Role of an ayurvedic treatment protocol as a prerequisite for in vitro fertilization in women with diminished ovarian reserve: elucidating mechanistic insights incorporating multi-omics approaches

The trial is designed as single arm pre-and post- clinical study. Study setting - Amrita Fertility Centre and Amrita School of Ayurveda, Amrita Vishwa Vidyapeetham.

Women diagnosed with DOR (AFC <5–7 follicles and AMH <0.5–1.1 ng/ml) undergoing IVF cycles will be screened at Amrita Fertility Centre. After due consent, these patients will be subjected to Ayurvedic treatment protocol at Amrita School of Ayurveda. Assessment criteria - Serum AMH and Ultrasonography count of ovarian Antral Follicle on Day 2/3 of the menstrual cycle. Intervention at Amrita School of Ayurveda - The therapeutic plan will be initially performed through Sodhana cikitsa (cleansing therapy), during which the patient will be admitted to the hospital for 21 days. It will be followed by Shamana cikitsa (oral medication) for 1 month. Sodhana chikitsa includes Accha Snehapāna (intake of oil/ghee) and Mridu Vamana/Virechana (emesis/purgation). In the final phase, the patient will be subjected to Yoga Basti and Uttara Basti (medicated enema through the anal route and vagina). After completing shodhana chikitsa shamana chikitsa will be done. After undergoing Ayurveda treatment for two months, participants will be sent back to Amrita Fertility Centre for post- assessment and further fertility treatments, during which follicular fluid will be collected for multi-omics analysis.

Study tools - Ultrasonography count of ovarian antral follicles, Antral follicle count (AFC) on Day 2/3 of menstrual cycle and Serum test of anti-Mullerian hormone (AMH) on Day 2/3 of menstrual cycle

Sample size - 40 women diagnosed with DOR satisfying inclusion and exclusion criteria after consent will be recruited to the study for Ayurvedic treatment protocol, Follicular fluid will be collected from 20 patients for multi-omics analysis (Treatment group - 10 and Control group -  10)

Study Interventions

Treatment protocol and Interventions – Sodhana chikitsa

|Treatment procedure

Method of administration

Treatment duration

|Dipana, pacana with Vaisvanara churna (preparatory procedure)

5g twice daily before food with warm water

Day 1–2

   |Snehapana with appropriate ghee or oil

Arohanakrama (Escalation of dose) after assessing the Agni and koshta (Digestion)

Day 3–8

   |Snehana and svedana (Oleation and sweating treatment)

Sarvanga abhyanga (whole body massage)with Dhanvantara taila followed by nadi sveda (sweating treatment)

Day 9 – 11

    |Mridu vamana or

Mriduvirecana with Avipatti choorna

 30 g given at 7 am

Day 10 or

Day 11

  |Yogabasti (medicated enema through anal route)

Niruhabasti with 750 ml of Mustadiyapanabasti and Anuvasanabasti with 150 ml of Mahanarayana taila

Day 13–20

     |Uttarabasti (medicated enema through vaginal route)

With 3 ml Mahanarayana taila into the uterine cavity on the day of Niruha vasti

Shamana cikitsa (oral medications)

·      Kalyanaka Ghrita/Phala sarpi – Ghrita formulation - 10ml once daily, orally

·      Mahanarayana taila– Taila formulation - 10ml once daily, orally

·      Satapushpa choorna/Hinguvachadi choorna– choorna formulation - 5gm twice daily, orally