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Male factors are responsible for more than forty percent of the infertility cases. Necrozoospermia is one among the main cause for infertility in male. Necrospermia i.e. 100% immotile and 0% viable spermatozoa in ejaculate, is a rare and poorly documented cause of male infertility. A 56-year-old man was referred for reproductive counseling with secondary infertility and diagnosed as necrozoospermia (Shukra Dosha). He presented with complaints of having no issues since 7 years of married life with his second wife. The patient has a son from divorced first wife. After the thorough clinical examination and laboratory investigations, diagnosis was confirmed as necrozoospermia. The patient was administered Koshtha-Shuddhi (purgation) with Eranda Taila (castor oil) as per the guidelines of Ayurvedic treatment. After the proper purificatory procedures depending on dominance of deranged Dosha, the patient was given Arogyavardhini VatiChandraprabha VatiShilapravanga and Phala Ghrita (medicated ghee) as Sneha (internal oleation). At the end of 3½ month, semen analysis showed marked improvement in sperm count and increase in the sperm motility. The present finding and the effective management of necrozoospermia with Ayurvedic formulations with no adverse effect highlight the promising scope of traditional medicine in male infertility disorders.

Keywords: Necrozoospermia, Semen analysis, Shukra Dosha

Introduction

Necrozoospermia is a rare condition and poorly documented cause of male infertility. Its incidence in an infertile male is reported to be from 0.2% to 0.5%.[] It is defined as a condition in which spermatozoa in the ejaculated semen are dead or immotile. According to sperm norms of the World Health Organization, sperm viability is higher than or equal to 75% in human semen samples. Fertility of the semen is impaired below this percentage.[]

In Ayurveda, Shukra Dosha (pathological disorders of sperm/semen) is mentioned as of eight types. They are VatajaPittajaKaphajaKunapaGranthiPutiPuya and Ksheena.[] Necrozoospermia is akin to Vataja Shukra Dosha in Ayurveda. Quality and quantity of Vataja Shukra Dosha are Phena (frothy), Tanu (less viscosity), Ruksha (lack of unctuousness), Kashta Alpa Matrayukta (painful ejaculation with less quantity of semen), and incapability of producing off spring.[]

The line of treatment for Shukra Dosha as mentioned in Ayurvedic texts are Snehana (oleation), Vamana (emesis), Virechana (purgation), Niruha (medicated enema with decoction) Anuvasana (medicated enema with oil)[] and Shamana Aushadhi (palliative therapy) depending on the condition. According to these principles, it is advocated to use Shamana therapy after performing Virechana Karma (purgation). In the present study, selected Shamana Aushadhi (palliative therapy) were easily available for prescription in OPD patients.

Case Report

Presentation

A male patient aged 56 years attended the outpatient department, presenting with the complaints of no issues since 7 years of married life with the second wife who is 35 years old. However, he has a son from his divorced first wife who is healthy. The patient did not report any problems with erections, orgasm, or ejaculation and he was not taking any medication for any systemic disorders like hypertension, diabetes mellitus etc. On physical examination, testes were in normal position. Rest of the physical examination was normal. Initial history of the female partner suggested regular ovulatory cycles and revealed no problems with her endocrine profile or the patency of her fallopian tubes. There was no history in the patient suggestive of sexually transmitted diseases, mumps, tuberculosis, filariasis, epididymo-orchitis, herniorrhaphy/herniotomy and chronic persistent genital infection, paraparesis and exposure to gonadotoxins, for example, cigarette smoke, alcohol, alkylating agent, gossypol and pesticides. Semen analysis from the laboratory revealed no sperm motility and on viability testing, it was shown that there was 100% necrozoospermia. As the patient could not afford, other investigations such as antisperm antibodies could not be carried out.

On examination

Clinical examination revealed no abnormality (physical and systemic). During scrotal examination, temperature was found normal and no scar or swelling was noticed. Position and size of the testes was normal in nature. Epididymis was palpable with swelling, spermatic cord was thickened and prostrate was normal during the examination. Table 1 shows the details of physical examination of the patient.

Table 1

Physical/local examination of the patient

On examination Observation
Pubic hair distribution Normal
Examination of penis
?Texture of skin Normal
?Body/shaft Shrunken
?Prepuce Normal
?Glans Normal
?External urethral meatus Normal

Examination of scrotum Right Left

Pigmentation Dark brown Dark brown
Temperature Normal Normal
Rugae Present Present
Scars No No
Swellings No No
Examination of testes
?Position Normal Normal
?Size Normal Normal
?Surface Smooth Smooth
?Consistency Firm Firm
?Borders Regular Regular
Examination of epididymis Palpable with swelling
Examination of vas deferens Not palpable
Examination of spermatic cord Thickened
Examination of prostate (P/R) Normal

Investigations Impressions

Semen analysis Necrozoospermia with infection
USG abdomen and pelvis Prostate is normal in contour (volume 13 cc) and echo pattern
USG scrotal Mild right varicocele
Small left epididymal cyst (0.42 cm)
Minimal left hydrocele

USG: Ultrasound sonography

Assessment criteria

The patient was assessed based on sexual functional parameters and semen analysis before and three and half months after the treatment. Details of the investigations carried out before and after the treatment are given in Table 2.

Table 2

Effect of Ayurvedic management on semen analysis

Semen analysis Before treatment After treatment
Volume (ml) 2 2
Color Grayish white Grayish white
Reaction Alkaline Alkaline
Liquefaction Liquefied after ½ h Liquefied after ½ h
Sperm count (millions) 2 9*
Motility (h) 1 1
Actively progressive (%) 0 30*
Slowly progressive (%) 0 15*
Nonprogressive (%) 0 10*
Nonmotile (%) 100 45*
Morphology
?Normal (%) 96 92
?Abnormal (%) 4 8
?Agglutination (%) Absent Present – 3%
?Head to head Absent Present
?Head to tail Absent Present
?Tail to tail Absent Absent
?Pus cells 4-6/hpf 4-6/hpf
?RBCs Nil Nil
?Epithelial cells 2-4/hpf 6-8/hpf
Impression Necrozoospermia with infection Oligozoospermia with infection*

Treatment

According to Ayurveda, the patient was diagnosed as having Vatika Shukra Dosha, with investigations showing evidence of necrozoospermia. He was treated for a period of 3 ½ months.

Plan of treatment

Shodhana (purification)

Purva Karma like LanghanaDeepanaPachana and Snehapana were not followed as the patient was not having Ama Lakshana assessed during the examination. So, 50 ml of Eranda Taila (castor oil) was administered at 7.30 AM for the purpose of Koshtha-Shuddhi (purgation) along with warm water, and the patient reported six Vegas (passed stools six times) during that day. He was advised to take light semi-solid diet and avoid exertion for 3 days.

Shamana therapy

  1. Phala Ghrita 15 ml with milk in the empty stomach once daily

  2. Chandraprabha Vati – 500 mg, Vati one tablet twice daily after food with water

  3. Shilapravang Vati – (250 mg), one Vati twice daily after food with milk

  4. Arogyavardhini Vati – (500 mg), one Vati twice daily after food with water.

Chandraprabha Vati and Arogyavardhini Vati were procured from IMPCL and dispensed through OPD. Phala Ghrita (Arya Vaidya shala, Kottakal) and Shilapravanga (Sri Dhootapeswar Ltd) were prescribed from outside.

All the above medicines were given for 3 months. Arogyavardhini Vati was replaced by Sarivadi Vati after a month and continued for 2 months. No adverse drug reaction was reported during the treatment which was confirmed during follow up visits.

Results

After the treatment, total sperm count was increased to 9 million from 2 million and there was also increase in sperm motility. Though 100% sperms were non- motile before treatment, only 45% remained non motile after the treatment. It is observed that, 30% were actively progressive, 15% were slowly progressive and 10% were non progressive. USG reports suggest that, there was necrozoospermia with infection initially and which is changed to oligozoospermia with infection. Table 2 shows before and after results of semen analysis. Table 3 shows sexual functional parameters.

Table 3

Effect of Ayurvedic management on sexual functional parameters

Parameter Score (before treatment) Score (after treatment)
Sexual desire 3 4
Orgasm 1 3
Rigidity 0 2
Erection 2 3
Ejaculation 3 4
Total score 9 16

Discussion

Necrozoospermia is the medical term for sperm that does not move at all. The sperm may be alive and just not moving or the sperm may be dead. Necrozoospermia is a potential cause of male infertility. Although there is no promising remedy for this ailment, Ayurvedic formulations have shown remarkable improvement in sperm count in isolated case reports[].

In Ayurveda, a separate branch has been devoted for aphrodisiac medicines (Vajikarana). The concept of Vajikarana, as described in the texts of Ayurveda, is a special category of treatment modalities which improve the reproductive system and enhance sexual functions. It offers a solution to minimize Shukra defects and to ensure a healthy progeny. Vataja Shukra Dosha can be compared with necrozoospermia where quality and quantity of semen is a vitiated by Vata Dosha.

Vataja Dushti (impairment of Vata) leads to defects in quantity due to Rukshata (lack of unctuousness) and Kapha Kshaya (depletion of Kapha) also causing defects in motility causing non-progressive and immobile sperms.[] After the treatment, it is observed that, 3% agglutination is seen in the semen analysis. Agglutination of spermatozoa suggests the existence of antisperm antibodies. But, other investigations such as antisperm antibodies could not be done, due to nonaffordability of the patient.

Aphrodisiac therapies are of three types:[]

  1. Shukra Karaka – Sperm generating or enhancing sperm count

  2. Shukra Rechaka – Those which help in ejaculation of seminal fluid

  3. Shukra Karaka and Rechaka – Medicines which serve both the above purposes.

Based on the above principles, multiple treatment modalities were applied in this case.

Acharya Kashyapa has emphasized on the role of Virechana Karma (purgation) for the purification of the Beeja (sperm), as it make Beeja (sperm) effective in achieving fertilization. It also improves sexual vigor and helps in achieving healthy progeny.[]

Koshtha-Shuddhi (purgation) with Eranda Taila (castor oil) was given for detoxification and to pacify Vata which is the main cause for vitiation of Shukra (sperm).[]

The medicated ghee (Phala Ghrita) was given early in the morning in empty stomach as Shamana Snehana (palliative mode of oleation), is indicated in Shukra Dosha.[] It acts as an aphrodisiac medicine. Chandraprabha Vati is a herbomineral compound preparation, has action on major systems such as urinary system and reproductive system. It has been reported to have immense free radical scavenging activity.[]

Inflammatory conditions in the entire genitourinary tract are amenable with administration of Chandraprabha Vati. It relieves the infection and acts as a spermatopoietic agent. In a nutshell, this is employed in male as well as female infertility. It is a choice of drug in urogenital diseases for treating the infection.[]

Liver plays an important role in regulating the amount of free testosterone in the body. About 40%–50% of total testosterone is bound to a protein called sex hormone-binding globulin which is produced in the liver. The rest of the testosterone is bound to a protein called albumin which is also produced in the liver. With decreasing liver function, plasma testosterone concentrations decrease significantly.[] With a view of improving the liver function, commonly prescribed classical Ayurvedic polyherbomineral formulation, Arogyavardhini Vati, was given. It contains drugs like Abhraka Bhasma (ash of mica), Shilajatu (Asphaltum), Eranda (Ricinus communis Linn.) and Katuki (Picrrorhiza kurrooa Royle ex Benth). It has been tested and found to be safe in an experimental study. No appreciable toxicological effects were observed on the brain, liver, and kidney of the rats when administered up to 28 days.[] Hence, it was prescribed to the patient for 1 month initially. It also has hepatoprotective action.[]

Sarivadi Vati is a drug of choice in Klaibya (male infertility) and urogenital infections.[] It mainly comprises Sariva (Hemidesmus indicus R. Br), Madhuka (Glycyrrhiza glabra Linn.)Kushtha (Saussurea lappa C. B. Clarke), Abhraka Bhasma (ash of Mica) and Loha Bhasma (ash of purified and processed iron).

Shilapravanga is well-known proprietary herbomineral aphrodisiac medicine which fights treats, exhaustion and debility and restores natural zest and is medicated in for male infertility.[] It contains Shuddha ShilajitPravala Pishti (calx of coral), Vanga Bhasma (ash of Tin), Mouktik PishtiSuvarna Makshika Bhasma, and other drugs; Shilajatu is a prominent Vrishya (aphrodisiac) drug as explained in Bhavaprakasha[] and Charaka Samhita.[]

Conclusion

It is therefore evident that the treatment approach based on Ayurvedic principles can produce encouraging results in the management of Shukra Dosha (necrozoospermia) not only in improvement in sexual functional parameters[] but also in increasing the quality and quantity of semen. Such encouraging results offer hope to many who are suffering from necrozoospermia and also instills confidence among new Ayurvedic physicians in handling male infertility without surgical interventions and managing with simple medication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors are grateful to Director General, CCRAS, New Delhi, and Incharge, NADRI, Bengaluru, for providing facilities and encouragement.

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