna[13,14]which acts on Intra uterine cleaning and purification and also act for the removal of Obstruction and further it acts as Healing (Ropan) and Bactericidal Action. Kshar tail and til uttrabasti, its cumulative action help in increases interstitial ciliary function, increases the free movements of fimbriae and reduces inflammation and flimsy adhesions, with this intervention tubal block effectively managed after average six weeks of treatment. Further better study needs to conduct to establish more evidence as intrauterine instillation (Uttarbasti) would be  alternative approach to tuboplasty in  managing the patients of infertility related to tubal block.  As oil is dense but not radio-opaque actual visual effects cannot be observed.

Conclusion

It was observed from this study that, Uttarbasti is the best solution to avoid the rate of ‘Tuboplasty’ Post-surgical intratubal and intra-abdominal adhesions can be avoided. Cost effective management of tubal block by reducing rate of Tuboplasty and IVF treatment.

Acknowledgement:

Dr.S.S.Choudhari, HOD, Dept of Prasutitantra Striroga, Govt. Ayurvedic College, Nanded