The standard definition of infertility is unsuccessful conception after an entire year of unprotected intercourse. In roughly 40% of infertility cases, the cause lies in the woman’s reproductive capacity, with another 40% of infertile couples being affected by the man’s fertility issues and the remaining 20% often arising from a combination of factors affecting both partners.

Female infertility can arise from a variety of factors including, general health and lifestyle issues, structural issues, mechanical issues, systemic hormonal imbalances, ovulatory issues and occupational and environmental factors.

General Health and Lifestyle Issues
A wide range of general health and lifestyle issues can affect fertility, including celiac syndrome, smoking, caffeine intake, obesity, previous cancer treatment and age-related fertility decline.  Undiagnosed celiac syndrome has been identified as an important cause of infertility, because lack of proper absorption and assimilation ultimately leads to impaired nutrition of artava dhatu. (1) Smoking is a form of prajnaparadh that can significantly impair fertility (2), as is excess caffeine consumption, which can exacerbate the impact of other causes of infertility. “A significant increase in the risk of infertility due to tubal disease or endometriosis was observed for the upper levels of caffeine intake, indicating a threshold effect.” (3) Obese women have higher rates of infertility, in part due to excess oestrogen production by adipose tissue and in part as a result of insulin resistance.  “Fertility can be negatively affected by obesity. In women, early onset of obesity favours the development of menses irregularities, chronic oligo-anovulation and infertility in the adult age. Obesity in women can also increase risk of miscarriages and impair the outcomes of assisted reproductive technologies and pregnancy, when the body mass index exceeds 30 kg/m. The main factors implicated in the association may be insulin excess and insulin resistance.” (4)
Management of these conditions mainly rests upon removal of the cause. For celiac syndrome, a gluten free diet will, over the course of a few months, reverse the infertility issues.  Smoking can be discontinued over a one month period, with support for pranavahasrotas being provided by Chyavanprash. Caffeine intake can gradually be stopped or at least reduced, with substitution of “coriander coffee” made from roasted, ground Coriander seeds. Weight can be reduced with diet, exercise and metabolic support from Trim Support. At the same time, artava vaha srotas can be tonified using Shatavari, Vidari or Women’s Support.

A well as these remediable lifestyle and general health issues, there are two issues blocking fertility that are not remediable in themselves, although measures can still be taken to enhance fertility.  Previous cancer treatment can be a cause of infertility since radiation and chemotherapy can damage the artava dhatu, killing oocytes and leading to premature ovarian failure and infertility. (5) Postponement of pregnancy until after the age of thirty five is increasingly common in contemporary society, and is accompanied by increased risk of infertility. (6) In these situations, all the Ayurvedic practitioner can do is to offer the best possible support to artava dhatu by doing pancha karma, balancing doshas and tonifying the reproductive system as above.
 
A thirty seven year old woman of kapha prakruti presented with a history of bilateral ovarian cysts which were removed in her twenties.  She wished to get pregnant but was concerned about fertility given her age and past history. She was given a formula that included Punarnava, Shatavari, Shankhapushpi, Chitrak and Dashamoola and was encouraged to break her chay habit. She then embarked on a seven day pancha karma protocol after which she continued her formula as above and also took Shatavari ghee. To her surprise and glee, she became pregnant shortly after her pancha karma—without even intentionally trying to conceive. She gave birth to a healthy kapha baby.

Structural Issues
About 15% of instances of female infertility are due to structural issues, including congenital anomalies such as uterine septa and unicornuate uterus, as well as acquired diseases of the uterus such as fibroids. (7) Here again, the Ayurvedic practitioner can be of assistance mostly in efforts to support artava vaha srotas and maximize the potential fertility in the face of the structural issues.                                                      

A twenty year old vata pitta woman had a history of repeated miscarriages that ultimately turned out to be due to a congenital anomaly of the uterus. She was supported with Shatavari, Vidari, Musta, and Hibiscus, resulting in a live birth by cesarean section of a premature (24 week) infant. Ultimately, with continued support with Shatavari and Vidari, she was able to carry a pregnancy to full term and fulfill her dream of a normal home birth.

Mechanical Issues                                                                                                                         
Up to 40% of female infertility arises from mechanical issues, chiefly scar tissue blocking the fallopian tubes. Pelvic inflammatory disease (PID) and endometriosis are the chief causes of these mechanical issues. Endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis all fall into the PID category and are typically due to undiagnosed or untreated sexually transmitted diseases, chiefly Chlamydia and Gonorrhoea (8). Because PID can result in sterility, ectopic pregnancy and even a severe life threatening septicaemia, Ayurvedic practitioners should refer any patients they suspect may be suffering from PID to an Allopathic physician, and should work in a mainly complementary capacity when dealing with this condition. For this reason, it is important that young, sexually active women experiencing pelvic or lower abdominal pain be referred for evaluation of possible PID. PID should also be considered where there is abnormal bleeding, vaginal discharge or dyspareunia (pain on intercourse). Rakta shodhan (blood cleansing) herbs such as Manjista, Neem, Turmeric and Burdock, as well as Blood Cleanse formula, will be beneficial for suspected PID, as will  pitta soothing herbs that target the uterus— Musta and Hibiscus. 

In the case of endometriosis, (cystic deposits of endometrial tissue), Ayurveda can be of immense help, as there is little to be done from the Allopathic side. The main symptom is dysmenorrhoea and there may also be chronic pain and deep dyspareunia(9). Shatavari, Ashoka, Vidari, Punarnava, Musta, Bilva and Kumari may be of help, as well as Women’s Support.

Systemic Hormonal Imbalances
Two main systemic hormonal imbalances affect female fertility—hypothyroidism and polycystic ovarian syndrome (PCOS). When the thyroid is under functioning, fertility may be lowered. Punarnava, Chitrak and Guduchi support optimal thyroid function, as does shilajit.  Trim Support, containing most of the above herbs, not only helps with obesity-related fertility issues but also helps optimize thyroid function. PCOS is a complex topic meriting an article in its own right. Briefly, it is a form of Kapha Syndrome characterised by multiple small cysts on the ovaries, abdominal obesity, androgenic features such as hirsuitism (excess facial and body hair growth) and acne, insulin resistance, irregular menstruation and anovulation. PCOS is a leading cause of female infertility. (12) Ayurvedic management includes a kapha soothing diet rich in phyto-nutrients, a good kapha pacifying yoga program, and herbal regimens to support weight loss, blood sugar balance and female hormonal balance. Punarnava is a key herb for managing kapha, Shardunika and Turmeric help regulate blood glucose and Vidari supports hormonal balance. A combination of Trim Support, to reduce visceral adipose tissue, Sweet Ease, to help balance blood sugar, and Women’s Support to normalize hormonal balance will be of great value in this situation.

Ovulatory Issues
Ovulatory issues include premature luteinization, luteinized unruptured follicle syndrome, and luteal phase defects, and may be present despite regular menstruation. (10) These issues can typically be addressed with Vidari, which contains progesterone precursors.  An Ayurvedic type of diet, with   “higher consumption of monounsaturated rather than trans fats, vegetable rather than animal protein sources, low glycaemic carbohydrates and high fat dairy,” has been of demonstrated help in ovulatory disorder infertility. (11)

Occupational and Environmental Factors
Contemporary agricultural and industrial practices present multiple threats to female fertility. Exposure to organochlorine herbicides can lead to infertility (13, 14) as can other workplace hazards including heavy metals and endocrine disruptors. (15). In evaluating a woman complaining of fertility concerns, it is important to take a detailed occupational and environmental history to determine whether external toxins are playing a role.  In the event that toxins appear to be significant, it is of course important to seek to remove the cause by a change of work environment if this is in any way possible. Pancha karma can be of immense value in clearing pesticide residues, solvents and heavy metals from the system, thus preparing the way for a healthy pregnancy. After pancha karma, Shatavari can be used to tonify the reproductive system and to balance the pittagenic effects of the environmental toxins.

In many cases of infertility, multiple factors may be involved. Lifestyle issues such as smoking or caffeine intake may co-exist with mechanical or structural issues, or heavy metal exposure may be a co-factor along with PCOS. By taking a detailed history that considers all aspects, the Ayurvedic practitioner can create an integrated plan to maximize fertility through dietary and lifestyle counseling alongside herbal therapies and cleansing practices.

1. Sher KS, Mayberry JF. Female fertility, obstetric and gynaecological history in coeliac disease. A case control study. Digestion. 1994;55(4):243-6

2. C Augood, K Duckitt and AA TempletonSmoking and female infertility: a systematic review and meta-analysis Human Reproduction, Vol 13, 1532-1539,

3. Francine Grodstein, Marlene B. Goldmanet al Relation of Female Infertility to Consumption of Caffeinated Beverages American Journal of Epidemiology Vol. 137, No. 12: 1353-1360

4. Pasquali R, Patton L, Gambineri A, Obesity and infertility  Curr Opin Endocrinol Diabetes Obse 2007 Dec;14(6):482-7.

5. Jonathan L. Tilly and Richard N. Kolesnick,  Sphingolipids, apoptosis, cancer treatments and the ovary: investigating a crime against female fertility Biochimica et Biophysica Acta (BBA) - Molecular and Cell Biology of Lipids Volume 1585, Issues 2-3, 30 December 2002, Pages 135-138

6. te Velde ER, Habbema JD,et al, The consequences of postponing pregnancy Ned Tijdschr Geneeskd. 2007 Jul 14;151(28):1593

7. Taylor E, Gomel V. The uterus and fertility Fertil Steril. 2008 Jan;89(1):1-16. Epub 2007 Dec

8. Hoof K. Pelvic inflammatory disease Ther Umsch. 2007 Jul;64(7):365-8

9. Carstensen A, Mundhenke C, Schollmeyer T. Endometriosis Ther Umsch. 2007 Jul;64(7):349-52

10. Check JH. Ovulation defects despite regular menses Clin Exp Obstet Gynecol. 2007;34(3):133-6

11. Chavarro JE, Rich-Edwards JW,et al, Diet and lifestyle in the prevention of ovulatory disorder infertility Obstet Gynecol. 2007 Nov;110(5):1050-8

12. Elghblawl E Polycystic ovary syndrome and female reproduction Br J Nurs. 2007 Oct 11-24;16(18):1118-21  

13. Greenlee, Anne R. *; Arbuckle, Tye E. +; Chyou, Po-Huang  Risk Factors for Female Infertility in an Agricultural Region Epidemiology 14(4):429-436, July 2003

14. Masata J, Jirsová S,et al, Comparison of organochlorine pesticide levels in blood and follicular fluid of infertile women Ceska Gynekol. 2005 Nov;70(6):440-6

15. Rice HR, Baker BA. Workplace hazards to women's reproductive health Minn Med. 2007 Sep;90(9):44-7

Alakananda Devi (Alakananda Ma) is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal teacher of Alandi School of Ayurveda, a traditional ayurvedic school and apprenticeship program. She can be reached at 303-786-7437 or by email at: info@alandiashram.org.

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