The Homoeopathic Similimum in Infertility of Unexplained Cause in Females
A research dissertation presented to the Faculty of Health Sciences, University of Johannesburg in partial fulfillment of the Masters degree in Technology: Homoeopathy
By
Bianca De Canha (Student Number: 820407128)
Supervisor: ______Dr K. Peck Date B.A., M.C.H.
Co-Supervisor: ______Dr Z. Bengis Date M. Tech (Hom) (Cum Laude)
Johannesburg, 2009 DECLARATION
I, Bianca De Canha, declare that this dissertation is my own, unaided work. It is being submitted for the Degree of Master of Technology at the University of Johannesburg. It has not been submitted before for any degree or examination in any other Technikon or University.
______Signature of Candidate
______day of ______
ii ABSTRACT
Infertility is defined as the inability to conceive after a minimum of one year of regular intercourse without contraception (Carlson et al, 2002). This may occur as primary infertility, where individuals have never had a biological child, or secondary infertility where individuals have had at least one previous documented conception (Greer et al, 2003). Infertility, in the African setting, is seen as a violation of the social norm. It contributes to psychological distress and marital instability as well as the loss of social security, social status and gender identity. Parenthood is considered culturally mandatory making childlessness unacceptable. Not only does Africa have the highest fertility rates in the world, Africa also has the highest number of infertility cases globally (Dyer et al, 2005; Ragone & Twine, 2000).
Unexplained infertility is diagnosed when the routine investigation of semen analysis, tubal patency and assessment of ovulation show no abnormality and the couple have engaged in regular sexual intercourse. Unexplained infertility is thus a diagnosis of exclusion. When a previously identified cause of infertility is corrected, yet infertility persists a diagnosis of unexplained infertility is also given (Behrman et al, 1988). Before a diagnosis of unexplained infertility can be made four aspects are generally assessed. Each aspect encompasses a different aspect of the reproductive process: the number and quality of sperm, maturation and release of the ova, barriers to fertilization and barriers to implantation and maintenance of pregnancy (Cooper-Hilbert, 1999).
The aim of this research was to evaluate the efficacy of homoeopathic similimum treatment in females pre-diagnosed with unexplained infertility using case studies. Cases were evaluated using fertility and parameters related to fertility which include basal body temperatures and midcycle cervical mucous changes. In addition, general parameters such as general well-being, premenstrual symptoms, dysmenorrhoea and sexual function were also evaluated. Concomitant symptoms were included in the analysis of each participant’s holistic case. The male partner was also required to be free of any structural and functional pathology.
This research was accepted by the Higher Degrees Committee and Ethics Committee of the University of Johannesburg on the 22nd of February 2008, ethical clearance number 04/08. The research study was advertised in pharmacies, local newsletters and newspapers in order to recruit volunteers for the study. All volunteers were required to complete a Participant Selection Questionnaire which ultimately resulted in the recruitment of eleven participants. The eleven
iii participants recruited matched the inclusion criteria and had undergone relevant investigations regarding their infertility. After the selection process had been completed, the first consultation was conducted where an informed consent form was completed. Pre-consultation counselling regarding the optimum circumstances for conception was completed. Thereafter a full case history was taken and a physical examination performed. Each participant’s unique physical, mental and emotional symptoms were holistically used by the researcher to determine the similimum remedy for each participant’s case. Each participant attended seven consultations over a period of six months.
At each consultation the participants were required to complete general well-being questionnaires which were collected and compared at the end of the trial. Participants were also required to record basal body temperatures and midcycle mucous changes on a daily basis.
Treatment focused on the constitutional and emotional aspects of the individual. The physical manifestations of each participant were also considered. This complies with the principles of classical homoeopathy which states that the individual is a holistic entity and should be treated as such. The study was predicted to provide an alternative and safe form of treatment to individuals pre-diagnosed with unexplained infertility.
The average age of the group of participants was 35.7 years of age. Five of the eleven participants had previously undergone artificial insemination. None of the artificial insemination attempts made by this group had been successful. Five of the eleven participants had undergone in vitro fertilisation therapy. Of this group a total of eight attempts had been made, with only two of the attempts producing a live birth. A minimum of two years before the trial, six of the participants had used Clomid® for purposes of assisted conception. This highlights the complexity of each case and ultimately, the research trial.
The results of the study showed that treatment with the homoeopathic similimum over six months was not effective in the treatment of unexplained infertility. However, improvement was noted regarding related fertility parameters, general parameters, related function in premenstrual symptoms, dysmenorrhoea and concomitant symptoms. A longer term study would be justified based on these results.
iv DEDICATION
This study is dedicated to the memory of Maria Dolores De Gouveia, my grandmother - whose work of art was her children, in the hope that more women may be given the opportunity to be the kind of mother she was.
v ACKNOWLEDGEMENTS
The researcher would like to thank the following individuals for their contribution in the realisation of this dissertation and dream:
To my parents, Tiago and Anabela De Canha, for their love and encouragement. Thank you for giving me the opportunity to study homoeopathy and for helping me to succeed. To Dr Kathryn Peck for her homoeopathic input and for the opportunity to learn through your experiences and gain from your knowledge. To Dr Zoë Bengis for her support and for giving of her time and assistance beyond the role of a co-supervisor. To the eleven participants who participated in this study. Thank you for the heartache, hope and tears you placed in my care. Without you, this study would not have been possible. To Dr Neil Gower for his valuable knowledge and insight as well as for all the time you put into my research in Dr Kathryn Peck’s absence. Your patience and unlimited support are greatly appreciated. To Dr Jaci Schultz for proof reading this dissertation and for her appreciated support and encouragement throughout the duration of the study as well as for her valued friendship. Dr Danny Pillay for proof reading this dissertation and for his willingness to provide assistance in the formation of this dissertation. Dr Leanne Scott, Dr Ameesha Manga, Dr Graeme Yutar and Dr Mareze Cape for their interest and assistance in this research project. Your reassurance and guidance will always be treasured and remembered. To Dr Radmilla Razlog for her advice, guidance and never ending support. To Jaclyn Smith and the Statkon team for assisting with their statistical expertise. To Adam Sayers for his encouragement, for his patience and mostly for his limitless love. Thank you for being there to celebrate the highs and to reassure me during the lows. To my friends Bernadete Grota, Kelly Joffe, Leanne Gouveia, Nicolette De Freitas, Reshma Patel and Sandra Pita who never held back their love and support. To my brother, Damian De Canha, my family and to my godchildren, Brigid Da Silva, Claudia Da Silva and Steven De Canha who were always so proud of me.
vi TABLE OF CONTENTS
DECLARATION……………………………………………………………………………...... ii ABSTRACT……………………………………………………………………………………….iii DEDICATION………………………………………………………………………………...... v ACKNOWLEDGEMENTS………………………………………………………………………vi TABLE OF CONTENTS………………………………………………………………………...vii LIST OF FIGURES…………………………………………………………………………...... xv LIST OF TABLES……………………………………………………………………………….xvi ABBREVIATIONS……………………………………………………………………………...xvii
CHAPTER ONE INTRODUCTION………………………………………………………………………………...1 1.1 PROBLEM STATEMENT…………………………………………………………..……1 1.2 IMPORTANCE OF THE PROBLEM………………………………………………...... 2 1.3 HYPOTHESIS………………………………………………………………………...... 3 1.4 PURPOSE OF THE STUDY……………………………………………………………...3 1.5 DELIMITATIONS………………………………………………………………...…...... 4 1.6 ASSUMPTIONS………………………………………………………………...…….…..4 1.7 DATA VALIDITY…………………………………………………………………...... 5
CHAPTER TWO REVIEW OF RELATED LITERATURE……………………………………………………....6 2.1 INTRODUCTION TO INFERTILITY……………………………………………………6 2.2 INCIDENCE AND EPIDEMIOLOGY……………………………………………………6 2.3 THE FEMALE REPRODUCTIVE SYSTEM……………………………………...…….8 2.3.1 Functional and Structural Anatomy of the Female Reproductive System……...…....8 2.3.2 The Ovarian Cycle…………………………….…………………………………….10 2.3.3 The Menstrual Cycle………………………………………………………………...11 2.3.4 Changes Experienced during the Menstrual and Ovarian Cycles…………………...12 2.3.5 The Functions of the Female Hormones…………………………………………….12 2.3.5.1 Oestrogen………………………………………………………………………….13 2.3.5.2 Progesterone……………………………………………………………………….13 2.3.5.3 Other Ovarian Hormones………………………………………………………….14
vii 2.4 THE MALE REPRODUCTIVE SYSTEM………………………………………………14 2.4.1 Functional and Structural Anatomy of the Male Reproductive System…………….14 2.4.2 Spermatogenesis……………………………………………………………………..16 2.4.3 Male Hormones……………………………………………………..……………….17 2.5 FERTILIZATION TO IMPLANTATION……………………………………………….18 2.6 EVALUATION OF THE INFERTILE COUPLE………………………………..……...20 2.7 CAUSES OF INFERTILITY………………………………………………………..…….23 2.7.1 Female Causes of Infertility…………………………………………………………24 2.7.1.1 Vaginal Factors…………………………………………………………………..24 2.7.1.2 Cervical Factors………………………………………………………………….24 2.7.1.3 Uterine Factors…………………………………………………………………...24 2.7.1.4 Tubal Factors…………………………………………………………………….25 2.7.1.5 Ovarian Factors………………………………………………………………….25 2.7.1.6 Endocrine Factors……………………………………………………………….26 2.7.1.7 Unexplained Infertility…………………………………………………………..26 2.7.1.8 Other Female Related Factors…………………………………………………...27 2.7.2 Male Causes of Infertility…………………………………………………………....29 2.7.2.1 Defective spermatogenesis…………………………………………………..…...29 2.7.2.2 Obstruction in the efferent ducts…………………………………………..……..30 2.7.2.3 Disorders of sperm motility……………………………………………………...30 2.7.2.4 Failure to deposit sperm high in the vagina……………………………………...30 2.7.2.5 Other Male Related Factors……………………………………………………...31 2.8 PSYCHOLOGICAL IMPLICATIONS OF INFERTILITY……………………………32 2.9 TREATMENT……………………………………………………………………………...34 2.10 HOMOEOPATHY……………………………………………………………………….37 2.10.1 The Definition of Homoeopathy…………………………………………………...37 2.10.2 The Principles of Homoeopathy…………………………………………………...38 2.10.3 Miasms……………………………………………………………………………..40 2.10.4 The Vital Force…………………………………………………………………….40 2.10.5 The Homoeopathic Method………………………………………………………..41 2.10.5.1 Sources of remedies……………………………………………………………41 2.10.5.2 Case Taking……………………………………………………………………41 2.10.5.3 Selecting a remedy…………………………………………………………….43 2.10.5.4 Selecting a potency…………………………………………………………….43
viii 2.10.5.5 Selecting the correct dosage and frequency of administration of the remedy...44 2.10.5.6 Repertorisation………………………………………………………………...44 2.10.5.7 Homoeopathic Side-Effects / Aggravations…………………………………...44 2.10.5.8 Case Management……………………………………………………………...45 2.11 HOMOEOPATHY AND INFERTILITY……………………………………………....46
CHAPTER THREE METHODOLOGY……………………………………………………………………………….48 3.1 STUDY DESIGN……………………………………………………………………………..48 3.2 RECRUITMENT OF PARTICIPANTS……………………………………………………48 3.3 RESEARCH PROCEDURE………………………………………………………………....50 3.4 HOMOEOPATHIC MEDICATION AND TREATMENT PROTOCOL………………..51 3.5 TOOLS UTILISED…………………………………………………………………………...51 3.5.1 Basal Body Temperature and Midcycle Mucous Changes charts…………………………51 3.5.1.1 Ovulation thermometer…………………………………………………………..51 3.5.1.2 Basal body temperature………………………………………………………….52 3.5.1.3 Midcycle mucus changes………………………………………………………...52 3.5.2 General Well-Being Questionnaire………………………………………………………...53 3.6 DATA ANALYSIS……………………………………………………………………………54
CHAPTER FOUR CASE DISCUSSIONS……………………………………………………………………………55 4.1 Case One………………………………………………………………………………………55 4.1.1 First Consultation…………………………………………………………………………..55 4.1.2 Second Consultation……………………………………………………………………….59 4.1.3 Third Consultation…………………………………………………………………………61 4.1.4 Fourth Consultation………………………………………………………………………..63 4.1.5 Fifth Consultation………………………………………………………………………….64 4.1.6 Sixth Consultation………………………………………………………………………….67 4.1.7 Seventh Consultation………………………………………………………………………69 4.1.8 Overview of Case One……………………………………………………………………..70 Results graph……………………………………………………………………………………..72
4.2 Case Two………………………………………………………………………………………74
ix 4.2.1 First Consultation…………………………………………………………………………..74 4.2.2 Second Consultation……………………………………………………………………….78 4.2.3 Third Consultation…………………………………………………………………………81 4.2.4 Overview of Case Two…………………………………………………………………….83 Results graph……………………………………………………………………………………….85
4.3 Case Three…………………………………………………………………………………….87 4.3.1 First Consultation…………………………………………………………………………..88 4.3.2 Second Consultation……………………………………………………………………….90 4.3.3 Third Consultation…………………………………………………………………………92 4.3.4 Fourth Consultation………………………………………………………………………..94 4.3.5 Fifth Consultation…..……………………………………………………………………...96 4.3.6 Sixth Consultation...………………………………………………………………………..97 4.3.7 Seventh Consultation……………..………………………………………………………..99 4.3.8 Overview of Case Three………..………………………………………………………...101 Results graph……………………………………………………………………………………102
4.4 Case Four…………………………………………………………………………………….104 4.4.1 First Consultation…………………………………………………………………………105 4.4.2 Second Consultation……………………………………………………………………...108 4.4.3 Third Consultation………………………………………………………………………..110 4.4.4 Fourth Consultation………………………………………………………………………111 4.4.5 Fifth Consultation………………………………………………………………………...113 4.4.6 Sixth Consultation………………………………………………………………………...114 4.4.7 Seventh Consultation……………………………………………………………………..116 4.4.8 Overview of Case Four…………………………………………………………………...117 Results graph……………………………………………………………………………………119
4.5 Case Five……………………………………………………………………………………..121 4.5.1 First Consultation…………………………………………………………………………121 4.5.2 Second Consultation……………………………………………………………………...124 4.5.3 Third Consultation………………………………………………………………………..126 4.5.4 Fourth Consultation………………………………………………………………………128 4.5.5 Fifth Consultation………………………………………………………………………...130
x 4.5.6 Sixth Consultation………………………………………………………………………...131 4.5.7 Seventh Consultation……………………………………………………………………..133 4.5.8 Overview of Case Five……………………………………………………………………134 Results graph……………………………………………………………………………………136
4.6 Case Six………………………………………………………………………………………138 4.6.1 First Consultation…………………………………………………………………………138 4.6.2 Second Consultation……………………………………………………………………...141 4.6.3 Third Consultation………………………………………………………………………..142 4.6.4 Fourth Consultation………………………………………………………………………144 4.6.5 Fifth Consultation………………………………………………………………………...145 4.6.6 Sixth Consultation………………………………………………………………………...147 4.6.7 Seventh Consultation……………………………………………………………………..148 4.6.8 Overview of Case Six…………………………………………………………………….149 Results graph……………………………………………………………………………………151
4.7 Case Seven…………………………………………………………………………………...153 4.7.1 First Consultation…………………………………………………………………………153 4.7.2 Second Consultation……………………………………………………………………...156 4.7.3 Third Consultation………………………………………………………………………..158 4.7.4 Fourth Consultation………………………………………………………………………160 4.7.5 Fifth Consultation………………………………………………………………………...161 4.7.6 Sixth Consultation………………………………………………………………………...163 4.7.7 Seventh Consultation……………………………………………………………………..165 4.7.8 Overview of Case Seven………………………………………………………………….166 Results graph……………………………………………………………………………………168
4.8 Case Eight……………………………………………………………………………………170 4.8.1 First Consultation…………………………………………………………………………170 4.8.2 Second Consultation……………………………………………………………………...173 4.8.3 Third Consultation………………………………………………………………………..175 4.8.4 Fourth Consultation………………………………………………………………………176 4.8.5 Fifth Consultation………………………………………………………………………...178 4.8.6 Sixth Consultation………………………………………………………………………..180
xi 4.8.7 Seventh Consultation……………………………………………………………………..181 4.8.8 Overview of Case Eight…………………………………………………………………..182 Results graph……………………………………………………………………………………184
4.9 Case Nine…………………………………………………………………………………….186 4.9.1 First Consultation…………………………………………………………………………186 4.9.2 Second Consultation……………………………………………………………………...189 4.9.3 Third Consultation………………………………………………………………………..191 4.9.4 Fourth Consultation………………………………………………………………………192 4.9.5 Overview of Case Nine…………………………………………………………………...194 Results graph……………………………………………………………………………………195
4.10 Case Ten…………………………………………………………………………………….197 4.10.1 First Consultation………………………………………………………………………..197 4.10.2 Second Consultation…………………………………………………………………….200 4.10.3 Third Consultation………………………………………………………………………202 4.10.4 Fourth Consultation……………………………………………………………………..204 4.10.5 Overview of Case Ten…………………………………………………………………..205 Results graph……………………………………………………………………………………207
4.11 Case Eleven…………………………………………………………………………………209 4.11.1 First Consultation………………………………………………………………………..209 4.11.2 Second Consultation…………………………………………………………………….212 4.11.3 Third Consultation………………………………………………………………………214 4.11.4 Fourth Consultation……………………………………………………………………..215 4.11.5 Fifth Consultation……………………………………………………………………….217 4.11.6 Sixth Consultation……………………………………………………………………….218 4.11.7 Seventh Consultation……………………………………………………………………220 4.11.8 Overview of Case Eleven………………………………………………………………..221 Results graph……………………………………………………………………………………223
CHAPTER FIVE RESULTS………………………………………………………………………………………..225 5.1 INTRODUCTION TO THE RESULTS…………………………………………………...225
xii 5.2 SAMPLE CHARACTERISTICS…………………………………………………………..225 5.3 ACHIEVEMENT OF PREGNANCY……………………………………………………...227 5.4 STATISTICAL ANALYSIS………………………………………………………………..227 5.5 CLINICAL ANALYSIS…………………………………………………………………….227 5.5.1 Related Fertility Parameters………………………………………………………………227 5.5.2 General Parameters……………………………………………………………………….227 5.5.3 Related Functional Symptoms……………………………………………………………229 5.5.4 Concomitant Symptoms…………………………………………………………………..230 5.6 STATISTICAL vs. CLINICAL SIGNIFICANCE…………………………………...…...231 5.7 COMPLIANCE……………………………………………………………………………...231
CHAPTER SIX CASE DISCUSSIONS, RECOMMENDATIONS AND CONCLUSION…………………...232 6.1 CASE DISCUSSIONS………………………………………………………………………232 6.1.1 Case One………………………………………………………………………………….233 6.1.2 Case Two…………………………………………………………………………………233 6.1.3 Case Three………………………………………………………………………………..234 6.1.4 Case Four…………………………………………………………………………………234 6.1.5 Case Five…………………………………………………………………………………235 6.1.6 Case Six…………………………………………………………………………………..235 6.1.7 Case Seven………………………………………………………………………………..236 6.1.8 Case Eight………………………………………………………………………………...236 6.1.9 Case Nine…………………………………………………………………………………237 6.1.10 Case Ten…………………………………………………………………………………237 6.1.11 Case Eleven……………………………………………………………………………...238 6.1.12 Final Conclusion………………………………………………………………………...238 6.2 PROBLEMS EXPERIENCED……………………………………………………………..239 6.3 RECOMMENDATIONS……………………………………………………………………239 6.3.1 Continued Studies………………………………………………………………………...239 6.3.2 Benefits of the Study……………………………………………………………………...240 6.3.3 Limitations of the Study…………………………………………………………………..240
REFERENCES…………………………………………………………………………………..242
xiii APPENDICES
APPENDIX A: Invitation and Information and Consent Form………………………………….253 APPENDIX B: Participant Selection Questionnaire…………………………………………….256 APPENDIX C: Pre-consultation Counselling…………………………………………………...263 APPENDIX D: Case Taking Form (First Consultation)………………………………………...265 APPENDIX E: Case Taking Form (Follow-up Consultation)…………………………………..270 APPENDIX F: Daily Basal Temperature and Mucous Charts…………………………………..273 APPENDIX G: General Well-Being Questionnaire……………………………………………..275 APPENDIX H: Advertising Poster………………………………………………………………277 APPENDIX I: Participant Two: S-Quantitative βhCG Results…………………………………278 APPENDIX J: Participant Two: S-Quantitative βhCG and βhCG Pregnancy Screen-S Test Results…………………………………………………………………………..279 APPENDIX K: Participant Two: Abdominal and Pelvic Ultrasound Report…………………...281
xiv LIST OF FIGURES
Figure 4.1: Basal Body Temperature of Participant 1 over the Treatment Period………………….....72 Figure 4.2: General Well-Being Questionnaire Scores of Participant 1 over the Treatment Period….72 Figure 4.3: Individual Question Ratings of Participant 1 over the Treatment Period…………………72 Figure 4.4: Basal Body Temperature of Participant 2 over the Treatment Period…………………….85 Figure 4.5: General Well-Being Questionnaire Scores of Participant 2 over the Treatment Period….85 Figure 4.6: Individual Question Ratings of Participant 2 over the Treatment Period…………………85 Figure 4.7: Basal Body Temperature of Participant 3 over the Treatment Period…………………...102 Figure 4.8: General Well-Being Questionnaire Scores of Participant 3 over the Treatment Period...102 Figure 4.9: Individual Question Ratings of Participant 3 over the Treatment Period………………..102 Figure 4.10: Basal Body Temperature of Participant 4 over the Treatment Period………………….119 Figure 4.11: General Well-Being Questionnaire Scores of Participant 4 over the Treatment Period..119 Figure 4.12: Individual Question Ratings of Participant 4 over the Treatment Period………………119 Figure 4.13: Basal Body Temperature of Participant 5 over the Treatment Period………………….136 Figure 4.14: General Well-Being Questionnaire Scores of Participant 5 over the Treatment Period..136 Figure 4.15: Individual Question Ratings of Participant 5 over the Treatment Period………………136 Figure 4.16: Basal Body Temperature of Participant 6 over the Treatment Period………………….151 Figure 4.17: General Well-Being Questionnaire Scores of Participant 6 over the Treatment Period..151 Figure 4.18: Individual Question Ratings of Participant 6 over the Treatment Period………………151 Figure 4.19: Basal Body Temperature of Participant 7 over the Treatment Period………………….168 Figure 4.20: General Well-Being Questionnaire Scores of Participant 7 over the Treatment Period..168 Figure 4.21: Individual Question Ratings of Participant 7 over the Treatment Period………………168 Figure 4.22: Basal Body Temperature of Participant 8 over the Treatment Period………………….184 Figure 4.23: General Well-Being Questionnaire Scores of Participant 8 over the Treatment Period..184 Figure 4.24: Individual Question Ratings of Participant 8 over the Treatment Period………………184 Figure 4.25: Basal Body Temperature of Participant 9 over the Treatment Period………………….195 Figure 4.26: General Well-Being Questionnaire Scores of Participant 9 over the Treatment Period..195 Figure 4.27: Individual Question Ratings of Participant 9 over the Treatment Period………………195 Figure 4.28: Basal Body Temperature of Participant 10 over the Treatment Period………………...207 Figure 4.29: General Well-Being Questionnaire Scores of Participant 10 over the Treatment Period207 Figure 4.30: Individual Question Ratings of Participant 10 over the Treatment Period……………..207 Figure 4.31: Basal Body Temperature of Participant 11 over the Treatment Period………………...223 Figure 4.32: General Well-Being Questionnaire Scores of Participant 11 over the Treatment Period222 Figure 4.33: Individual Question Ratings of Participant 11 over the Treatment Period……………..223 Figure 5.1: Mean Values for Individual Questions…………………………………………………..228
xv Figure 5.2: Averages of the General Well-Being Questionnaire Scores of all Participants over the Treatment Period……………………………………………………………………………229
LIST OF TABLES
Table 3.1: A table of the mucous change ratings used by participants…………………………..53 Table 3.2: The 5 point scale used to grade the general well-being questionnaire………………..53 Table 4.1: Midcycle Mucous Changes of Participant 1 over the Treatment Period……………...73 Table 4.2: Midcycle Mucous Changes of Participant 2 over the Treatment Period……………...86 Table 4.3: Midcycle Mucous Changes of Participant 3 over the Treatment Period…………….103 Table 4.4: Midcycle Mucous Changes of Participant 4 over the Treatment Period…………….120 Table 4.5: Midcycle Mucous Changes of Participant 5 over the Treatment Period…………….137 Table 4.6: Midcycle Mucous Changes of Participant 6 over the Treatment Period…………….152 Table 4.7: Midcycle Mucous Changes of Participant 7 over the Treatment Period…………….169 Table 4.8: Midcycle Mucous Changes of Participant 8 over the Treatment Period…………….185 Table 4.9: Midcycle Mucous Changes of Participant 9 over the Treatment Period…………….196 Table 4.10: Midcycle Mucous Changes of Participant 10 over the Treatment Period………….208 Table 4.11: Midcycle Mucous Changes of Participant 11 over the Treatment Period………….224 Table 5.1: The Mean Scores of all Eleven Participants at Consultation One and Seven………...228 Table 6.1: A Table Showing the Remedy and Potency Selection for each Participant over the Treatment Period……………………………………………………………………...232
xvi LIST OF ABBREVIATIONS
AI: Artificial insemination AMH: Anti- müllerian hormone ATP: Adenosine triphosphate βhCG: Beta human chorionic gonadotropin BMI: Body mass index DES: Diethylstilbestrol DNA: Deoxyribonucleic acid FSH: Follicle stimulating hormone GIFT: Gamete intrafallopian-tubal transfer GnRH: Gonadotropin-releasing hormone HIV: Human immunodeficiency virus hMG: human menopausal gonadotrophin HSG: Hysterosalpingogram ICSI: Intracytoplasmic sperm injection IUI: Intrauterine insemination IVF: In vitro fertilisation HyCoSy: Hysterosalpingo-contrast sonography LH: Luteinizing hormone LHRH: Luteinizing hormone-releasing hormone MAR: Mixed agglutination reaction OHSS: Ovarian hyperstimulation syndrome TAT: Tray agglutination test ZIFT: Zygote intrafallopian-tubal transfer
xvii CHAPTER ONE
INTRODUCTION
1.1 PROBLEM STATEMENT
The ability to conceive and bear a child is an instinctive birthright of every woman, regardless of whether she wants to have children or not. Almost all women assume that they will be able to have children some day which makes the diagnosis of infertility a traumatic and life changing event.
Infertility may be due to specific male and/or female factors; however, often the cause is multifactorial or remains unexplained (Carlson et al, 2002). Unexplained infertility is a diagnosis assigned to a couple who have undergone an extensive diagnostic evaluation which has failed to reveal a definite underlying cause for their infertility. Diagnosis is made by a process of elimination until it is clinically determined that there is no identifiable pathological reason for infertility in either partner. The diagnosis of unexplained infertility may also be given in the event that a previously identified cause of infertility is corrected, yet infertility persists (Behrman et al, 1988).
Domar et al (1992) explain that women who have been diagnosed as infertile are twice as likely to be depressed as a control group. This depression typically peaks about two years after they start trying to conceive. Wischmann et al (2001) documented that women diagnosed with unexplained infertility had higher scores of depression and anxiety than women diagnosed with infertility due to specific identifiable causes.
Conventional treatment of infertility entails hormonal stimulation of the female ovulatory cycle. To a large degree, conventional treatment ignores the emotional, psychological and even nutritional and lifestyle factors that have physical and hormonal implications (Northrup, 2003). First line treatment includes drug treatment, typically with Clomiphene citrate. In the event that drug treatment fails, the only alternative is assisted conception including drug stimulated superovulation as well as intrauterine insemination, in vitro fertilization, gamete intrafallopian-tubal transfer, zygote intrafallopian-tubal transfer, or intracytoplasmic sperm injection. All assisted conception techniques mentioned, although effective for unexplained infertility, have disadvantages, side effects and excessively high costs. These assisted conception techniques can only be performed a certain number of times and have associated risk factors (Drife & Magowan, 2004).
1 Homoeopathy is a system of therapeutics that is aimed at treating the individual with minimal or no side effects (Bloch & Lewis, 2003). In this research study, homoeopathic similimum remedies were prescribed for each participant. These remedies were selected based on classical homoeopathic principles. The cost of homoeopathic infertility treatment is dependent on the duration of treatment required and is a fraction of the cost of conventional infertility treatment. Homoeopathic treatment treats without any negative damaging side-effects and is non-invasive (Prinsloo, 2004; Hershoff; 2000).
Homoeopathy has been used for many years by homoeopaths in the treatment of infertility with positive anecdotal reports. The aim of homoeopathic infertility treatment in the female is to restore optimum health to the endocrine and reproductive organs, address the stress associated with infertility as well as the lifestyle issues affecting fertility. Included in this is the focus on achieving the highest level of fertility (Prinsloo, 2004).
Positive research on the effect of homoeopathic treatment of male infertility exists, however, research on female infertility, treated homoeopathically, is outstanding (Gerhar & Wallis, 2002)
1.2 IMPORTANCE OF THE PROBLEM
In the African setting, infertility is seen as a violation of the social norm thus contributing to psychological distress and marital instability. Included in this is loss of social security, social status and gender identity. Parenthood is considered culturally mandatory making childlessness unacceptable. Not only does Africa have the highest fertility rates in the world, Africa also has the highest number of infertility cases globally (Dyer et al, 2005; Ragone & Twine, 2000).
The high incidence of unsafe abortions and prevalence of sexually transmitted diseases have been cited as major causes of Africa’s highest world infertility rate. A Ugandan HIV/AIDS study pinpointed infertility as the leading cause of marital instability as well as a leading risk factor for HIV and AIDS (Nabaitu et al, 1994).
A comparison with data from the Western world suggests greater emotional distress in infertile women in South Africa because of their infertility. This was noted when South African infertile couples were compared with infertile couples living in developed countries as well as with non- infertile couples in South Africa (Dyer et al, 2005).
2 According to estimates made by the primary health care sector in the United Kingdom, infertility is caused by ovulatory failure in 26% of cases, male infertility in 20% of cases and 14% of cases constitute tubal damage. Endometriosis may be the cause of infertility in 5% of cases while a diagnosis of unexplained infertility is given in 30% of cases. The remaining 5% may be multifactorial or due to other causes (Manassiev & Whitehead, 2003).
There has been an increase in the demand for infertility services over the last two decades (Drife & Magowan, 2004). Of those that seek medical treatment, an estimated 50% are unsuccessful in their attempts to conceive (Daniluk, 1996).
Turiel (1998) explains that the expensive and most invasive procedures are being recommended too early in the fertility assessment. She goes on to explain how a systematic investigation is not being performed, leading to the cause of infertility being missed. Further more she states that the least invasive tests should be performed first, and if so indicated, the least invasive treatments should be performed. From there couples should be allowed to wait a reasonable amount of time for pregnancy to occur before proceeding to the next step where more expensive and invasive tests and treatment are performed and utilized.
Because of the high costs of assisted conception technologies many infertile couples are unable to undergo therapies to correct their childlessness. For this reason many couples turn to alternative therapies such as acupuncture, homoeopathy, reflexology and herbal medications that are less expensive, yet sometimes as effective in the treatment of infertility (Naished, 2004). More research on the efficacy and safety of these alternatives would be useful.
1.3 HYPOTHESES
Null hypothesis: The homoeopathic similimum is ineffective in the treatment of females previously diagnosed with unexplained infertility.
Hypothesis: It is hypothesized that the homoeopathic similimum will increase the successful conception rate in women suffering from previously diagnosed unexplained infertility.
1.4 PURPOSE OF THE STUDY
The aim of this research was to evaluate the efficacy of homoeopathic similimum treatment in
3 females pre-diagnosed with unexplained infertility using case studies. In addition to the positive outcome of pregnancy, cases were evaluated using the additional parameters related to fertility of basal body temperatures charts and midcycle cervical mucus changes. The parameters of general well-being, premenstrual symptoms, dysmenorrhoea and sexual function were also analysed. Changes in individual concomitant symptoms were also assessed.
1.5 DELIMITATIONS
The researcher did not prescribe a single routine remedy that was known to be useful in treating infertility, as this is against the principles of the similimum method. Other intervention that may have improved the participant’s fertility, such as diet, supplementation, lifestyle, exercise and stress management were not altered during the study. For the purpose of this study the intervention was individualised homoeopathic similimum treatment only
1.6 ASSUMPTIONS
It is assumed that:
Homoeopathic remedies used in the study were from a reliable source and were accurately prepared according to the recognised French pharmacopoeia. The participants in this study took the homoeopathic medication in the manner prescribed. The participants in the study truthfully and honestly reported all symptoms and changes that occurred. The participants in the study truthfully and honestly reported all temperature readings and midcycle mucus changes. The participants in the study truthfully and honestly completed all general well-being questionnaires. The participants in the study had not deviated from their normal lifestyle, exercise or dietary habits immediately prior to, or during the study. The participants in the study had not made use of herbal medicines, other homoeopathic medicines, acupuncture or reflexology during the study. The participants’ subjective assessments of treatment progress were honestly presented.
4 1.7 DATA VALIDITY
The following variables were considered:
The participants’ honesty when divulging their symptoms and any changes thereof. Each participant’s ability to take the prescribed homoeopathic remedies in the correct manner. Each participant’s ability to use the ovulation thermometer provided and record her temperature daily, and observe midcycle mucus change accurately. Any changes in the participants’ environment or daily habits during the research period. The researcher’s knowledge of the materia medica and the principles of homoeopathy. The researcher’s case taking abilities and objective interpretation and evaluation of the case. The researcher’s selection of the similimum remedies under the supervision of the supervisor. The researcher’s aim was to exclude women with known cause of infertility. It is possible, however, that some of the participants may have had unidentified underlying pathologies. Such underlying pathologies could have prevented the effective treatment of their infertility.
5 CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 INTRODUCTION TO INFERTILITY
Infertility is generally defined as the inability to conceive after a minimum of one year of regular intercourse without contraception (Carlson et al, 2002). It may be divided into primary infertility, where individuals have never had a biological child, or secondary infertility where individuals have had at least one previous documented conception (Greer et al, 2003). Infertility typically affects both partners who are attempting conception, for although one partner may carry the medically diagnosed cause, both partners experience the inability to realise their goal of having a child (Stanton & Dunkel-Schetter, 1991).
An estimated 80% of the normal fertile population will conceive within one year, and 92% will conceive by the end of the second year. The percentage of women exposed to the risk of pregnancy for one menstrual cycle who will produce a live-born infant is termed fecundability. The normal human fecundability rate is about 20%, indicating that twenty out of one hundred couples will conceive in any given month if engaged in unprotected sexual intercourse. Women tend to be most receptive to impregnation in their late teens and early twenties, while the likelihood of becoming pregnant with each cycle declines during the second and third decades. For this reason, after age thirty, it may require more cycles in order for a woman to fall pregnant, while a woman at age twenty may become pregnant almost immediately (Reading, 1983). Hence we see that fecundability diminishes slightly with each passing month of not conceiving. The effect of age in men is far less pronounced than in women, although older men are less fertile (Drife & Magowan, 2004; Manassiev & Whitehead, 2003).
The prevalence of infertility does not appear to have altered significantly, however there has been an increase in the demand for infertility services over the last two decades (Drife & Magowan, 2004). Of those that seek medical treatment, an estimated 50% are unsuccessful (Daniluk, 1996).
2.2 INCIDENCE AND EPIDEMIOLOGY
The prevalence figures of infertility in South Africa are inconsistent. It is estimated that some 15- 20% of South African couples report difficulties with conception. A high percentage of infertility in
6 South Africa is a consequence of untreated sexually transmitted diseases (Cooper et al, 2004).
In the United Kingdom, infertility is an extremely common condition which affects one in six couples (16%) at some stage in their reproductive lives (Drife & Magowan, 2004). The number of women known to have fertility problems in the United States of America increased from 4.9 million in 1988 to 6.2 million in 1995, and about 44% of those sought medical help (Burt & Hendrick, 2005). According to a study done in the United States of America, in a sample size of five thousand one hundred and twenty nine couples, 14% of the sample group were diagnosed with unexplained infertility (Drife & Magowan, 2004).
Data obtained from the National Survey of Family Growth was used to calculate the percentage of currently married women who would conceive during twelve months of unprotected intercourse (Hendershot et al, 1982). The pregnancy rates declined from 86% for women aged twenty to twenty-four years to 52% for women aged thirty-five to thirty-nine years. Studies of fertility rates in populations of women who do not use contraception also reveal a substantial decline in fertility after age thirty, with an greater rate of decline after thirty-five (Stanton & Dunkel-Schetter, 1991).
The incidence of primary infertility varies between countries. The percentages are as low as 2% in Turkey and Thailand, to 21% in Democratic republic of Congo and 32% in Gabon. In most European countries, it is estimated to be between 3 and 7%, and about 6% in the United Kingdom and United States of America (Larsen & Wyshak, 2005; Lunenfeld & Van Steirteghem, 2004). Africa not only has the highest fertility rates, but also the highest number of infertility cases reported globally. The prevalence and frequency of sexually transmitted diseases as well as unsafe abortions throughout African countries has been linked to the increase in infertility statistics (Holtz, 2007)
Many women become pregnant while awaiting fertility assessment or treatment. This is estimated at 2.02% a month and a cumulative rate of 24.2% a year. A follow-up of couples with unexplained infertility showed that 64% of women with primary infertility and 79% of women with secondary infertility will conceive within nine years without treatment (Manassiev & Whitehead, 2003).
7 2.3 THE FEMALE REPRODUCTIVE SYSTEM
2.3.1 Functional and Structural Anatomy of the Female Reproductive System
The female reproductive system consists of six main components namely the ovaries, uterine (fallopian) tubes, the uterus, vagina, vulva and the mammary glands. These structures are supported and held in place by a series of ligaments which hold and support the uterus in an anteverted position. They also limit side-to-side movement and rotation as well as prevent superior-inferior movement of the uterus. Uterine and ovarian blood vessels are found within these ligaments and form an anastomotic loop (Drife & Magowan, 2004; Martini, 2004).
The ovaries are two small, oval shaped organs located near the lateral wall of the pelvic cavity. Production of female gametes or oocytes as well as sex steroid hormones, occurs in the ovaries in response to pituitary gonadotrophins (Martini, 2004). Each ovary can be divided into an outer cortex and inner medulla. The surface of the ovaries is covered with simple cuboidal epithelium while the cortex is composed of a connective tissue stroma which supports thousands of follicles. The medulla is composed of supporting stroma as well as a rich network of vessels and nerves that enter the ovary at the mesovarium (Drife & Magowan, 2004).
The uterine or fallopian tubes are about 7-12cm in length. Each has four recognisable portions and opens into the pelvic cavity (Drife & Magowan, 2004). Each tube passes through the cornu at the uterus. The isthmic portion follows which has a narrow lumen and a thick muscular wall (Ransom & McNeeley, 1997). Next is the ampulla which has an expanded lumen and a more convoluted mucosa (Ransom & McNeeley, 1997). The infundibulum is the trumpet-shaped expansion which is fringed by a ring of delicate fimbriae (Drife & Magowan, 2004). The fimbriated part of the tube provides a wide surface for ovum pickup. The outer layer is the tunica muscularis which is composed of longitudinal fibres; the internal layer has a more circular orientation which aids in movement of the ovum from the ovary toward the uterus (Ransom & McNeeley, 1997).
The uterus is a fibromuscular organ whose shape, weight and dimensions vary considerably depending on both oestrogenic stimulation and previous parturition (Ransom & McNeeley, 1997; Martini, 2004). The uterus is composed of two parts; the body or corpus and the cervix, which are joined by the isthmus. The convex upper surface of the body is called the fundus of the uterus, while the lower part of the uterus, called the cervix, protrudes into the vagina (Bickley & Szilagyi, 2003). The cervix forms a curving surface at the distal end that surrounds the cervical os which
8 leads into the cervical canal. This is a constricted passageway that opens into the uterine cavity at the internal os (Martini, 2004). The wall of the uterus has three distinct layers: the endometrium which is the innermost layer, the myometrium and the serosa or outermost layer of the uterus. The endometrium is the epithelial lining of the cavity which consists of two layers – a superficial functional layer and a basal layer. It is composed of uterine mucus-secreting glands within a cellular stroma and undergoes cyclical changes which lead to shedding and renewal approximately every twenty-eight days (Drife & Magowan, 2004). The myometrium is the thickest portion of the uterine wall and is composed of smooth muscle that is arranged into longitudinal, circular and oblique layers (Martini, 2004).
The vagina is an elastic, muscular tube extending between the cervix and the vestibule which is a space bounded by the female external genitalia. The lining of the vagina is composed of stratified squamous epithelium and is corrugated into transverse folds which facilitate stretching during childbirth. This epithelium contains no glands. During the reproductive years the more superficial cells contain glycogen. Glycogen is broken down by lactobacilli forming the normal flora of the vagina. Lactic acid is thus formed which accounts for the low pH of the vaginal lumen (average pH 4.5). An extensive venous plexus lies between the epithelium and muscular layer and facilitates vascular engorgement during sexual arousal. This allows for distension of the transverse folds as well as increased transudation into the vagina (Drife & Magowan, 2004).
The area containing the female external genitalia is called the vulva or pudendum. A central space bounded by small folds is known as the labia minora. The labia majora are prominent folds that encircle and partially conceal the labia minora. The outer limits of the vulva are established by the mons pubis and the labia majora. The clitoris lies anterior to this and projects into the vestibule. It contains erectile tissue comparable to the corpora cavernosa of the penis. These areas are moistened and lubricated by sebaceous glands and apocrine sweat glands. The Bartholin’s glands discharge into the vestibule during sexual arousal (Ransom & McNeeley, 1997; Martini, 2004).
The mammary glands are specialized organs of the integumentary system that are controlled mainly by hormones of the reproductive system and by the placenta. The glandular tissue of the mammary glands consists of separate lobes each containing several secretory lobules. Dense connective tissue surrounds the lobes forming suspensory ligaments of the breast (Martini, 2004).
9 2.3.2 The Ovarian Cycle
The menstrual and ovarian cycles are the processes by which the female prepares for possible fertilization. The system is driven by feedback loops, namely between hypothalamic gonadotrophin releasing hormone (GnRH) pulses, pituitary luteinizing hormone (LH), follicle stimulating hormone (FSH) release and ovarian oestrogen, progesterone, inhibin and activin release (Guyton & Hall, 1997). Unless interrupted by either pregnancy or pathology, these feedback loops generate a cycle that lasts between twenty-four and thirty-two days and commences on the first day of menstruation. The cycle is divided into two stages, each lasting about fourteen days. At about day fourteen of the cycle, ovulation occurs (Drife & Magowan, 2004).
Follicular maturation and ovulation is controlled by the hypothalamo-pituitary-ovarian axis (Boon et al, 2006). This may be affected by factors such as anxiety or stress, as higher centres in the brain may influence the hypothalamo-pituitary-ovarian axis. This axis functions by secreting GnRH in a pulsatile manner approximately every ninety minutes via blood vessels to the anterior pituitary where it stimulates the synthesis and release of FSH and LH (Guyton & Hall, 1997).
The ovarian cycle is composed of the follicular phase, ovulation and the luteal phase. At the beginning of the cycle the levels of FSH and LH are relatively high. This is because of a fall in the levels of oestrogen and progesterone at the end of the preceding cycle. These high levels stimulate the development of ten to twenty follicles. A single dominant follicle appears during the mid- follicular phase, while the remainder of the follicles undergo atresia (Drife & Magowan, 2004). This occurs between days one and eight of the ovarian cycle.
Between days nine and fourteen, a localised accumulation of fluid appears near the granulosa cells as the follicle increases in size. This turns the primary follicle into a Graafian follicle. Three layers of granulosa cells surround the Graafian follicle which then causes the oocyte to occupy an eccentric position. These granulosa cells of the developing follicle produce an increase in oestrogen. The release of GnRH is suppressed by the rise of oestrogen thus preventing hyperstimulation of the ovary and maturation of multiple follicles (Drife & Magowan, 2004).
Ovulation usually occurs on day fourteen of the cycle where there is rapid enlargement of the follicle followed by protrusion from the surface of the ovarian cortex. Rupture of the follicle may result in a short-lived pain in one or both of the iliac fossae (Drife & Magowan, 2004). A final rise in oestradiol concentration is responsible for a mid-cycle surge in LH and to a lesser extent, the
10 positive feedback of FSH. Just before ovulation there is a fall in oestradiol levels and an increase in progesterone production. LH contributes to steroidogenesis in the follicle and influences the production of progesterone (Guyton & Hall, 1997).
The luteal phase falls between day fifteen and twenty-eight where GnRH levels decrease until there is regression of the corpus luteum at days twenty-six to twenty-eight followed by menstruation (Guyton & Hall, 1997). The corpus luteum is formed by granulosa cells that have undergone luteinization. It is retained in the ovary and is penetrated by capillaries and fibroblasts. It is a major source of sex steroid hormones, oestrogen and progesterone which are secreted after ovulation. The next cycle is initiated by GnRH because of a fall in the levels of steroid hormones. Should conception and implantation occur, the corpus luteum does not regress and is maintained by gonadotrophin secreted by the syncytiotrophoblast (Drife & Magowan, 2004).
2.3.3 The Menstrual Cycle
The ovaries induce changes in the uterine endometrium and cervical mucus, by cyclical production of steroid hormones. During the follicular phase the endometrium is exposed to oestrogen secretion. At the end of menstruation regeneration of the endometrium rapidly occurs and this is known as the proliferative phase. During this phase the endometrial glands become tubular and arranged in a regular pattern. These endometrial glands lie parallel to each other and contain little secretion (Martini, 2004; Drife & Magowan, 2004).
As soon as ovulation has occurred, progesterone production induces secretory changes in the endometrial glands. This is first evident as the appearance of secretory vacuoles in the glandular epithelium below the nuclei. Secretion of material into the lumen of the glands progresses thereafter, resulting in tortuous glands (Martini, 2004).
At the end of the luteal phase, when regression of the corpus luteum results in a decline in oestrogen and progesterone production, intense spasmodic contraction of the spiral section of the endometrial arterioles occurs. This gives rise to ischaemic necrosis of the endometrium. At the same time prostaglandins are released. Prostaglandins cause the muscles of the uterus to contract. This ultimately results in the shedding of the superficial layer of the endometrium and bleeding ensues, known as the menstrual period or menses (Guyton & Hall, 1997).
11 2.3.4 Changes Experienced during the Menstrual and Ovarian Cycles
The permeability of the cervical mucus varies during the month as it responds to hormonal changes. After a five-day menstrual flow, there are three to four dry days where no mucus is present. Early in the follicular phase and after the dry days, the cervical mucus becomes viscid and impermeable. Later in the follicular phase the increasing oestrogen levels induce changes in the composition of the mucus. The water content increases progressively so that just before ovulation occurs the mucus has become watery, clear, slippery, very stretchy, similar to egg white and is easily penetrated by the spermatozoa. Ovulation occurs within two days of the time when the cervical mucus becomes clearest, slippery and most stretchy. After ovulation has occurred the progesterone secreted by the corpus luteum counteracts the effect of the oestrogen resulting in the mucus becoming impermeable again. The cervical os contracts at this time. Thus the cervical mucus acts as a barrier to hazardous infectious agents, offering some prevention from infection of female structures.
The circulating hormones also affect other organs. Owing to the thermogenic effect of progesterone acting at the hypothalamic level, a slight drop in temperature occurs before ovulation, and is followed by a rise in basal body temperature of between 0.4°C to 1°C. This indicates that ovulation has just occurred. The temperature spike occurs within twelve hours of ovulation and is sustained until the onset of menstruation. The most fertile days are just before the temperature spike and three days following this spike. Should conception occur, the elevation in basal body temperature is sustained throughout pregnancy (Drife & Magowan, 2004; Burris et al, 2008).
Oestrogen and progesterone act synergistically on the breast. Breast swelling typically occurs during the luteal phase in response to increased progesterone levels. This swelling is due to vascular change and not because of changes in the glandular tissue.
Changes in mood during the menstrual cycle may be noticed in some women. This is seen as an increase in emotional lability during the late luteal phase. These changes may be due to falling progesterone levels. However, the dividing line between normal cyclical changes and the premenstrual syndrome is unclear (Drife & Magowan, 2004).
2.3.5 The Functions of the Female Hormones
The female reproductive tract is under the control of the female hormones that ultimately control the ovarian and uterine cycles. In the event that the uterine and ovarian cycles cannot be
12 coordinated normally, infertility results (Martini, 2004). There are three different hierarchies of hormones. The first is the hypothalamic releasing hormone, GnRH; the second is the anterior pituitary hormones, FSH and LH which are released in response to GnRH. The third, the ovarian hormones, oestrogen and progesterone are secreted by the ovaries in response to hormones from the anterior pituitary (Guyton & Hall, 1997).
The main hormones produced in the female cycle include oestrogens, progestogens and androgens (Guyton & Hall, 1997).
2.3.5.1 Oestrogen
Oestrogens are secreted at the start of the menstrual cycle in response to LH and FSH. Their synthesis takes place in the developing ovarian follicle, requiring both the thecal and granulosa cells. The theca interna secretes androgens in response to LH. It also activates the enzyme that converts cholesterol to pregnenolone. This is the first step in steroid production. The majority of androgens cross the basement membrane into the granulosa cells. Here FSH activates the aromatase enzyme produced by the granulosa cells. This allows the thecal androgens to be converted to oestrogens, mainly oestradiol (Guyton & Hall, 1997; Martini, 2004). The main actions of oestrogen are for the development of the reproductive organs and secondary sexual characteristics. Proliferation of the functional layer of the endometrium of the uterus and the production of watery cervical mucus to allow sperm penetration are dependant on the presence of oestrogen. Oestrogens also stimulates bone and muscle growth, affects central nervous system activity such as sex drive, and the production of glycogen by the vaginal epithelium (Martini, 2004; Drife & Magowan, 2004; Boon et al, 2006)
2.3.5.2 Progesterone
Progesterone is secreted in the second half of the menstrual cycle by the corpus luteum and in response to the pituitary gonadotropic hormones (Guyton & Hall, 1997). It is synthesised from cholesterol and transported in the blood. Its main actions are to maintain the uterine endometrium thus preparing the uterus for implantation and to stimulate uterine secretions. The promotion of the survival and development of the embryo and foetus, and the production of viscid cervical mucus to form an impenetrable barrier are other functions of progesterone (Martini, 2004; Drife & Magowan, 2004; Boon et al, 2006). Should pregnancy not occur, the corpus luteum degenerates and about
13 twelve days after ovulation it becomes non-functional and the oestrogen and progesterone levels fall (Martini, 2004).
2.3.5.3. Other Ovarian Hormones.
Inhibin and actin are polypeptide hormones secreted by the granulosa cells of the ovarian follicle. Inhibin inhibits pituitary FSH secretion, while actin stimulates FSH secretion and inhibits androgen production. Actin also stimulates the conversion to oestrogens. Thus together, actin and inhibin regulate FSH secretion and local sex steroid levels and the balance between oestrogens and androgens (Guyton & Hall, 1997; Martini, 2004).
Relaxin is a polypeptide hormone secreted by the corpus luteum and placenta. It prepares the female body for childbirth by causing cervical softening and dilatation, and increases the flexibility of the pubic symphysis. This permits the pelvis to expand during delivery and to relax the pelvic ligaments (Martini, 2004).
2.4 THE MALE REPRODUCTIVE SYSTEM
2.4.1 Functional and Structural Anatomy of the Male Reproductive System
The male reproductive system consists of six main components namely the testes, epididymis, vas deferens, prostate gland, seminal vesicles and the penis, each of which is positioned outside of the peritoneal cavity.
The testes are two oval-shaped organs. The testes consist of fibrous partitions or septa which subdivide each testis into lobules. Distributed among these lobules are approximately eight hundred slender and tightly coiled seminiferous tubules within which sperm production occurs. Each seminiferous tubule contains spermatogonia, spermatocytes at various stages of meiosis, spermatids, spermatozoa and large sustentacular cells or Sertoli cells (Martini, 2004). Surrounding each seminiferous tubule is a delicate capsule, areolar tissue, blood vessels and interstitial cells or Leydig cells (Boon et al, 2006).
The testes are suspended within a fleshy pouch known as the scrotum which is divided internally into two chambers. Each testis is surrounded by three layers - the tunica vasculosa, tunica albuginea and tunica vaginalis (Martini, 2004; Bickley & Szilagyi, 2003).
14
The epididymis is a firm, comma-shaped structure and can be described in three sections namely the head, the body and the tail. It is attached posteriorly to the top of the testis and consists of tightly coiled spermatic ducts (Bickley & Szilagyi, 2003). The functions of the epididymis are to monitor and adjust the composition of the fluid produced by the seminiferous tubules and to act as a recycling centre for damaged spermatozoa. It also stores and protects spermatozoa as well as facilitates their functional maturation (Martini, 2004).
The vas deferens otherwise known as ductus deferens, begins at the tail of the epididymis and ascends within the scrotal sac. The vas deferens passes posteriorly toward the prostate gland (Bickley & Szilagyi, 2003). The junction of the ampulla and the seminal vesicles marks the start of the ejaculatory duct. The vas deferens is composed of three muscular layers which help to propel the spermatozoa along its length, and may also store spermatozoa for several months. Each vas deferens is closely associated with blood vessels, nerves and muscle fibres which make up the spermatic cord (Martini, 2004).
The fluid component of semen is a mixture of secretions from the seminal vesicles, prostate gland and bulbourethral glands, each with distinctive biochemical characteristics. These secretions activate spermatozoa and provide nutrients to the spermatozoa needed for motility, and for propelling spermatozoa. They also produce and are rich in bicarbonate buffers that counteract the acidity of the urethral and vaginal environments. They also produce nutrient citric acid and fibrinolytic enzyme which liquefies the semen (Martini, 2004).
The prostate is a chestnut-sized gland that surrounds the prostatic urethra at the base of the bladder and secretes seminal fluid into the urethra during ejaculation (Bickley & Szilagyi, 2003). This gland is composed of three concentric rings of glands namely the inner periurethral (mucosal) gland, the outer periurethral (submucosal) glands and the peripheral zone gland. It is surrounded by smooth muscle and a fibrous capsule and its secretory activity is dependant on testosterone (Martini, 2004).
The seminal vesicles are two pear-shaped tubular glands found above the prostate gland between the bladder and the rectum. They secrete a fructose-rich, alkaline fluid that forms about 60% of ejaculated semen. The high concentration of fructose is easily metabolised by spermatozoa while the prostaglandins stimulate smooth muscle contraction along the female and male reproductive tract. The fibrinogen within this secretion forms a temporary clot within the vagina after ejaculation. When mixed with this secretion the spermatozoa undergo the first step of capacitation, the
15 maturation and functioning of spermatozoa, and begin beating their flagella. Peristaltic contractions in the vas deferens, seminal vesicles and prostate gland are under the control of the sympathetic nervous system (Martini, 2004; Bickley & Szilagyi, 2003).
Inferior to the prostate are two small bulbourethral glands or Cowpers glands that empty into the urethral lumen. Secreted from these glands is a thick, alkaline and sugar rich mucus that helps to neutralize any urinary acids that may remain in the urethra and lubricates the glans of the penis (Martini, 2004).
The penis is a tubular organ that is the outlet for urine and semen. During intercourse the penis deposits semen into the female’s vagina (Bickley & Szilagyi, 2003). This organ is divided into three regions namely the root, the body, and the glans. The penis is composed of three cylinders of erectile tissue, each surrounded by a fibrous capsule called the tunica albuginea. Two cylinders of corpora cavernosa and one corpus spongiosum make up the body of the penis (Martini, 2004; Bickley & Szilagyi, 2003). A thin layer of pigmented skin surrounds these structures and forms the foreskin or prepuce. The majority of vessels and nerves supplying the penis are found on the dorsal side while the deep arteries (branch of the internal pudendal artery) are found within the corpora cavernosa (Martini, 2004).
2.4.2 Spermatogenesis
Spermatogenesis is the process by which haploid spermatozoa, having twenty-three chromosomes, are formed from diploid stem cells or spermatogonia, having forty-six chromosomes. There are three integral processes that are involved in spermatogenesis which include mitosis, meiosis and spermiogenesis (Guyton & Hall, 1997).
Spermatogonia can be found close to the basement membrane of the seminiferous tubules in the basal compartment of the tubule where they undergo mitosis (Martini, 2004). The mitotic cell division of spermatogonia is incomplete so that the daughter cells remain connected by thin cytoplasmic bridges. This process continues throughout the adult life of the spermatogonia and results in one daughter cell being pushed toward the lumen of the seminiferous tubule. Here they differentiate into primary spermatocytes and prepare to begin meiosis (Guyton & Hall, 1997).
The primary spermatocytes undergo meiosis, a special form of cell division, which is the first division forming two haploid secondary spermatocytes. The second meiotic division occurs soon
16 afterwards forming four haploid spermatids. These spermatids are small and relatively unspecialised cells (Martini, 2004). As meiosis progresses, germinal cells migrate from the basal compartment to the adluminal compartment of the Sertoli cells. The function of the Sertoli cells is to provide nutrients, remove waste and phagocytose excess cytoplasm or poorly developed spermatids. They form the blood-testes barrier and produce androgen-binding protein to raise the local androgen concentration necessary for meiosis to take place (Guyton & Hall, 1997).
The process of spermiogenesis involves the physical maturation of spermatids into a single spermatozoa or sperm. During the maturation phase the tail of the sperm starts to develop and excess cytoplasm is pinched off. Spermiation occurs where a spermatozoon loses its attachment to the Sertoli cells and enters the lumen of the seminiferous tubules. Fully mature spermatozoa are stored in the epididymis until they are ejaculated or broken down. This process from spermatogonial division to spermiation takes about nine weeks (Guyton & Hall, 1997).
The mature spermatozoa have a distinct head, middle piece and tail. The head is composed of condensed chromatin in a pointed nucleus. The front of the head is surrounded by a giant lysosome called the acrosome that allows the sperm to penetrate the oocyte. A short neck attaches the head to the middle piece and contains mitochondria which provide the adenosine triphosphate (ATP) necessary to move the tail. The tail is a long and specialised flagellum which moves the cell from one place to another. The spermatozoa lack the intracellular structures that other less specialised cells contain. For this reason the cell size and mass is reduced allowing its motility (Martini, 2004).
2.4.3 Male Hormones
The testes, as well as the adrenal glands, are the site of androgen production and secretion. The main androgen is testosterone, which is the hormone responsible for the male hormonal effects. Testicular androgens are secreted by the interstitial Leydig cells. They are found between the seminiferous tubules where they convert cholesterol into the steroid testosterone by a series of reactions (Guyton & Hall, 1997).
Testosterone is transported in the plasma and acts via intracellular receptors to regulate protein synthesis. It thus produces actions such as the growth and development of the male reproductive tract, the development of male secondary sexual characteristics and the stimulation of spermatogenesis. The stimulation of growth and the fusion of the growth plates of the long bones is also dependant on testosterone (Guyton & Hall, 1997).
17
Testosterone synthesis and release is controlled by the same hormones in the male as oestrogen in the female. Gonadotrophin-releasing hormone (GnRH) from the hypothalamus is transported to the anterior pituitary gland by the portal veins. This stimulates the gonadotroph cells to secrete gonadotrophins, namely LH and FSH (Martini, 2004).
Luteinizing hormone (LH) acts on the Leydig cells to stimulate the first step in testosterone production. Testosterone feeds back to the hypothalamus and pituitary gland to inhibit LH release, but has little effect on FSH. Follicle-stimulating hormone (FSH) acts on the Sertoli cells and increases the number of receptors to stimulate spermatogenesis. It also causes inhibin B release from the Sertoli cells, which feeds back to the hypothalamus and pituitary gland to inhibit further FSH release. Inhibin has little effect on LH and therefore regulates sperm production without inhibiting testosterone levels (Martini, 2004).
2.5 FERTILIZATION TO IMPLANTATION
Fertilization is the process by which two haploid gametes fuse thus producing a zygote containing forty-six chromosomes. This normally occurs near the junction between the ampulla and the isthmus of the uterine tube, usually within a day after ovulation (Gold & Josimovich, 1980). A secondary oocyte has, by this time, travelled a few centimetres while the spermatozoa cover the distance between the vagina and ampulla of the uterine tube. It is postulated that contraction of the uterine musculature as well as ciliary currents of the uterine tubes accelerates the movement of spermatozoa from the vagina to the site of fertilization. Of the estimated two hundred million spermatozoa introduced to the vagina during intercourse, about ten thousand spermatozoa enter the uterine tubes and less than one hundred reach the isthmus (Martini, 2004).
One successful sperm penetrates the layers surrounding the oocyte and in the process prevents other sperm from fertilizing the oocyte. This is achieved by penetration of the corona radiata of the ovum which triggers the release of the enzyme hyaluronidase which disrupts the cell matrix, and enables the sperm in full to push through the remaining granulosa cells (Guyton & Hall, 1997). Penetration of the zona pellucida of the ovum is followed by release of an enzyme, acrosin, which digests the glycoprotein chains present in the zona pellucida. The sperm can now push through the weakened outer structure. The membranes of the sperm and oocyte bind via integrin receptors. They fuse causing depolarisation of the oocyte and thus preventing further binding of other sperm. The sperm nucleus then enters the oocyte cytoplasm leaving its tail and membrane behind. The oocyte now
18 completes the second meiotic division producing two haploid cells; a female pronucleus with the majority of cytoplasm and a second polar body with almost no cytoplasm. The DNA within each pronucleus replicates and the nuclear membranes surrounding the pronuclei break down. The maternal and paternal chromosomes mix producing a diploid chromosome of forty-six chromosomes (Martini, 2004). The zygote begins to divide thirty-six hours after fertilization by mitosis and a copy of the replicated DNA enters each cell (Drife & Magowan, 2004).
Thereafter the zygote undergoes a further four mitotic divisions at intervals of seventeen hours each, thus becoming a ball of cells called a blastomere. After the fifth mitotic division a trophoblast is formed with a single-cell-layered wall and inner cell mass. This inner cell mass contains the cells necessary for the formation of the embryo itself. The seventh division results in a total of one hundred and twenty-eight cells which occupy the same volume as the initial fertilized egg and the zona pellucida is shed. This process occurs over five days, during which time the developing embryo is transported along the uterine tube toward the uterus. Once the embryo reaches the endometrium it implants itself within this layer thus gaining access to the maternal circulation. After differentiation of the inner cell mass, the morphology of the embryo changes to that of two discs containing distinct cells. These discs are composed of the epiblast which is on the dorsal region and the hypoblast, on the ventral region. The largest cavity at this stage is the umbilical vesicle, lined by hypoblast cells. The amniotic cavity is lined with epiblast cells by gestational day nine. An oval shape and head-tail axis becomes apparent by day sixteen and gastrulation occurs. This is where epiblast cells migrate toward a groove in the caudal end of the disc known as the primitive streak. Here a new embryonic compartment, called the mesoderm is formed, so that now the embryo has three layers bounded by the umbilical vesicle ventrally and the amniotic cavity dorsally (Drife & Magowan, 2004).
Thereafter, organogenesis takes place where there is division into five main areas. These areas include the neural tube and brain, the gut tube and derivatives, the heart and lung, the face and the limbs and skeletal muscles (Drife & Magowan, 2004).
Beta Human Chorionic Gonadotropin (βhCG) levels rise once implantation has occurred. βhCG is produced by the placental trophoblast cells. βhCG may be detected in blood or urine samples as early as seven to eight days after ovulation and may be used to show progression of change throughout pregnancy (Kovalevskaya et al, 1999). For individuals who are sexually active and have regular menstrual cycles, missing a menstrual cycle for one week or more is considered presumptive evidence of pregnancy. βhCG quantitative testing and βhCG screen are performed on
19 blood samples and may indicate pregnancy. Similarly, βhCG urine tests may indicate a positive reading in the event of pregnancy. However positive βhCG readings may also be observed in the presence of trophoblastic tumours, hydatidiform mole, ectopic pregnancy and choriocarcinoma.
Symptoms of pregnancy include enlarged and engorged breasts, nausea with possible vomiting, increased frequency of urination, fatigue and abdominal bloating. These symptoms are a result of βhCG stimulation of the corpus luteum which in turn results in increased levels of oestrogen and progesterone. Pregnancy is maintained by the high levels of oestrogen and progesterone (Beers et al, 2006).
2.6 EVALUATION OF THE INFERTILE COUPLE
Four aspects are generally assessed in fertility evaluation, each of which encompasses different aspects of the reproductive process: the number and quality of sperm, maturation and release of the ova, barriers to fertilization, barriers to implantation and maintenance of pregnancy (Cooper- Hilbert, 1999). The diagnosis of infertility is a process of exclusion which identifies those patients where the cause is clear, those in whom there is a possible cause, and those in whom the cause is essentially unexplained. The diagnostic procedure used prior to a diagnosis of unexplained infertility includes the following: A history-taking, physical examination of both partners, temperature charts for several months, postcoital examinations and tests, blood tests and hormone analysis, sperm count and semen analysis, and laparoscopy (Greer et al, 2003; Collins, 2004).
The initial evaluation of the infertile couple should begin with a complete history and physical examination. The history taking should be thorough and include details of age and duration of infertility, any past evaluation and results and pubertal progression in both partners. Any urologic or genital injury, infection or surgery in men, as well as menstrual, gynaecological and obstetric histories in women should be included. Other important factors to be considered are history of abortion, sexually transmitted disease, pelvic inflammatory disease and exposure to diethylstilbestrol (DES). Menorrhagia, uterine enlargement, prior pelvic or abdominal surgery or abnormal cervical cytology are important factors to consider. Social habits such as tobacco, alcohol and recreational drug use may have a detrimental affect on fertility and should be addressed at the initial visit and behaviour modification recommended. The female partner’s body mass index should be within normal ranges of nineteen and twenty-five, as a body mass index that is too high or low lowers fertility. Body hair distribution should be noted so as to eliminate the possibility of hyperandrogenism, hyperprolactinaemia and hypothyroidism as possible causes of infertility (Drife
20 & Magowan, 2004; Ransom & McNeeley, 1997).
Physical examination of the female may show uterine structural abnormality or a fixed or tender uterus which may be indicative of endometriosis or pelvic inflammatory disease associated with tubal disease. In the male partner physical examination would be necessary should semen analysis show abnormal features. The size, consistency and position of the testes, outline of the epididymis and any swelling of the scrotum may be the cause of poor sperm quality. Examination of the prostate can be omitted unless there is evidence of chronic infection (Drife & Magowan, 2004; Collins, 2004).
A sexual history should be obtained with special emphasis on the frequency and timing of intercourse as well as on the use of lubricants during intercourse. The couple should be instructed on the optimum time for conception and should be encouraged to have regular intercourse during this time (Stanton & Dunkel-Schetter, 1991). Basal body temperature charts should be kept by the female partner for several months so as to determine the length of cycles, and, based on temperature elevation, probable date of ovulation. This is used so as to time the best days for intercourse during ovulation as accurately as possible (Harkness, 1992).
Investigations should be arranged in a logical manner with reference to the history and additional tests conducted depending on the clinical circumstances. Baseline investigations for females include early follicular phase LH, FSH and oestradiol levels. This is then followed by luteal progesterone levels so as to assess ovulation. Thereafter a test of tubal patency by laparoscopy, hysterosalpingo- contrast sonography or hysterosalpingogram may be conducted. The baseline test for males includes two semen analyses (Drife & Magowan, 2004).
Sperm production, sperm function or sperm delivery may be a cause of male infertility. Semen analysis provides information about the spermatogenesis and characteristics such as volume, pH, liquifaction, colour and sperm delivery. Motility and morphology but not function may also be assessed (Stanton & Dunkel-Schetter, 1991). The World Health Organization criteria for semen analysis states that the volume must be > 2ml, pH between seven and eight and a concentration > 20 x 106 /ml. Motility must be >50% forward and 25% with rapid linear progress, morphology >15% normal and >50% alive. Negative antisperm antibodies and a white cell count of < 1 x 106 /ml must also be observed. Because spermatogenesis takes about three months to complete, sperm counts vary considerably and in the presence of an abnormal result, a second count should be performed approximately three months later. (Drife & Magowan, 2004). Tests of sperm function may be
21 conducted via the postcoital test, or through the penetration test into cervical mucus substitutes. Yet another test is to test the sperm’s ability to swim through a physiological culture medium (Ransom & McNeeley, 1997).
The Friberg micro tray agglutination test (TAT) is a test used to detect spermagglutinating antibodies. This is observed when washed motile spermatozoa from a normal control donor, agglutinate due to the exposure to serial dilutions of test body fluid (Mortimer, 1994). This test is used to ascertain whether agglutination due to antisperm antibodies is causing a couple’s infertility.
Mid-luteal phase progesterone levels (between seven and ten days before the next menstrual period of a normal cycle) are the most commonly used investigation to indicate that ovulation has occurred. A luteal phase progesterone value of greater than 28 nmol/l is generally regarded as evidence of satisfactory ovulation. Other tests for ovulation include serial ultrasound scans to monitor the growth and subsequent disappearance of a Graafian follicle.
The postcoital test involves asking the couple to have sexual intercourse at the woman’s mid-cycle, and then six to twelve hours later a sample of endocervical mucus is tested for the presence or absence of sperm (Ransom & McNeeley, 1997). Mixed agglutination reaction (MAR) tests, and the immunobead test may be used to test antibodies against sperm (Harkness, 1992).
Tests for tubal patency may be conducted with diagnostic laparoscopy, which is the standard investigation as it provides a direct view of the pelvic organs. Methylthioninium chloride (methylene blue) dye is inserted through a cannula in the cervix to demonstrate tubal patency.
Hysterosalpingography (HSG) involves inserting an instrument, with a watertight seal, into the cervix and passing a radio-opaque fluid into the uterine cavity and fallopian tubes thus demonstrating their outline. This is performed under X-ray and the result may be confirmed by laparoscopy.
Salpingoscopy is a more detailed investigation of the interior of the fallopian tubes. A fine telescope, a salpingoscope, is passed down an operating laparoscope and inserted into the ampullary portion of the fallopian tube. This may show fine intratubal adhesions which may be found in 50% of patients.
Falloscopy is conducted by inserting a very fine instrument with a diameter of less than 1mm into
22 the fallopian tube via the uterine cavity. This procedure is effective in detecting tubal pathology but is mainly used as a tool in research.
Hysterosalpingo-contrast sonography (HyCoSy) is a technique which involves using a standard pelvic ultrasound scan at which galactose-containing ultrasound contrast medium is inserted into the uterine cavity, outlining any abnormalities such as submucosal fibroids and endometrial polyps. It then passes down the fallopian tubes to confirm tubal patency (Drife & Magowan, 2004).
Additional investigations for female patients include a pelvic ultrasound scan for ovarian morphology and uterine abnormalities, prolactin and thyroid function tests as well as testosterone and sex hormone binding globulin. In males, additional investigations include FSH, LH and testosterone in the event of a low sperm count. Transrectal ultrasound may also be used to determine any abnormalities of the seminal vesicles and prostate (Ransom & McNeeley, 1997).
Evaluating Anti-Müllerian hormone (AMH) levels in serum may be used in a quantitative investigation of ovarian reserve. AMH in the ovary has an inhibitory effect on the primordial follicle recruitment. The responsiveness of growing follicles to follicle stimulating hormone is also affected by AMH. Serum levels of AMH decrease with age and correlate with the number of antral follicles. This suggests that AMH levels reflect the size of the primordial follicle pool. In this way evaluating AMH levels is a good diagnostic tool for assessing ovarian dysfunction (Visser et al, 2006).
2.7 CAUSES OF INFERTILITY
Infertility may be due to specific male and/or female factors, however, often the cause is multifactorial or remains unexplained (Carlson et al, 2002). Causes for infertility vary between countries as well as within countries. Estimates made by the primary health care sector show that infertility is caused by ovulatory failure in 26% of cases, male infertility in 20% of cases and 14% due to tubal damage. Endometriosis may be the cause of infertility in 5% of cases while a diagnosis of unexplained infertility is given in 30% of cases. The remaining 5% may be multifactorial or due to other causes (Manassiev & Whitehead, 2003). The causes of female infertility include vaginal, cervical, uterine, tubal, ovarian, endocrine, unexplained, as well as social and behavioural factors.
23 2.7.1 Female Causes of Infertility
2.7.1.1 Vaginal factors
Factors such as partial or complete vaginal atresia, narrow introitus or transverse vaginal septa affect the individual’s ability to conceive. Vaginal atresia is the incomplete formation of the vagina which makes penetration, deposition of sperm and ultimately conception very difficult. Other vaginal causes include vaginal stenosis and vaginismus which similarly make penetration and ultimately conception difficult to achieve (Kandpal et al, 2004; Beers et al, 2006).
Infectious vaginitis also affects a couple’s ability to conceive. This is because the bacterial or fungal pathogens change the pH of the vagina resulting in a spermicidal action on the male partner’s sperm (Beers et al, 2006).
2.7.1.2 Cervical factors
An elongation of the cervical canal or obstruction of this canal affects fertility as the transportation of sperm through the cervix is prevented. The presence of antisperm, or sperm immobilizing antibodies in the cervical mucus prevent the penetration of sperm or the migration of sperm through the female reproductive tract. It may also interfere with the sperm-oocyte interaction (Kandpal et al, 2004; Ransom & McNeeley, 1997). Abnormal cervical mucus contributes to infertility as it is impenetrable during the time of ovulation while chronic cervicitis and cervical stenosis also cause poor penetration of sperm (Beers et al, 2006).
2.7.1.3 Uterine factors
Uterine hyperplasia and congenital malformation of the uterus contribute to a diagnosis of infertility. Uterine fibroids causing distortion of the uterine cavity also play a role in a diagnosis of infertility as they prevent pregnancy, while during pregnancy they may cause recurrent miscarriage or premature contractions.
Asherman’s syndrome, a condition which is characterised by amenorrhoea secondary to the formation of endometrial synechiae prevents implantation during fertilization. This is as a result of trauma to the endometrium due to vigorous curettage during procedures such as abortion.
24 Uterine prolapse, or descent of the uterus toward or past the introitus as well as adenomyosis affects the ability to conceive and maintain pregnancy (Kandpal et al, 2004; Beer et al, 2006).
According to the American Fertility Society scoring system, endometriosis may be categorised as minimal, mild, moderate or severe. Moderate and severe endometriosis impair fertility by interfering with ovulation, ovum pick-up by the fimbria, and by distorting tubal and pelvic anatomy (Manassiev & Whitehead, 2003). In a study analysing the possible correlation between tampon use in women with endometriosis it was found that a possible link exists. The rates of tampon use for individuals with endometriosis were seventy-five to eighty-three percent (Lamb & Berg, 1985). Teague (2006) explains that the use of tampons predisposes females to endometriosis which ultimately results in their infertility.
2.7.1.4 Tubal factors
Tubal infertility may be caused by sexually transmitted diseases, pelvic inflammatory disease, endometriosis, intraligamentous fibroids, obstruction due to infection or mechanical compression and ovarian or fimbrial cysts or previous abdominal surgery. These conditions ultimately result in occlusion of the tubes. Occlusion of the fallopian tubes, impaired tubal motility and loss of cilia prevent the transportation of the ovum and sperm.
Peritubal adhesions also prevent the union of sperm and ovum. Fertility may also be affected by salpingitis as well as by congenital tubal defects (Kandpal et al, 2004; Beer et al, 2006; Ransom & McNeeley, 1997).
2.7.1.5 Ovarian factors
Anovulatory cycles make fertilization unlikely as ovulation is abnormal, irregular or absent. Chronic oophoritis, ovarian tumours and cysts also affects a couple’s ability to fall pregnant as ovulation becomes irregular or absent. Decreased ovarian reserve is a decrease in the quantity or quality of oocytes which leads to impaired fertility.
Polycystic Ovarian Syndrome is characterised as a combination of a history of chronic anovulation, excess androgens as well as multiple subcortical ovarian cysts. These negative findings affect fertility. Similarly, chocolate cysts or ovarian endometrial cysts may prevent fertilization (Kandpal et al, 2004; Beers et al, 2006; Manassiev & Whitehead, 2003; Gold & Josimovich, 1980).
25 2.7.1.6 Endocrine factors
Thyroid disturbances such as hypothyroidism and hyperthyroidism can prevent pregnancy because thyrotrophin-releasing hormone stimulates prolactin secretion which may result in amenorrhoea. Hypogonadotrophic amenorrhoea is frequently associated with stress both physically and emotionally as well as changes in body weight. This stress and change in body weight results in suppression of the hypothalamo-pituitary-ovarian axis and subsequent amenorrhoea and anovulation.
Hyperprolactinaemia, a pituitary disorder, is characterised by high prolactin levels which suppresses ovarian activity by interfering with the release of gonadotrophins. This may be caused by pituitary adenomas, primary hypothyroidism, chronic renal failure, drugs, Polycystic Ovarian Syndrome or may be idiopathic.
Corpus luteum insufficiency resulting in low progesterone levels also result in infertility. Frohlich’s syndrome, a hypothalamic disorder, is characterised by amenorrhoea which decreases fertility (Kandpal et al, 2004; Gold & Josimovich, 1980; Ransom & McNeeley, 1997).
Haemochromatosis may be a cause of infertility in both males and females. This is because of iron deposition in the pituitary gland or the gonads which leads to hypogonadism (Tweed & Roland, 1998).
Preliminary data on reproductive problems associated with toxic chemicals supports the fact that fertility is decreased. Fertility is negatively impacted due to prolonged exposure to wood preservatives. This is because endocrine and immunological disorders may be induced in women (Gerhard et al, 1991). This was explained by Gerhard et al (2002) to be because the preservatives act on a hypothalamic level, resulting in mild ovarian and adrenal insufficiency.
2.7.1.7 Unexplained infertility
Unexplained infertility is diagnosed when the routine investigation of semen analysis, tubal patency and assessment of ovulation show no abnormality and the couple have engaged in regular sexual intercourse. It is generally regarded as a diagnosis of exclusion. The diagnosis of unexplained infertility may also be given in the event that a previously identified cause of infertility has been corrected, yet infertility persists (Behrman et al, 1988). However, Barad and Gleicher (2006),
26 maintain that unexplained infertility may be the result of multiple minor aberrations in how the couple’s respective reproductive systems cooperate. They suggest that diagnostic techniques should become more sensitive so as to detect even subtle and multifactorial abnormalities in the reproductive process.
According to Collins & Rowe (1989) the longer the infertility the less likely the couple is to conceive on their own. Thus after five years of infertility, a couple with unexplained infertility has less than a 10% chance of success on their own. A study conducted on couples with unexplained infertility, who had been trying to conceive for over three years on their own, showed that the cumulative pregnancy rate after twenty-four months of attempts at conception, without any treatment, was 28%. This percentage was found to be reduced by 10% for each year that the female was over thirty-one years of age. (Collins & Rowe, 1989).
In a study conducted in Turkey, patients with unexplained infertility underwent induced ovulation so that in vitro fertilisation and embryo transfer could be performed. After βhCG injection and follicular aspiration, apoptosis, or programmed cell death, of the granulosa cells was assessed using the in situ DNA nick end labelling method. The apoptosis rate was further determined by flow cytometry and these rates were compared to those of a control group. It was found that apoptosis rates were significantly higher in the unexplained infertility group (33.20 ± 35.62% versus 10.10 ± 17.23%). Thus, Ídil et al (2003) state, that abnormal granulosa cell apoptosis may play a role in the aetiology of unexplained infertility.
Another study conducted in the United Kingdom on ten women with unexplained infertility showed that these women have a genetic susceptibility to failure of embryo implantation. This group of women were compared to a control group of ten fertile women. It was discovered to be because of a smaller MUC 1 allele size in the women with unexplained infertility when compared to the control group. The MUC 1 mucin is an oxygen-glucosylated epithelial glycoprotein which could potentially modulate embryo attachment. Because of this, Horne et al (2001) states that women with unexplained infertility may in fact have an innate susceptibility to implantation failure.
2.7.1.8 Other Female Related Factors
Diet and the use of drugs, alcohol and tobacco can have a negative affect on the female reproductive system. Hypertensive medication, steroids, antidepressants and recreational drugs such as cocaine, heroin and ecstasy can cause long-term damage to reproductive organs. Women consuming more
27 than six alcoholic beverages per day are more likely to suffer from hormonal imbalances which effect ovulation. Cigarette smoking and tobacco chewing have both been related to fertility problems. Women who smoke can suffer from reduced ovarian reserve and chromosomal abnormalities of the ovum, and are at risk of miscarriage or stillbirth (Tucker, 1997).
The Oxford Family Planning Association Study demonstrated that the incidence of infertility in women increased with the number of cigarettes smoked. It has been reported that nicotine in tobacco affects fallopian tube peristalsis and motility. There is also an association between tobacco use and the finding of chlamydia in cervical cultures, thereby increasing the risk for fallopian tube disease and ectopic pregnancy.
A study conducted on exposure of rodents in utero to a class of compounds found in cigarette smoke (polycyclic aromatic hydrocarbons) showed that foetal ovaries were destroyed. This thus leads to early reproductive failure in these animals. It is therefore possible that maternal smoking leads not only to tubal infertility but also to reduced fertility in female offspring (Ransom & McNeeley, 1997).
Weight plays an important role in the control of ovulation. This is because leptin, a serum hormone, is secreted by adipose tissues in proportion to total body lipid stores. The level of circulating leptin is directly proportional to the total amount of fat in the body. Leptin acts on hypothalamic neurons responsible for the secretion of gonadotropin-releasing hormone (GnRH). Substantial weight loss thus results in decreased leptin-secreting fat cells, and leads to the disappearance of the normal twenty-four hour secretory pattern of luteinizing hormone-releasing hormone (LHRH). This reverts the individual to nocturnal patterns seen in pubescent girls. The ovaries thus develop a multifollicular appearance which can be detected by ultrasound. Severe exercise can have the same effect by increasing muscle bulk and decreasing body fat (Drife & Magowan, 2004). At the other extreme it was found by Thomas et al (2004) that infertility was associated with elevated leptin levels in obese mice. The high leptin levels were associated with reduced leptin-signalling capacity, which thus contributed to the suppression of the reproductive axis. Studies in humans have shown that 30-47% of obese women will have irregular menstrual cycles. Thus the likelihood of irregular menstrual cycles increases in direct proportion to increases in weight (Gracia, 2006)
Excessive weight gain may also have an adverse effect on ovulation. The adipose tissue produces excess oestrogen from androgens and thus interferes with the normal feedback mechanism to the
28 pituitary gland (Drife & Magowan, 2004). This ultimately results in anovulatory cycles making conception impossible.
Stress has been found to cause intermittent hyperprolactinaemia. This is evident in women undergoing assisted conception. It has been postulated that the stress of infertility, the investigations and the treatment may in fact delay spontaneous conception (Gillies, 1991).
Some early studies have shown that focus on the goal of having a child may result in premature maturation of the eggs in the ovary. This resulted in subsequent release of eggs that were not ready for fertilisation thus making conception impossible (Menninger, 1939; Benedek & Rubenstein, 1939; Mayer, 1935).
Thompkins (1990) documented that fertility is negatively effected by electromagnetic field disturbances around the Earth. These disturbances interfere with normal human reproduction and result in reproductive problems and disturbances. Studies conducted on the effects of extremely low frequency magnetic fields on the fertility of male and female rats have shown that fertility was significantly reduced. It was found that the mean number of implantations and live births was significantly decreased (Al-Akhras et al, 2000).
2.7.2 Male Causes of Infertility
In male infertility, causes include defective spermatogenesis, obstruction in the efferent ducts, disorders of sperm motility and failure to deposit sperm high in the vagina.
2.7.2.1 Defective spermatogenesis
Spermatogenesis may be impaired by heat, endocrine or genetic disorders, drugs or toxins. This results in inadequate quantity or defective quality of sperm. This may be caused by congenital conditions such as cryptorchidism or testicular atresia. Testicular atresia occurs when one or both testes fail to descend into the scrotum leading to infertility as well as an association with an increased incidence of testicular carcinoma. Infections such as mumps may cause orchitis. In these conditions sperm count is reduced by systemic bacteria and/or viral infections, resulting in reduced fertility. Other infections such as syphilis, gonorrhoea and tuberculosis can similarly cause infertility.
29 Scrotal temperature may also rise in conditions such as variocele. This is characterised by a collection of large veins, usually in the left scrotum, and is associated with infertility. Other factors which raise scrotal temperature include the use of tight underwear, hot baths, and cycling or motorbike racing.
Endocrinal factors such as hypopituitarism (Hypogonadotrophic hypogonadism), thyroid dysfunction and adrenal hyperplasia also affect spermatogenesis. Fertility in males may also be affected by iatrogenic causes such as radiation, cytotoxic drugs and antihypertensives. Similarly anticonvulsants and antidepressants interfere with spermatogenesis (Kandpal et al, 2004; Beers et al, 2006; Patil & Deshpande, 2000).
2.7.2.2 Obstruction in the efferent ducts
Obstruction in the efferent ducts results in impaired sperm emission. Causes include retrograde ejaculation into the bladder due to diabetes, neurological dysfunction, retroperitoneal dissection and prostatectomy. Obstruction of the vas deference also effects fertility as deposition of sperm in the vagina becomes difficult or absent. Infections such as tuberculosis and gonorrhoea also cause obstruction of efferent ducts. Surgical trauma such as surgery for hernias, hydrocele and variocele may also result in obstruction (Kandpal et al, 2004; Beers et al, 2006).
2.7.2.3 Disorders of sperm motility
Sperm motility may be effected by a low fructose content of semen, high viscosity as well as high prostaglandin content of semen (Kandpal et al, 2004).
2.7.2.4 Failure to deposit sperm high in the vagina
Conditions such as hypospadias effect the ability to deposit sperm high up in the vagina. This is because hypospadias is caused by tubularisation and fusion of the urethral groove. The urethra thus opens onto the underside of the penile shaft. Congenital bilateral absence of the vas deferens and epididymis due to cystic fibrosis also poses a problem as far as deposition is concerned.
Impotence and ejaculatory defects such as premature ejaculation also result in failure to deposit sperm high in the vagina (Kandpal et al, 2004; Beers et al, 2006).
30 Peyronie’s disease is another condition which has a negative effect on fertility. It is characterised by the development of fibrous plaques in the substance of the penis. This causes difficulty in maintaining an erection as well as difficulty in vaginal penetration. Pain and bending or deformity of the erect penis is also noted in this disease (Levine, 2006).
2.7.2.5 Other Male Related Factors
As with female individuals, diet and the use of drugs, alcohol and tobacco can have a negative effect on the male’s reproductive system. Hypertensive medication, steroids, antidepressants and recreational drugs such as cocaine, heroin and ecstasy may also cause long-term damage to the reproductive organs of males. Anabolic steroid use results in hypogonadotropic hypogonadism which results in infertility. Men consuming more than six alcoholic beverages per day are more likely to suffer from hormonal imbalances which effect the formation of sperm. This is because of a reduced serum testosterone level and may also be caused by marijuana use. Cigarette smoking and tobacco chewing have both been related to fertility problems. Men who smoke may have low sperm counts and poor sperm motility. It has also been found that impairment of sperm density and morphology may be observed in male smokers (Tucker, 1997; Ransom & McNeeley, 1997).
The use of lubricants such as K-Y jelly, Keri lotion, Lubrifax and saliva have a negative impact on fertility as these have been reported to effect sperm motility in vitro and thus diminish sperm function (Ransom & McNeeley, 1997).
Prolonged exposure to radiation, trauma to the testes or vas deferens, testicular sarcoma and chromosomal abnormalities such as Klinefelter’s syndrome effect male fertility and prevent conception (Patil & Deshpande, 2000).
Coital frequency is essential in couples trying to fall pregnant. Macleod and Gold (1953) found that couples who engaged in sexual intercourse more than three times a week were more likely to conceive within six months than couples who had a lower coital frequency. This is because when coital frequency is optimal, sperm is present in the fallopian tubes at the time of ovulation. This ultimately enhances the chances of conception.
Associated with coital frequency, it has been found that decreasing the number of exposures per week decreases male fertility (Stanton & Dunkel-Schetter, 1991). Other factors which contribute to a couple’s fertility include dyspareunia and apareunia (Patil & Deshpande, 2000).
31 2.8 PSYCHOLOGICAL IMPLICATIONS OF INFERTILITY
Clause twenty-six of the World Health Organisation states that infertility is a disease that has ramifications in terms of psychological trauma to couples. Infertile couples may pass through a series of phases including disbelief, denial, frustration, anger, grief and hopefully eventual acceptance. For those who choose fertility treatment the financial implications increase stresses they are already experiencing (Burt & Hendrick, 2005).
The effects of infertility that are mentioned most frequently in descriptive literature include emotional reactions, feelings of loss of control, affects on self-esteem, identity and beliefs as well as on social relationships.
When considering the emotional reactions of couples, five emotional responses are recurrent. These include grief and depression, anger, guilt, shock or denial and anxiety. Menning (1980) and Mahlstedt (1985) found that the most common reactions observed in individuals after a diagnosis of infertility were depression and grief. Feelings of anger may be directed toward their spouse, family, friends, doctors or society. Feelings of guilt may be because of prior sexual practices, contraceptive methods, poor life-style habits or because of prior delays at attempts at conception.
Loss of control may be felt in the couple’s or individual’s inability to control events that are current. This includes a loss of one’s daily activities and bodily functions. Loss of control of the future, specifically the ability to predict or plan ahead, are expressions of this feeling. The inability to meet life goals also contributes to the feelings of loss of control. Couples undergoing treatment may also feel that they lose control over their sexual relationship and privacy. This is because they must report details to their physicians and timed intercourse is required. Career progress, promotions or relocations are also influenced by a diagnosis of infertility (Stanton & Dunkel-Schetter, 1991).
The effects on self-esteem, identity and beliefs are marked. Extended infertility produces identity changes or changes in self concept resulting in the questioning of gender identity. Their specific identities as spouses or parents are challenged and negative body images may be held by infertile individuals (Anderson et al, 2003). Included in this are high levels of psychological distress, dysphoria and a decline in sexual functioning as well as an obsession about fertility with a lack of interest in other issues (Burt & Hendrick, 2005).
Socially, the effects of infertility challenge marital interactions and satisfaction. This may be
32 reported as positive or negative. Negative reports include hostility or blaming of their spouse, lack of spousal understanding or emotional support, or a lack of commitment from their spouse. Fears of abandonment or break-up may also be felt. Positive reports include a feeling of closeness, love and support from their partners. Sexual functioning may also be effected due to a loss of sexual desire, pleasure or spontaneity. Difficult social interactions, changes in relationships with network members, loneliness and embarrassment have also been reported. Feelings of jealousy, rivalry, resentment, and envy may also be felt toward people with children (Stanton & Dunkel-Schetter, 1991).
A study conducted in Germany aimed at the identification of psychological characteristic differences between couples with unexplained infertility and a representative sample. A total of five hundred and sixty-four couples were required to complete a psychological questionnaire pertaining to sociodemographic factors, motives for wanting a child, dimensions of life satisfaction and couple relationships, physical and psychic complaints as well as personality.
Of the five hundred and sixty-four couples, 27% (one hundred and forty) presented with unexplained infertility. The results showed that there were no remarkable differences in the psychological variables between infertile couples and the representative sample. The only exception was that the women in the unexplained infertility group had higher scores of depression and anxiety. They also showed a greater dissatisfaction with self and their life styles compared with the women in other groups. The women diagnosed with unexplained infertility also showed emotional instability and difficulty accepting their role as a woman.
The unexplained infertility group showed a higher level of education. It was established through the questionnaires that the couples with unexplained infertility set out to realise their desire for a child later on in life. Hence there may be a correlation between levels of education, age and infertility.
The study showed that infertility is more stressful for women than for men. Some 82% of women and 75.1% of men were favourably disposed to treatment by means of naturopathy, acupuncture and homoeopathy (Wischmann et al, 2001).
A qualitative study on the transition to biological childlessness of infertile women showed that nine common phenomenological themes may be identified. The sample group comprised thirty-seven white women. They were educated, middle to upper income women between the ages of twenty- five and forty-four years. They had been attempting conception for between two to fifteen years.
33
The first theme was a sense of futility in continuing to pursue solutions to their infertility. The second theme was a sense of physical, emotional and spiritual depletion while the third theme was a profound sense of loss and grief. The fourth theme that was noted was the sense of emptiness and missed experience and the fifth theme a sense of marginalisation and envy. In the sixth theme these women expressed a desire for closure while the seventh theme showed a need to redefine themselves and the future. The eighth theme showed a need for acceptance and support from significant others, while the ninth and final theme was a sense of relief at taking back their lives (Daniluk, 1996).
Domar et al (1992) explain that women who have been diagnosed as infertile are twice as likely to be depressed as a control group. This depression typically peaks about two years after these women start trying to conceive. Even though infertility is not life-threatening, infertile women have depression scores that are indistinguishable from women with cancer, heart disease or HIV (Human immunodeficiency virus) (Domar et al, 1993).
A comparison between data of infertile couples from the Western world suggests greater emotional distress in infertile men and women in South Africa. This was noted when South African infertile couples were compared with infertile couples living in developed countries. The reason for their higher level of emotional distress was deduced to be because of the negative impact on psychological well-being and their social status, as well as the cultural consequences of their infertility (Dryer et al, 2002).
A study at Harvard Medical School comprising one hundred and eighty-four women was conducted on the impact of psychological interventions on women experiencing infertility. The study found that the ten week course on relaxation training, cognitive restructuring and stress reduction had a positive effect on the individual’s ability to conceive. Statistically significant differences were noted between participants in different groups. Thus group psychological interventions lead to increased pregnancy rates in infertile women (Domar et al, 2000)
2.9 TREATMENT
If no cause for infertility can be found, first-line treatment for the female partner is oral Clomiphene Citrate. Clomiphene, commonly known as “Clomid®,” is a combination of a strong antioestrogen and a weak oestrogen which works at the level of the hypothalamus. It displaces oestrogen from the
34 hypothalamic receptor sites thus removing the negative feedback mechanism and increasing the GnRH secretions. It thus neutralizes the suppressant effect of oestrogens on FSH thus stimulating ovulation (Dreyer, 2005; Slade et al, 1993).
Clomid® is generally given during days two to six of the menstrual cycle and is administered at a dose beginning at 50mg daily to a maximum of 200mg/day (Drife & Magowan, 2004; Slade et al, 1993). The increase from 50mg to 200mg occurs by an increase of 50mg every two cycles until the maximum of 200mg is reached. Clomid® is continued for five days after bleeding has commenced. Ovulation usually occurs five to ten days after the last day of Clomid®. If ovulation occurs, menses follow within thirty-five days of the prior bleeding episode (Beers et al, 2006).
Clomid® is commonly given for up to six menstrual cycles in the United States of America. However the improvement in pregnancy rates is questionable. Statistically the likelihood of conception diminishes with each succeeding course of treatment (Drife & Magowan, 2004). Side effects of Clomid® include abdominal discomfort; ovarian hyperstimulation syndrome (OHSS); hot flushes; blurring and other visual symptoms such as, spots or flashes, double vision, intolerance to light, decreased visual sharpness, loss of peripheral vision, and distortion of space; headaches; mood changes; severe pelvic pain; nausea; vomiting; weight gain; diarrhoea; difficult or laboured breathing; and reduced urine production (Nashed, 1990). Vaginal dryness, breast tenderness, ovarian cysts and rashes are other reported side effects (Beers et al, 2006; Slade et al, 1993).
Prolonged use of Clomid®, as well as other fertility drugs, have been noted to markedly increase the risk of ovarian cancer (Kahlenborn, 2004). Whittemore et al (1992), found that women who used fertility drugs and who did not fall pregnant had an increased risk in developing ovarian cancer when compared with women who never took fertility drugs.
Clomid® treatment also increases the risk of multiple births (Carlson et al, 2002). Increased birth defects have been reported following treatment to induce ovulation with Clomid® (Nashed, 1990). Other drugs which may be used in cases of infertility include Tamoxifen® which is a drug is similar to Clomid®. It is used when individuals are unable to tolerate Clomid®. It is administered at a dose of 20mg/day for five days. Cyclofenil® is yet another drug which may be used in infertility but is not an antioestrogen. It increases FSH levels and enhances the production of a thin watery cervical mucus. This favours sperm transportation through the cervix. This is a well-recognised drawback of Clomid® as cervical mucus becomes impenetrable while using Clomid® (Slade et al, 1993). Pergonal® is an extremely potent drug that is usually prescribed when Clomid® does not work. This is human menopausal gonadotrophin (hMG) with each ampoule containing 75IU of LH activity and 75IU of FSH activity. It is usually used for the assisted technologies of IVF, GIFT and
35 ZIFT. The two major side effects of Pergonal® are ovarian hyperstimulation and multiple pregnancies (30%), while the abortion rate (10%) and still birth rate (28%) are also high (Slade et al, 1993; Weschler, 2003).
In the event that drug treatment fails, the only alternative is assisted conception including superovulation with intrauterine insemination, in vitro fertilization, gamete intrafallopian-tubal transfer, zygote intrafallopian-tubal transfer, and intracytoplasmic sperm injection. All of the above mentioned assisted conception techniques, although effective for unexplained infertility, have disadvantages and risks (Drife & Magowan, 2004).
Artificial insemination (AI) or intrauterine insemination (IUI) is the process by which sperm is inserted by syringe or catheter into a woman’s vagina or uterus at the time of ovulation. This process may use the male partner’s sperm or donor sperm. This technique is favourable in cases where couples experience low sperm count, poor sperm motility, sperm antibodies or unexplained infertility (Harkness, 1992). IUI therapy has a small effect on conception rates. This is noted in two well conducted trials which reported a conception rate of 5-7% or one additional pregnancy in twenty to twenty-five IUI cycles compared with control cycles (Manassiev & Whitehead, 2003). However, according to Keck et al (1998), intrauterine insemination is still effective as first line treatment for couples with unexplained infertility.
In vitro fertilisation (IVF) is the combined procedure of stimulation of follicle growth and maturation, follicle puncture and oocyte capture, insemination in vitro, and placement of the conceptus directly into the uterine cavity. It is the treatment of choice if ovarian stimulation and IUI do not result in pregnancy after three to six cycles. Pregnancy rates in excess of 20% have been reported per transfer, however, live birth rates seldom exceed 15% (Robin & Collins, 1991). Some in vitro fertilisation programmes have reported lower fertilisation rates for couples with unexplained infertility than in those with obstructive infertility (Burslem & Osborn, 1986).
In intracytoplasmic sperm injection (ICSI), sperm is introduced into the cytoplasm of the egg. This process bypasses all natural sperm selection and quality control systems in the female genital tract. ICSI also damages the oocyte during injection resulting in cell degeneration. This method is used in cases of male infertility, however, children born via ICSI may be premature and male offspring may inherit some or all of the factors that led to the father’s infertility (Manassiev & Whitehead, 2003).
Gamete intrafallopian-tubal transfer (GIFT) and zygote intrafallopian-tubal transfer (ZIFT) are the
36 technologies of choice in cases of male infertility, sperm antibodies, cervical mucus problems and especially in cases of unexplained infertility. These technologies parallel the IVF process in duration and initially in procedure. With GIFT, the egg and sperm are not fertilized in the laboratory. Rather up to four oocytes are combined with sperm and injected by catheter into the fallopian tube(s) during laparoscopy. With ZIFT, follicles are removed from the female via vaginal aspiration, fertilized and incubated in the laboratory. Viable embryos are then transferred the next day into the fallopian tube(s) by laparoscopy. Some studies show that treatment with GIFT leads to pregnancy in over 15% of cases. This technique is invasive, requires general anaesthesia and the costs involved are similar to IVF (Manassiev & Whitehead, 2003).
Assisted reproductive technologies increase the probability of multiple gestation to about 25% and there is also a 6% chance of severe ovarian hyperstimulation syndrome which is a potentially life threatening complication (Burt & Hendrick, 2005). In a study of registry data for births over a four year period in Australia, it was found that infants conceived with assisted reproductive technology may be more than twice as likely as naturally conceived infants to have both major birth defects as well as multiple major defects (Hansen et al, 2002). Other long term effects to the offspring remain unknown as the first in vitro birth only occurred in 1978, while Clomid® has only been in use since 1960 (Oehninger, 2006).
Personal communications with fertility labs regarding costs for assisted reproductive technologies, namely Medfem Clinic, Vitalab, C.A.R.E. Clinic and Kloof Fertility labs revealed costs per attempt. According to the above mentioned labs, the costs per attempt of artificial insemination falls between R3500-R7000 depending on the use of donor sperm. The costs per attempt of in vitro fertilization, falls between R25 000-R60 000. This includes doctor’s fees and lab work as well as medication. Special investigations such as laparoscopy, hysteroscopy, hysterosalpingography and more specialised investigations are not included. Fertility treatment by ICSI, GIFT or ZIFT has been quoted to be within the same ranges as those for in vitro fertilisation (Pentz & Hogewind, 2009; Van Schouwenburg et al, 2009; Ramdeo & Naidoo, 2009; Jacobson et al, 2009 ).
2.10 HOMOEOPATHY
2.10.1 The Definition of Homoeopathy
Homoeopathy is a system of medicine whose aim is to cure an illness or disorder by treating the whole individual. The German physician, Dr. Samuel Hahnemann, founded this system of medicine
37 known as Homoeopathy. The word Homoeopathy comes from the Greek terms ‘homoios’ and ‘pathos’ meaning ‘similar suffering’ respectively. Hence, the fundamental concept of Homoeopathy is ‘similia similibus curentur’ or to cure like with like (Danciger, 1987).
Classical homoeopathy looks at the whole person in terms of their mental, emotional and physical states. Homoeopathy stimulates the body’s own healing mechanism to reinstate health and well- being in the diseased or disordered individual using medicines which match the diseased state (Vithoulkas, 2002; Treacher, 2000).
2.10.2 The Principles of Homoeopathy
The Law of Similars
The basis and foundation of homoeopathy and the prescription of a homoeopathic remedy is based on the Law of Similars (Vithoulkas, 2002). This law of treating by similars is an ancient philosophy that can be traced back to the 5th century BC, when it was formulated by Hippocrates and then later used by Dr Samuel Hahnemann (De Schepper, 2006).
The Law of Similars involves treating a patient’s symptoms with minute amounts of the substance that would cause similar symptoms in a healthy person (Bloch & Lewis, 2003). This law was discovered when Dr. Samuel Hahnemann ingested crude doses of Peruvian bark for several days. At the time, Hahnemann had successfully treated malaria with quinine, which was derived from Peruvian bark. He noticed that he produced in himself all the symptoms of malaria after the ingestion of the Peruvian bark. After he stopped ingesting the Peruvian bark he noticed that the malaria-like symptoms he had experienced disappeared. He described this phenomenon as the Law of Similars (Rowlands, 1997; De Schepper, 2006).
Provings
After ingesting Peruvian bark himself and developing malaria-like symptoms, Dr. Samuel Hahnemann began to conduct other trials using single medicines on healthy individuals. This process became known as a proving.
Dr. Samuel Hahnemann performed more than 100 provings on himself and thus played a huge role in the development of the Homoeopathic Materia Medica that is used today (De Schepper, 2006). It
38 was stated by Hahnemann that “there is no other possible way in which the peculiar effects of medicines on the health of the individuals can be accurately ascertained than to administer the several medicines experimentally, in moderate doses, to healthy persons, in order to ascertain what changes, symptoms and signs of their influence each individually produces on the health of the body and of the mind…” (Hahnemann, 2003).
The Single Remedy
De Schepper (2006) explains that the classical homoeopath administers one remedy at a time. Hahnemann states “In no case under treatment is it necessary and therefore it is not permissible to administer to a patient more than one single simple medicinal substance at one time” (Hahnemann, 2003). This is advisable, as the administration of more than one remedy at a time may result in difficulty distinguishing the effects of individual remedies as well as interfering effects of other substances. Each remedy has its own rhythm, hence two or more remedies with separate rhythms may create disharmony (De Schepper, 2006).
The Minimum Dose
When the dosage of medication is increased, a strong physiological response is produced along with uncomfortable reactions. Hahnemann was aware of this unnecessary strain that was placed on the patient’s body which was already weakened by disease. He discovered that by diluting the raw material he actually increased the medicinal qualities while reducing the negative side effects or aggravations of those crude doses. Because there is no residue left in the body because of the high dilutions of the remedy, no adverse reactions are experienced.
For this reason Hahnemann believed that the smallest dose that causes enough of a reaction in the diseased patient should be used for the restoration of health (Hahnemann, 2003).
Potentisation
Potentisation is the step by step dilution and rhythmic shaking, termed succussion, of drugs which brings out the latent medicinal energy of the substance. In performing this process the toxicity of the drug is minimised while the therapeutic effects of the substance is enhanced (Sankaran, 1995). Different scales of potency are currently used. These include the decimal scale (1/10), centesimal scale (1/100) or the fifty-millesimal scale (1/50 000). These scales are designated “X” or “D”, “C”
39 or “cH”, and “LM” respectively.
Hering’s Law of Cure
According to Hering’s Law, when curing disease, symptoms move in four characteristic directions. The first is from the interior to the exterior. In this way the disease is driven out of the body to the surface. The second is from above to below. This occurs when an ailment presents high up on the body, and as healing progresses it moves lower down on the body. The third is when disease moves from the most vital organs to less vital organs. The fourth is when symptoms return in reverse order of appearance. The last symptoms to appear are the first symptoms to disappear, and old symptoms return in a reverse chronological order (De Schepper, 2006).
Holism
In classical homoeopathy the human being is described as consisting of three levels - the mental, emotional and physical levels (Vithoulkas, 2002). Vithoulkas’ representation of this hierarchy shows that the mental sphere is the most central and important of the three. The physical sphere is the most peripheral and thus holds the least significance. There is no clear distinction between all three levels, but their presence allows for homoeopathic treatment of the individual to be more specific, as the remedy selection may encompass all aspects of the patient (Vithoulkas, 2002). Hence we see that holism refers to the patient as a whole entity which incorporates the mental, emotional and physical spheres (Roy, 1999; James, 2002).
2.10.3 Miasms
Hahnemann used the term ‘miasm’ in his theory of the origins of chronic disease (De Schepper, 2006). Vithoulkas (2002) describes miasms as a predisposition to chronic ailments. These predispositions may be transmissible from generation to generation. He goes on to explain that three major factors predispose the individual to weakness or chronic disease, namely hereditary influence, strong infectious disease and previous treatments or vaccinations. These states respond favourably to the prescription of the corresponding nosode which may be prepared from either the pathological tissue or from the relevant drug or vaccine (Vithoulkas, 2002).
40 2.10.4 The Vital Force
The vital force refers to the energy force within the body which allows for health and healing. In aphorisms nine and ten of the Organon, Hahnemann speaks of the vital force’s ability to animate, protect and maintain harmony in the body. Thus we see that when an individual is effected by disease, it is the vital force that resists it and attempts to restore order and health. It does this by repelling the morbific agent, provided that it is not stronger than the individual’s vital force (De Schepper, 2006; Hahnemann, 2003, Roberts, 1995), hence acting as the defence mechanism of the body (Vithoulkas, 2002).
Vithoulkas (2002) describes this defence mechanism as not only being limited to a physical level, but being present on a mental and emotional level as well. Thus its functioning is as a totality. Hence all regions of the organism are defended against the progression of disease.
2.10.5 Homoeopathic Method
2.10.5.1 Sources of remedies
Homoeopathy makes use of substances derived from the animal, plant and mineral kingdoms including medicinal drugs. Other substances, in addition to this, such as diseased products called nosodes, and healthy animal tissues and secretions called sarcodes are frequently used. Imponderable substances such as x-ray and electricity may also be used for their therapeutic benefits as well as neutral substances such as salt. Although toxic substances are sometimes used, the safety of the final remedies is ensured by the potentisation process (Sankaran, 1995; De Schepper, 2006).
2.10.5.2 Case Taking
Taking a case is the eliciting of reliable characteristic prescribing symptoms from a patient. The process involves obtaining objective and subjective symptoms. This allows for remedy and potency selection as well as the assessment of any need for other appropriate treatment. (Roy, 1999).
Precise information about each symptom volunteered by the individual should then be elicited. Modalities of time, temperature, duration, location, sensation, amelioration and aggravation should be noted in the patient’s own words (Hahnemann & Dudgeon, 2001).
41
Initial Consultation
During the first consultation the homoeopath should enquire about the individual’s main complaint and physical general symptoms. This includes the individual’s appetite and food cravings, aversions and aggravations, thirst, perspiration and sexual function. Energy levels, sleep, dreams and environmental preferences are other symptoms which the homoeopath would enquire about. A systemic review of all organs and functions, as well as the individual’s mental state, are important aspects of the initial consultation. The individual’s past medical history, family history, social history and habits are also regarded as important information (Gunavante, 1994; Jouanny, 1993).
Follow-up Consultation
The follow-up consultation is focused on interpreting the patient’s reaction to the carefully selected remedy given to him/her at the initial consultation. It is then determined if there was any response to the remedy whether it be curative, partial or suppressive. This allows for decisions to be made regarding repetition of the remedy or changing the potency of the remedy. During this time it should be assessed whether a new remedy is needed, a repeat of the previous script is required or if it would be beneficial to not give any prescription in order to allow the previous remedy time to act.
According to Vithoulkas (1993), the homoeopath should ask the following questions so as to investigate the individual’s response to the remedy:
• Was there a response to the remedy? • Was the response curative, partial or suppressive? • How does the patient feel in general? • Have any of the symptoms (mental, general or particular) discussed in the initial consultation improved, worsened or remained unchanged? • Have any new symptoms presented? • Is another prescription required? • Should the potency be changed or is it best to wait?
If no change was noticed one of four things are possible: Firstly, the wrong remedy may have been prescribed, the wrong potency may have been prescribed, obstacles to cure were present or the
42 change in the symptoms was so subtle that it went unnoticed by the patient or homoeopath (De Schepper, 2006; Vithoulkas, 1993).
2.10.5.3 Selecting a remedy
Selecting a remedy involves the matching of all the patient’s symptoms with a remedy symptom picture (Roy, 1999). Treatment with this method of remedy selection may be termed constitutional homoeopathic treatment, which consists of prescribing on the mental, emotional and physical symptoms as well as on the past history of that patient (Foubister, 2002). Patients with unexplained fertility have no pathological symptoms therefore the holistic case using individualised characteristic, peculiar, mental and general symptoms is especially suitable.
2.10.5.4 Selecting a potency
The selection of potency is a matter of experience and observation. The potency chosen depends on the reactivity of the vital force and may change with the choice of remedy. According to Allen (2001), any potency of the similimum remedy will work. This theory is opposed by Chatterjee (1993) who states that even the correct remedy will not cure unless administered in the correct potency.
Potency selection, based on the principle’s set out by De Schepper (2006) states that the major indications for potency selection are the “sensitivity of the patient, the nature of the disease and the nature of the remedy”.
The healthy vital force first produces physical symptoms which usually occur on the level of sensation or inflammation. In these cases the 6th potency is sufficient in causing a physiological response. The closer the organism approaches structural change, the lower the potency required. This is because the amount of action is limited and very slow. Similarly the 12th potency may be used.
The disturbance penetrates deeper if the vitality is weakened or the exciting cause is stronger. These situations include the general level and may involve a mild emotional state as well. The 30th potency would thus be used in these situations.
43 In cases where violent acutes and emotional turmoil are involved higher potencies are used, namely the 200th potency. In other words, when the physical symptoms present with much violence, and when strong emotions upset the body, one would use the 200th potency.
The 1M and 10M potencies may be considered in constitutional treatment. This is especially so where there is no pathological or structural problems in any part of the body (De Schepper, 2006).
2.10.5.5 Selecting the correct dosage and frequency of administration of the remedy
The dose refers to the amount of the remedy ingested at one time. With reference to the principle of the minimum dose, the smallest dose necessary to have a curative action should be given.
The potency of the remedy as well as the purpose, whether therapeutic or constitutional, determines the frequency at which the remedy is administered. The pace at which the remedy is used in the patient’s body, also determines the frequency of administration. This depends on the patient’s constitution, the strength of the vital force, the nature of the remedy and the presence or absence of maintaining causes (De Schepper, 2006).
2.10.6 Repertorisation
Repertorisation is an integral part of homoeopathy. This process makes use of cross referencing rubrics of symptoms containing lists of remedies in which the characteristic symptoms of a patient may be found. This allows for the prompt analysis of the remedies known to have produced the symptoms described by the patient. For this reason only the symptoms which are offered spontaneously, felt intensely or which are clear and unequivocal are used and thus ranked highly during repertorisation. Thereafter, remedies yielded by the repertorisation process can be studied in the materia medica so as to find the best suited remedy for the case, or the similimum (Gunavante, 1994; Vithoulkas, 1998).
2.10.7 Homoeopathic Side-Effects / Aggravations
An aggravation is an increase in the intensity of the presenting symptoms. This occurs because there is stimulation of the vital force (Roy, 1999). The true healing response is preceded by a homoeopathic aggravation which should not be considered harmful. This occurs because the defence mechanism reacts to the stimulus. The homoeopathic aggravation is considered an
44 encouraging sign that the remedy is working and that the patient is en route towards cure (Vithoulkas, 1998).
2.10.8 Case Management
Case management involves not only the prescribing the first remedy, but also the second prescription. When managing a case where the first prescription did not work, changing the prescription to a better suited remedy is still considered the first prescription. If the first prescription worked then the remedy selected thereafter is considered the second prescription (De Schepper, 2006).
According to Vithoulkas (1998), a basic sequence may be followed when gathering information, so as to make the second prescription:
• How does the patient feel in general? This involves the improvement or decline of the individual’s health. They may experience no change in general symptoms. • Has the degree of energy been affected? Included in this is the patient’s ability to cope with various life stresses. • Has any change occurred in the physical chief complaint and what was the pattern of change? • Have any changes occurred on the mental and emotional spheres? Because the mental and emotional spheres represent the core of the patient, even the slightest changes can signal important effects of the remedy. • A symptom by symptom review should be conducted so as to determine any improvement, decline or unchanged symptoms. Here, all the symptoms mentioned in the initial consultation should be covered. • Have any new symptoms presented since the last consultation? These ‘new’ symptoms may be the occurrence of symptoms from the past which are in accordance with Hering’s Law of Cure. • Patients should be encouraged to elaborate on any previously described symptoms. The purpose of this is for further penetration into the ‘essence’ of the case.
When considering the second prescription the following principles are crucial in the treatment of the individual:
45
1. Where the patient feels better within himself, no intervention is needed. 2. Unless the symptom picture has cleared completely, another remedy should not be given. 3. When previously experienced symptoms return, the advised route of management is to wait. 4. When general amelioration is accompanied by a skin eruption or discharge, a remedy should not be prescribed. This is known to occur as chronic cases or in individuals with strong defence mechanisms 5. If the symptoms are only mildly disturbing, another remedy is not required. 6. If symptoms are moving in accordance with Hering’s Law of Cure, another remedy should not be prescribed.
Once the reaction has started, any interference is likely to bring the progress of the remedy to a halt. In cases where there are doubts regarding the next step, it is advised to take time to watch and study the case first (Gunavante, 1994).
2.10.9 HOMOEOPATHY AND INFERTILITY
The aim of homoeopathic infertility treatment in the female is to restore optimum health and to address lifestyle issues affecting fertility. Included in this is the focus on achieving the highest level of fertility (Prinsloo, 2004).
According to Naished (2004), homoeopathic remedies can be profoundly effective in nearly all physical and emotional conditions. According to Naished (2004) and Prinsloo (2004), when treating infertility the exact, single remedy needs to be found for each individual case. In order to do this all aspects of the individual’s health needs to be considered and a detailed history, as well as investigations, needs to be conducted
Acording to Prinsloo (2004) the patient needs to consult with a homoeopath on a monthly basis. This should continue for the duration of treatment, atleast until conception can be confirmed by appropriate testing. Depending on complications and previous infertility treatment interventions, homoeopathic infertility treatment aims at success after four to six months. This may take longer as factors such as a history of multiple laparoscopies, hormonal treatment, in vitro fertilisation and a history of abortion and/or ectopic pregnancy prolong successful treatment. Previous medroxyprogesterone acetate injection treatment, endometriosis, candidiasis and frequent urinary tract infection also prolong the duration of successful infertility treatment. Other factors prolonging
46 the duration of treatment include ovarian cysts, anovulation and menorrhagia, which take longer to rectify.
Homoeopathy has also been described as an effective therapy in the successful treatment of stress associated with infertility. High levels of stress effect ovarian, tubal and other reproductive functions, such as hormone balance. Rectification of these stress levels improve the individual’s potential fertility and may ultimately contribute to conception (Naished, 2004; Weschler, 2003).
The cost of homoeopathic infertility treatment is dependent on the duration of treatment required. Complications caused by previous infertility treatment as well as the severity of the underlying problem determine the duration of treatment. Homoeopathic treatment is generally a fraction of the cost of conventional infertility treatment. It treats without negative damaging side-effects (Prinsloo, 2004). In a study conducted in Europe on the homoeopathic treatment of infertility, it was found that homoeopathic treatment was thirty times less expensive per successful delivery than the matched comparison group under conventional infertility treatment (Gerhard et al, 1991).
47 CHAPTER THREE
METHODOLOGY
3.1 STUDY DESIGN
This study was a qualitative study, and involved the individualised homoeopathic treatment of each of the participants. A total of eleven females were recruited by the researcher. Each participant was required to attend seven consultations over a six month period. Eight out of the eleven recruited participants completed the study.
Each participant had been previously diagnosed with either primary or secondary infertility of unknown cause by a qualified practitioner, or had undergone successful treatment and restoration of a previously diagnosed cause of infertility and they were now considered clear of pathology.
Owing to the complexity of the cases and evaluation of each participant, the sample size was kept at eleven participants. This was a suitable sample size as the study was a minor dissertation.
3.2 RECRUITMENT OF PARTICIPANTS
Posters (APPENDIX H) advertising the study were posted at clinics, health shops, pharmacies and in private practices to recruit volunteers. Volunteers were then made aware of the six month duration of the study. They were then required to complete a Participant Selection Questionnaire (APPENDIX B) with the assistance of the researcher. A total of eleven volunteers were selected to take part in the study according to the following criteria:
Inclusion Criteria: Subjects were females between the ages of eighteen and forty. Subjects had active menstrual cycles. Subjects were previously diagnosed with either primary or secondary infertility. Subjects experienced normal ovulation (pre-diagnosed). Subjects had normal pelvic structures. Pelvic health was good. Subjects had healthy lifestyles and eating habits.
48 Moderate exercise was required. The male partner was required to be free of all structural and functional pathology. Sperm analysis, focusing on motility, morphology and sperm function, was required to be within normal ranges.
Exclusion Criteria: The recent use of long-acting contraceptives A body mass index of abnormal range Current use of recreational drugs Social habits such as smoking and excessive alcohol intake Eating disorders Excessive exercising Use of herbal supplements Current utilisation of other homoeopathic remedies Current treatment by acupuncturist, reflexologist or herbalist Decreased oocyte quality or anovulatory cycles Polycystic Ovarian Syndrome Hyperandrogenism Hyperprolactinaemia Luteal phase deficiency Pelvic adhesions of any kind Hydrosalpinges Current illness of chlamydia or gonorrhoea Polymicrobial pelvic inflammatory disease Endometriosis Prior tubal sterilization Congenital uterine abnormalities Asherman’s syndrome (severely scarred endometrium) Exposure to DES (Diethylstillbestrol) in utero Fibroids Any pathology effecting tubal patency
Subjects were asked to stop therapies such as acupuncture, herbal remedies, reflexology and other homoeopathic treatment in order to participate in the study.
49 3.3 RESEARCH PROCEDURE
Volunteers were screened for suitability (APPENDIX B) by use of the Participant Selection Questionnaire. This questionnaire asked relevant questions which made it possible for the researcher to select participants based on the inclusion and exclusion criteria. On acceptance into the study, participants were required to read and complete an Information and Consent form (APPENDIX A) stating that their participation in the study was voluntary. The information and consent form also stated that participants could withdraw from the study at any time and that they consented to a physical examination.
The initial consultation took place immediately after selection. The initial consultation reviewed the basic steps required for pregnancy (APPENDIX C) and included a review on factors which effect fertility. A full case history (APPENDIX D) was then subsequently taken from each participant, recording mental, general and characteristic symptoms of the patient, and especially their female symptoms. A physical exam was also conducted.
After the initial consultation, the researcher analysed the history gathered from the participant holistically. Under the supervision of the research supervisor, an appropriate similimum remedy and potency was then selected. The participant was then given the remedy after the initial consultation. They were advised as to the correct dosage, and frequency of administration, as well as correct storage of the medication.
Participants were provided with an ovulation thermometer and instructions were provided on how to accurately utilise the thermometer. Participants were required to observe midcycle mucus changes as well as their daily basal body temperature, and to record these readings in the relevant recording charts (APPENDIX F), which were given to the participants at each consultation. A General Well-being Questionnaire (APPENDIX I) was given to each participant at each consultation. These were collected from participants at each consultation for analysis.
The second to seventh consultations took place at monthly intervals thereafter. At each consultation participants were required to complete a General Well-being Questionnaire and hand in recording charts of basal body temperature and midcycle mucus changes for the previous month. At each consultation a follow-up case history and focused physical examination was conducted. The case was evaluated and if the results were unsatisfactory the researcher changed the remedy, under the supervision of the research supervisor. Participants were, once again, advised on the dosage and
50 frequency of administration.
At the seventh and final consultation the researcher took a final follow-up case history, performed a physical examination, and collected recording charts and the General Well-being Questionnaire.
3.4 HOMOEOPATHIC MEDICATION AND TREATMENT PROTOCOL
Under the supervision of the research supervisor, the similimum remedy was given to each participant after the first consultation. The potency and frequency of administration of the remedy was selected according to each individual case. The remedies were dispensed in the form of powders and each participant was provided with enough medication to last until the next follow-up consultation. Remedy selection was re-evaluated after each consultation. If the remedy was found to be unsuitable, a new similimum was prescribed under the supervision of the research supervisor. Potency and frequency of administration were revised.
3.5 TOOLS UTILISED
3.5.1 Basal Body Temperature and Midcycle Mucus Changes Chart (APPENDIX F)
3.5.1.1 Basal body temperature
Basal body temperature reading is the method of measurement of body-at-rest temperature. Benefits of taking a basal body temperature every day include confirmation of ovulation, knowledge of when menstruation is about to commence and the identification of potential problems in the female’s cycle (Weschler, 2003).
At the initial consultation and at each follow up consultation, participants were given basal body temperature and midcycle mucus changes charts. Both temperature reading, and the time at which the temperature was taken were recorded in the appropriate section of the chart every day.
3.5.1.2 Ovulation thermometer
Each participant was provided with a glass basal body thermometer at the initial consultation. Glass basal body thermometers are considered the most reliable thermometers for detecting waking basal body temperature. In order to achieve an accurate reading a full five to ten minutes are required
51 when using the thermometer. The temperature readings of these thermometers are shown in increments of .1 as opposed to fever thermometers, whose increments are .2 (Naished, 2004).
Participants were instructed to take their temperature daily, in the morning on waking, before any other activity. The thermometer was to be placed orally and taken at about the same time every day. The glass basal body thermometer was to be shaken down before each temperature reading and left in the mouth for at least five minutes before reading and recording the temperature. The participants were also advised that the temperature be taken after at least three consecutive hours of sleep.
Participants were instructed that if the temperature fell between two numbers on the thermometer, the lowest temperature should always be recorded. Unusual events such as stress, illness or fever should also be noted (Bickley & Szilagyi, 2003).
3.5.1.3 Midcycle mucus changes
Observation of the changes in the mucus or cervical fluid is the most reliable and important method of assessing fertility. This is because the cervical mucus is adaptable in times of change (after childbirth, miscarriage, menstrual irregularities, menopause and amenorrhoea). This method is easily learnt by most women, is applicable under nearly all conditions, it requires no technology or apparatus, and is effective. A World Health Organisation survey, conducted in five countries including developing countries, demonstrated that over 90 per cent of women were able to return an interpretable chart of the changes in their cervical mucus by the end of their first cycle (Naished, 2004).
Cervical fluid was checked from the first day after menstruation had ended, until the first day of the following menstrual period. Mucus changes were checked throughout the day by wiping one’s finger tips at the opening of the vagina. The mucus quality and quantity was noted paying particular attention to the feel, colour, consistency and amount of mucus obtained. Once mucus had been obtained the participants were instructed to place two fingers together and then slowly open the fingers to observe whether the mucus stretched or not. If no mucus was noted at the vaginal opening, participants were instructed to check internally by using the index and middle fingers to draw out cervical fluid from the cervix itself (Weschler, 2003).
Using the key provided with each basal body temperature and midcycle mucus changes charts, participant’s recorded their daily mucus changes accordingly.
52
Table 3.1: A table of the mucus change ratings used by participants. Colour: 1-Clear 2-White 3-Yellow
Consistency: 1-Thick 2-Sticky 3-Stretchy (Egg white like)
Feel: 1-Dry 2-Wet 3-Sticky 4-Slippery
3.5.2 General Well-Being Questionnaire (APPENDIX G)
The General Well-being Questionnaire was initially designed to evaluate the psychiatric status of patient and was developed by Overall and Gorham (1962). It was then modified by Hachler (2008) to include questions pertaining to general physical health. This questionnaire can be administered rapidly and can be used to monitor any well-being changes in the patient.
Table 3.2: The 5 point scale used to grade the General Well-being Questionnaire. Measure Points Not present 5 Mild 4 Moderate 3 Moderate to severe 2 Severe 1 Extremely severe 0
The questionnaire consists of eight questions pertaining to the individual’s general health, the presence of illness, anxiety and depression over the last month and their energy level. Included in
53 this is their ability to perform everyday tasks and their level of happiness or worry throughout the month. Each question acts as a measure to their general well-being. Each measure was evaluated using a five point scale and is based on the seven point Likert Scale.
The minimum score that may be attained by the questionnaire is zero. The maximum score which may be attained is forty. Hence it may be interpreted that the lower the score the more severe the disorder or state in which the individual is in, while the higher the score, the greater the improvement in that individual. This scale shows good inter-rater reliability (Institute for Algorithmic Medicine; 2006-2007).
3.6 DATA ANALYSIS
An initial consultation allowed for the gathering of information which then aided the researcher in the selection of the similimum remedy for each participant. A placebo group was not included in this research. The justification for this is based on the complexity of each case and the improbability of being able to generate a comparable control group.
In addition to pregnancies achieved, other fertility parameters were assessed. At the initial consultation ovulation thermometers and basal body temperature and midcycle mucus changes charts where given to participants and instruction on their use was provided. Participants were also given General Well-being Questionnaires to complete before commencement of the consultation. At each follow up consultation the researcher collected General Well-being Questionnaires and basal body temperature and midcycle mucus change charts and re-evaluated the case history of each participant.
In total, seven General Well-being Questionnaires and full case histories as well as six basal body temperature and midcycle mucus charts were collected over the six month duration of the study. This data was used to determine each participant’s progress over the six month period. The results were analysed using case history analysis. No inferential statistics were used because of the nature of the study and the small size of the sample group. Graphs and frequencies were used to draw a conclusion. Statistical analysis as well as the graphs and frequencies were compiled by Statkon, University of Johannesburg.
54 CHAPTER FOUR
CASE DISCUSSION
4.1 CASE ONE
Age: 30 (1978) Gender: Female Race: Black Occupation: Housekeeper Marital Status: Married Weight: 66kg Height: 1,64m BMI: 24.1 Menarche: 15 years of age History of Pregnancy: One pregnancy and one still birth in 2004.
The participant and her partner had been trying to conceive for between one to two years and had consulted with a gynaecologist concerning their infertility. The participant had undergone a basic fertility evaluation. Confirmation of ovulation was conducted in 2007 and found to be normal. A laparoscopy in 2007 found normal findings and thyroid function tests showed normal functioning. Other tests that were conducted included postcoital tests which were found to be normal. The participant’s husband underwent semen analysis in 2007 as well as a test of sperm function. These results showed normal morphology and function. The diagnosis was unexplained infertility.
Her partner had fathered two children with a previous partner and her last surgery, dilation and curettage, was due to a still birth four years previously. As a child she had contracted chicken pox and she was only aware of having received the polio vaccination.
4.1.1 First Consultation – March 2008
General History
The participant explained that she liked to keep busy and described her energy levels as normal. She described herself as better for cold and worse for exposure to heat. 55
The participant’s appetite was good and she added that when her stomach was full she wanted to sleep. She craved ice cream and attributed this craving more toward the desire for milk rather than the desire for cold, ice or sugar. She was not a thirsty person and would only perspire when sick.
The participant’s sleep was disturbed and she awoke everyday at 5:30 am. On waking she felt unrefreshed. The participant would wake up during the night, after dreaming and would be unable to fall asleep again. Her dreams included events where she was with her late mother. She also dreamt of people running away from her as well as of children. She also experienced a dream where her menses had unexpectedly commenced and she was unable to control the flow. In this dream she experienced much anxiety and embarrassment because of this. The participant also mentioned that sleep was easily achieved if her husband was holding her, but she would be unable to sleep if he was not there.
There were no problems with urination besides burning on urination after dyspareunia. She had infrequent bowel movements. At best she had a bowel movement every two days. She would use milk as it had a laxative effect on her.
The participant explained that her menses consisted mostly of clots and little fluid. The flow was dark red and very heavy on the first day as well as at night. She experienced severe cutting pains in the abdomen as well as lower backache and pain in the legs and feet during her menses. The pain in her feet was very severe and was better for cold application. Before menses commenced she experienced much flatulence as well as severe breast tenderness. She also experienced itching of the nipples which was only ameliorated by squeezing the nipples. When she squeezed the nipples a clear, watery fluid would come out in small amounts. The nipples would become contracted and painful particularly in the mornings and were worse for cold. She would not experience breast symptoms during the rest of her cycle. She was easily upset and sad before her menses and became angry easily and would cry. The duration of her menses was five days.
The sanitary wear she used included tampons and panty liners. She had used the contraceptive pill five years previously as a method of controlling or rectifying her dysmenorrhoea. Adverse effects of the use of the pill included weight gain.
She described her sexual function as normal with an increased desire the day before her menses. The frequency and timing of intercourse depended on the severity of her vaginal dryness. She
56 experienced pain on intercourse which was worsened by the vaginal dryness. She noted that the dryness was especially worse one week after her menses and she had not noticed a discharge.
Mentally and emotionally the participant had no complaints besides the fear that she would die childless. When asked of her thoughts and feelings about her infertility she explained that not having children or not being able to have children made her think that there was no point in working hard for the future when there were no children to benefit from it. She felt sad when she thought about it and felt that it had negatively affected her life. She also feared robbers. Their infertility affected her husband’s life because he wanted to make her happy. During the consultation it was noted that the participant would laugh at inappropriate times, and especially at serious issues.
Review of Systems
The participant presented with small elevations on the skin under the eyes. These were not pimples and appeared about a year previously. There were no symptoms associated with the elevations. There had been an aching sensation in both ears only when the environment was cold. Nothing ameliorated this symptom. The participant experienced heart palpitations when she was angered. She would also, when angered, experience an urge to pass stool after which she would be relieved.
Family History
Mother: Deceased - Cerebral malaria Father: Deceased - Mining accident Grandparents: Deceased - Natural causes Siblings: Healthy Family history: Tuberculosis
Medication
The participant was taking Medlemon® and Disprin® for relief of common headaches and menstrual pain.
57 Physical Examination
Vital Signs:
Blood Pressure: 142/90 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.0ºC Weight: 66kg
General Examination:
Slight yellow discolouration of the sclera was observed.
Focused Physical Examination:
Abdominal examination was performed. On auscultation the bowel sounds were normal. On percussion the left and right iliac fossae were tympanitic as well as along the ascending, transverse and descending colon. There was pain on deep palpation in both right and left iliac fossae.
Motivation for Remedy Selection
Natrum muriaticum was chosen for this participant by the researcher after repertorisation and analysis of the case. Natrum muriaticum is the top ranking medicine in homoeopathy for sterility (Kandpal et al, 2004; Vermeulen, 2001). The key note of Natrum muriaticum is suppression of emotional pain which was evident in the history taking of the participant (Bailey, 1995). During the first consultation the participant showed much suppression of emotional pain, particularly over the loss of her first child which was stillborn. Symptoms of the participant which matched Natrum muriaticum included: ‘dryness and soreness of the vagina resulting in painful coition’, ‘profuse and irregular menses’, ‘headache during or after menses’, ‘headache from sneezing, disappearing on pressure’, ‘worse for heat’, ‘weary and sleepy after eating’, ‘craving for milk’, ‘laughing over serious matters’, ‘sadness before menses’, ‘fear of robbers’ (Vermeulen, 2001), ‘sleep disturbed by dreams’, ‘despair about future’ (Schroyens, 1995). Owing to the physical nature of the case as well as the mental picture, the researcher decided to prescribe the 12th potency so as to avoid
58 aggravations as well as to administer the medication more frequently. The participant was advised to reduce her salt intake because of her raised blood pressure reading.
Prescription
Natrum muriaticum 12cH, one powder taken twice daily for one month.
4.1.2 Second Consultation – April 2008
General History
At the second consultation the participant described significant improvement in her menstrual symptoms. Her dysmenorrhoea had significantly improved. She had not experienced any back pain with her menses and had no cutting pains in the abdomen. She had had a slight cramp in her right leg during her menses but had not felt sick as she usually would have. She still experienced a strong sexual desire the day before her menses began and described a marked improvement in her vaginal dryness. Her menstrual blood was dark red and clotted and the amount of menstrual fluid had significantly decreased. Her menses lasted two and a half days whereas before her menses had lasted five days. She did not experience any pain on intercourse.
Before her menses she still experienced flatulence. Her breast symptoms were significantly improved. They were not as painful as before and did not feel heavy. Although there was still a fluid discharge from the nipple, there was no itching of the nipples. The nipples did not contract and there was no pain in the nipples. She noted slight spotting on day twenty-five of her cycle which she described as “one spot” while her menses started on day twenty-eight of her cycle. Menses continued for two days and was followed by a pounding headache located over the temples that was worse for sneezing.
The participant was excited and happy about the remarkable improvement of her dysmenorrhoea. She recalled experiencing severe pain in her feet during her menses that was ameliorated by cold application. She had not experienced this foot pain since starting the trial. She noted that she felt more energetic now as she had no pain during her menses. Her appetite was good and she still craved ice cream. Her thirst was unchanged as well as her perspiration and sleep. She no longer experienced burning on urination after intercourse. Her stools were more solid than before.
59 Mentally the participant was worried due to political issues affecting family members in neighbouring countries. Apart from that she described herself as happy that her dysmenorrhoea had improved. She also mentioned that her even husband had noted how much better and active she was feeling. She dreamt the same dreams she had described in the first consultation, in which she was having her period and was embarrassed about it. She described it as an anxious dream.
Review of Systems
The participant had not noticed any changes in the skin elevations and had not experienced any earache during the last month.
Physical Examination
Vital Signs:
Blood Pressure: 128/78 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.6ºC Weight: 66kg
General Examination:
Slight yellow discolouration of the sclera was observed.
Focused Physical Examination:
Abdominal examination was performed. On auscultation the bowel sounds were normal. On percussion tympanitic areas were as before. There was pain on deep palpation in the area under the umbilicus and above the symphysis pubis. There was no pain on palpation of the iliac fossae
Discussion
The participant showed significant and marked improvement in her menstrual complaints. She felt more energetic and mentally positive and optimistic. Her blood pressure had normalised and there
60 was general improvement in all her symptoms. The researcher decided to continue with the same remedy, potency and frequency.
Prescription
Natrum muriaticum 12cH, one powder taken twice daily for one month.
4.1.3 Third Consultation – May 2008
General History
At the third consultation the participant reported that her menses had started unexpectedly after she had received bad news. She experienced some abdominal pain during her menses but no back pain. The abdominal pain started about six hours after her menses had started and only lasted for a few hours. She described the pain as cutting from side to side across her abdomen. The pain was better for motion and worse for lying down. The pain went from the left side of her abdomen down to her feet. The pain in her feet was like a heat or burning pain that was better for cold application. Her sexual desires were greatest during her menses. Her menses was very dark in colour, much heavier than the previous month, and clotted. There was abdominal bloating and much flatus before her menses which was relieved soon after her menses had commenced. There was no breast tenderness before or during menses and the nipples were not contracted, cracked or sore. She reported that her breasts were not as big and swollen as they had been previously. There was a slight white discharge from the nipples during her menses. The vaginal dryness had completely resolved and there was no longer pain on intercourse.
She did not have a headache this month and noticed that she was not sneezing as much as before. Her sneezing however was made worse by drinking cold water. Her energy levels were very good and her appetite remained unchanged with the continued craving for ice cream.
The participant reported that she was now sleeping more than before. She also mentioned that she had experienced several dreams in the past month but particularly she had once again dreamt of having her period and bleeding profusely. There was increased frequency of urination before her menses and she had experienced hard and mucusy stools in the past month. Her stool at the time of the consultation was soft and yellow and bowel movements occurred once a day. Mentally and emotionally she felt good but was worried and concerned for her brother’s well-being.
61
Review of Systems
The participant had noticed an improvement in the skin elevations, and had experienced slight photophobia on watching television or being in the light of day or of a room.
Physical Examination
Vital Signs:
Blood Pressure: 110/70 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 16 breaths per minute Temperature: 36.6ºC Weight: 65kg
General Examination:
Slight yellow discolouration of the sclera was observed.
Focused Physical Examination:
Abdominal examination was performed. On auscultation the bowel sounds were normal. The abdomen was not as tympanitic as before. There was discomfort on deep palpation under the umbilicus and above the symphysis pubis. There was no pain on palpation of the iliac fossae
Discussion
The researcher was pleased with the participant’s progress over the last three months but felt that the remedy needed to be given more time to work. She continued to show improvement in her menstrual symptoms as well as in other general symptoms. For this reason the same remedy and potency was continued twice daily.
62 Prescription
Natrum muriaticum 12cH, one powder taken twice daily for one month
4.1.4 Fourth Consultation – June 2008
General History
The participant reported very good energy levels and her appetite was good and she had experienced an aversion to fish and beans. Her cravings for ice cream were still strong. Generally she noted that she was not sneezing as much. The participant reported that her sleep was good and that she had been dreaming of the police and of bad things that had happened in her life. She noted that she was sleeping on her sides. It was reported that her urinary frequency had increased before her menses and that her bowel movements were normal and daily.
The participant’s menstrual period was much better than previous periods. She described the period as having come and gone without realising it. There had been no back or abdominal pain with her menses and there were no clots. The blood was described as dark, liquid and heavy. She had felt bloated before the menses and had experienced much flatus which was relieved after the menses had begun. Her sexual desires remained increased before menses and there was no pain on intercourse. No breast pain was noted before or during menses as well as no discharge or itching of the nipples. The participant had noted a slight increase in size of her breasts before menses. Mentally the participant felt happy. She expressed much relief at the improvement of her menses as it was no longer affecting her daily functioning during the time she was menstruating.
Review of Systems
Further improvement had been noted in the skin elevations.
Physical Examination
Vital Signs:
Blood Pressure: 128/90 mmHg (Right arm, sitting upright) Heart Rate: 52 beats per minute
63 Respiratory Rate: 15 breaths per minute Temperature: 35.2ºC Weight: 66kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
Abdominal examination was performed. On auscultation the bowel sounds were normal. There was no discomfort or pain noted on palpation.
Discussion
The participant continued to show improvement in her menstrual symptoms as well as in other general symptoms. For this reason the same remedy, potency and frequency were continued as it was felt by the researcher that continuing the remedy would prove beneficial to the participant’s health and well-being.
Prescription
Natrum muriaticum 12cH, one powder taken twice daily for one month.
4.1.5 Fifth Consultation – July 2008
General History
At the fifth consultation the participant explained that her energy levels were very good. She felt energetic and was able to perform her daily tasks with ease and without fatigue. She reported that the recent cold weather had made her sneeze more frequently.
The participant mentioned that before the trial she would become photophobic and would get headaches if she was in the sun. This had not happened to her within the last month. Generally she was aggravated by being in the sun.
64
Her appetite had been good and cravings unchanged. She had recently started craving lasagne for its cheese content. She was still averse to fish. Recently her thirst had increased considerably, and she was now drinking just over a litre of water per day. Her thirst was most pronounced in the afternoon. She preferred her water to be room temperature.
Her sleep was good. She had recently dreamt of giving birth to a baby girl and nursing her. Urination was normal and there was also increased urination before her menses. The participant experienced normal bowel function with one movement a day.
The participant described her last menstrual cycle as being completely pain free. Before her menses began she did not experience any symptoms besides slight bloating and much flatulence which had both disappeared at the onset of her menses. During her menses she had not experienced any back pain, pain down the legs or abdominal pain. She described the blood as light to dark in colour, clot free and more fluid. The flow was lighter than before and lasted for four days - two days of a proper bleed and two days of scanty discharge. There was still a pronounced sexual desire before her menses and she had noted a significant improvement in the pustular eruptions she would get on her face before her menses. She noted that she only had very few on her cheeks, whereas before she would experience break outs mostly on her forehead and cheeks. She had not experienced breast tenderness before or during her menses, there was no discharge from the nipple, no itching of the nipples, and no painful hardening of the nipples. On retrospection the participant noted that she had not experienced any irritability or mental symptoms before her menses. She recalled feeling disappointed when her menstrual period began.
Nine days after her menses began the participant experienced pain in the left iliac fossa. The pain was described as a sore pain that was not like the cutting pain she had previously experienced with her menses. This pain lasted for about one hour and was accompanied by a very thick, slippery and white discharge. This was the first time that she had experienced this pain. Mentally the participant was felt happy due to the fact that she felt good physically and mentally, and because her relationship with her husband was good as well.
Review of Systems
Further improvement in the skin elevations had been noted.
65 Physical Examination
Vital Signs:
Blood Pressure: 130/74 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.3ºC Weight: 66kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
Abdominal examination: On auscultation the bowel sounds were normal. The abdomen was tympanitic on percussion of the ascending colon and part of the transverse colon, and dull on percussion of the descending colon. Pain and discomfort was noted on deep palpation of the left iliac fossa.
Skin observation: It was noted that the skin elevations which had been noted in the first consultation had greatly improved and were now not as visible as before.
Discussion
Because of continued improvement and the presence of mild symptoms the prescription was repeated for the next month. The participant was pleased with the progress thus far.
Prescription
Natrum muriaticum 12cH, one powder taken twice daily for one month.
66 4.1.6 Sixth Consultation – August 2008
General History
At the sixth consultation the participant complained of heartburn which she had experienced in the mornings. She described having experienced this symptom many years prior as well as during her pregnancy six years ago. These symptoms went away for many years and had returned a few weeks ago. The heartburn was worse in the mornings and was better for eating and drinking. She described the pain as burning in nature.
Her energy levels had been very good. She had not sneezed as much. In the past she would experience an attack of sneezing when she drank cold water. She could now drink cold water and she would not sneeze. She had not experienced a headache from the sun in the last month.
Her appetite was good and she was still craving ice cream, lasagne, beans and especially milk. She was even thirstier than last month and was drinking about two litres of water per day. It was noted that her thirst was greater after 10am and that she would become even thirstier after eating or drinking something sweet.
She had not dreamt the recurrent embarrassing dream she had had previously. Her urination had increased in frequency from the last month. Stool was normal and bowel movements increased in frequency to twice a day.
Her menstrual cycle had lasted five days this month. There had been no pain at all in the abdomen, back or legs. The blood was red and not as dark as before. There were no clots at all, only thin membranes which were slippery like mucus, and the flow was light. She experienced no premenstrual symptoms before her menses and had no breast symptoms before or during her menses. There was not as much flatus before her menses and her bloating before menses was better than previous months. Both these symptoms were relieved by the flow of blood. There was no headache, no pain in the legs and only a few skin eruptions before her period. She experienced no irritability or mental symptoms before or during her menses and for the first time experienced pain in the lower abdomen on day fourteen of her cycle. This pain did not last long.
67 Mentally and emotionally she was happy. She had thought of the baby she had lost a lot in the last month, especially at the time of her menses. She mentioned that the improvement and change in her period had made her more positive about falling pregnant. She felt good overall.
Review of Systems
The participant reported that the elevations had continued to improve and were now only barely visible. There had been great improvement with her sinuses as she was no longer sneezing.
Physical Examination
Vital Signs:
Blood Pressure: 124/68 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.3ºC Weight: 65.5kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
Skin observation: It was noted that the skin elevations under her eyes had greatly improved and were now barely visible. A random glucose test was performed because of her polydipsia, polyuria and polyphagia. Her glucose level was 4.9 mmol/l.
Discussion
The participant was feeling better within herself. The occurrence of the heartburn was accepted as a return of old symptoms, in accordance with Hering’s Law of Cure. The researcher prescribed the Natrum muriaticum 12cH once a day for the next month.
68 Prescription
Natrum muriaticum 12cH, one powder taken once daily for one month.
4.1.7 Seventh Consultation – September 2008
General History
At the final consultation the participant reported no heartburn over the last month. Her energy levels were high throughout the day. Her appetite was very good and her craving for ice cream and her aversion to fish were still marked. She was no longer as thirsty as she had been previously.
The participant still slept on her sides and her sleep had been disturbed over the past few days. She had been dreaming of deceased family members. She would wake from the dream and would experience great difficulty in falling asleep again. Generally these dreams were of an anxious nature and tended to have a religious theme throughout. Her urinary frequency was unchanged but was dependant on her water intake. Her bowel movements were regular and at times she experienced two bowel movements a day.
Her menses had been completely pain free and there were no breast symptoms experienced before or during menses. She had experienced flatus before her menses which was improved from the previous month, as well as slight bloating. Before commencing her menses the participant reported no bloating at all and only slight flatus before menses. She had not experiencing any abdominal, back or leg pain. Her menstrual flow was not as heavy as it had usually been. The blood had been red in colour, had few membranes of mucus and very small clots. It was also noted at the time of ovulation that there was pain felt in the left iliac fossa that lasted a few hours.
Mentally and emotionally the participant was worried about a sister’s health. She explained that she was also feeling very positive and happy with the progress that had been made in her health and well being. She expressed her husband’s happiness and gratitude to homoeopathy for helping her with her dysmenorrhoea. She also said that if her period remained as pain free as it had been in the last six months she would not mind if she never fell pregnant.
69 Review of Systems
The participant’s cuticles had become dry and cracked.
Physical Examination
Vital Signs:
Blood Pressure: 120/70 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.5ºC Weight: 67kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
Skin observation: The skin elevations under her eyes had continued to improve.
Discussion
The participant was now asymptomatic. The researcher was pleased with the results and the general health of the participant. The researcher did not feel that it was necessary to repeat the prescription.
Prescription
Nil
4.1.8 Overview of Case One
The participant showed a favourable response to Natrum muriaticum. Figure 4.1 demonstrates that the participant was estimated to have ovulated between days ten and sixteen of her cycle. Figure 4.2
70 shows the General Well-being scores of the participant over the treatment period. The participant showed continued improvement in general well-being over the treatment period. The participant showed stable improvement over the first two months of the trial, while the greatest improvement was observed from month three to four. Thereafter the participant showed excellent general well- being over the last three months of the trial. Figure 4.3 shows the ratings of the individual questions of the General Well-being Questionnaire. When comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial it was noted that improvement had occurred in her general well-being, health, depression, nervousness and anxiety as well as energy levels. No significant change was noted in her level of worry or happiness. She expressed her satisfaction with the results when she explained that if her health and menstrual cycle were to stay as asymptomatic as they were at the end of the trial she would not mind if she never fell pregnant. Table 4.1 demonstrates the participant’s midcycle mucus changes which show that only on day twelve, thirteen and fifteen of her cycle did she experience ideal ovulatory mucus changes (clear, stretchy and slippery). Although the participant showed overall improvement, pregnancy was not achieved during the treatment period.
71
Participant 1 - Basal Body Temperature over the Treatment Period
37.3
37.1 Cycle 1 Cycle 2 36.9 Cycle 3 Cycle 4 36.7 Cycle 5 Cycle 6 36.5
Temperature reading Temperature Cycle 7
36.3 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 Day of cycle
Figure 4.1: Basal Body Temperature of Participant 1 over the Treatment Period
Participant 1 - General Well-Being Questionnaire Scores over the Treatment Period
37 40 35 35 35 30 30 30 27 28 25 20 15
Total Score Total 10
5 0 1 2 3 4 5 6 7
Consultation
Figure 4.2: General Well-Being Scores of Participant 1 over the Treatment Period
Individual Question Rating How are you feeling in general? 5 Have you been ill or unwell in the past month? 4 Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? 0 Have you felt worried or upset during the past month? 1 2 3 4 5 6 7 How often have you felt happy Month during the past month?
Figure 4.3: Individual Question Ratings of Participant 1 over the Treatment Period 72 Table 4.1: Midcycle Mucus Changes of Participant 1 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Cycle 7 Day 1 Menses Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses Menses Menses Menses Menses Menses Clear, Stretchy, Menses Menses Day 5 Wet White, Thick, Menses Menses Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Sticky, Day 6 Slippery Wet Wet Wet Wet Clear, Sticky, Clear, Stretchy, Menses Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Sticky, Day 7 Wet Slippery Wet Wet Wet Wet Clear, Sticky, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Sticky, Day 8 Slippery Slippery Wet Wet Wet Wet Wet Clear, Clear, Sticky, Clear, Stretchy, Clear, Stretchy, White, Stretchy, White, Stretchy, Clear, Sticky, Day 9 Thick, Slippery Wet Wet Wet Wet Sticky Wet White, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, White, Stretchy, Day 10 Sticky Sticky Wet Wet Wet Wet Sticky White, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, White, Stretchy, Day 11 Slippery Slippery Wet Wet Wet Wet Slippery Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 12 Slippery Slippery Wet Wet Wet Wet Slippery White, Stretchy, White, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, Clear, Stretchy, White, Thick, Day 13 Wet Wet Wet Wet Wet Wet Wet Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 14 Wet Wet Wet Wet Wet Wet Wet Clear, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, White, Stretchy, Day 15 Wet Wet Wet Wet Wet Wet Wet White, Stretchy, White, Stretchy, Clear, Stretchy, Clear, Stretchy, White, Stretchy, Clear, Stretchy, White, Stretchy, Day 16 Wet Wet Wet Wet Wet Wet Wet White, Stretchy, White, Thick, Clear, Stretchy, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Thick, Day 17 Wet Wet Wet Wet Wet Sticky Wet White, Stretchy, White, Thick, Clear, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Thick, Day 18 Wet Wet Wet Wet Wet Sticky Wet White, Stretchy, White, Thick, Clear, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Thick, Day 19 Wet Wet Wet Wet Wet Sticky Wet White, Stretchy, White, Thick, Clear, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Stretchy, Day 20 Wet Wet Wet Wet Wet Sticky Wet White, Thick, Clear, Stretch, Clear, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Stretchy, Day 21 Wet Slippery Wet Wet Wet Sticky Wet White, Thick, White, Thick, Clear, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Stretchy, Day 22 Wet Wet Wet Wet Wet Sticky Wet White, Thick, White, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Stretchy, Day 23 Wet Wet Wet Wet Wet Sticky White, Thick, White, Thick, Clear, Stretchy, White, Stretchy, White, Stretchy, White, Stretchy, Day 24 Wet Wet Wet Wet Wet Sticky White, Thick, White, Thick, White, Thick, White, Stretchy, White, Stretchy, White, Thick, Day 25 Wet Wet Wet Wet Wet Wet White, Thick, White, Thick, White, Stretchy, White, Stretchy, White, Thick, Day 26 Wet Wet Wet Wet Wet Clear, Stretch, Clear, Stretchy, White, Stretchy, White, Thick, Day 27 Slippery Wet Wet Wet White, Thick, White, Thick, White, Stretchy, White, Thick, Day 28 Wet Wet Wet Wet White, Thick, Clear, Stretchy, Day 29 Wet Wet White, Thick, Day 30 Wet White, Thick, Day 31 Wet White, Thick, Day 32 Wet White, Thick, Day 33 Wet
73 4.2 CASE TWO
Age: 40 (1967) Gender: Female Race: White Occupation: Veterinary Receptionist Marital Status: Married Weight: 100kg Height: 1,67m BMI: 35 Menarche: 13 years of age History of Pregnancy: Two pregnancies, one live birth in 1991, and one miscarriage in 1993.
The participant and her partner had been trying to conceive for more than five years and had consulted with a gynaecologist as well as with a general practitioner concerning their infertility. The participant had undergone a basic fertility evaluation. Results of hysterosalpingogram and laparoscopy in 2001 were normal and thyroid function tests in 2004 showed normal function. Confirmation of ovulation was conducted in 2005 and found to be normal. Other tests that were conducted included postcoital tests in 2006 which were found to be normal. The participant’s husband underwent semen analysis in 2006 as well as a test of sperm function. These results showed normal morphology and function. She last consulted a gynaecologist in 2007 and all was found to be normal. The diagnosis was unexplained infertility.
She had experienced toxic exposures to radiation. Childhood illnesses she contracted included mumps, chicken pox, whooping cough and measles. She received the polio and DPT vaccination.
4.2.1 First Consultation – March 2008
General History
At the first consultation the participant explained that she had experienced brown blotchy areas on her skin which started six years prior, after the use of self tan products. These brown areas had irregular edges and were located on her back, shoulders and groin. These areas had a sour odour and were very itchy. These were worse for scratching, perspiration and better for applying vinegar.
74 She added that she experienced asthmatic attacks. She explained that it felt as though her chest closed up, and her breathing would be accompanied by wheezing. Her asthma was worse for eating yeast and dairy products and pork, for severe emotional stress and for cigarette or wood smoke. It was very difficult to clear the expectoration which was clear and sticky. Clearing the expectoration was made easier by sitting upright and allopathic medication.
Her energy levels were very poor and she felt constantly tired. This was particularly worse in the mornings on waking. She was sensitive to cold but could not tolerate heat. The participant described her appetite as ravenous. She always felt hungry especially in the mornings and late afternoons and was not easily satisfied. She craved butter, creamy, fatty foods and bread. She explained that she was thirstless but felt most thirsty at night.
The participant explained that she perspired profusely on her face, her head and scalp and generally all over her body. This would occur after the least exertion and especially at night on her upper body and around her throat and neck. She had also experienced troubled sleep which was very restless. She would wake three to four times a night to urinate and would awake in the mornings feeling tired. She slept mostly on her right side. Urination occurred infrequently during the day and she experienced several bowel movements a day. She described the stool as small in amount and light brown and pasty.
The participant experienced skin eruptions, severe breast tenderness and swelling, abdominal bloating and flatulence as well as becoming easily angered before her menstrual period. She explained that her menses lasted between seven to ten days, at which point she would use allopathic medication to stop the profuse bleeding she experienced. She explained that the blood appeared dark red in colour, membranous and clotted. From the first day of menstrual bleeding the flow became heavier as each day went by. She described intense pelvic pain which felt sore and hot and increased bowel movements of loose stool at this time. The participant explained that one month she would experience extremely heavy and painful menses alternating with a milder menstrual cycle that was pain free and light in flow. The milder menstrual period lasted between three to four days and she explained that before this milder menstrual cycle there were no premenstrual symptoms, and very little pain was experienced. The flow was light and no clots were evident. The blood was dark in colour and membranous. Before her “milder menstrual period” she experienced mild breast tenderness and no skin eruptions or irritability. It was anticipated by the participant that her next menstrual cycle would be very heavy and extremely painful. Her choice of sanitary wear was sanitary towels and tampons.
75
She had used a copper intrauterine device in 1993 three weeks before her second pregnancy, also for contraceptive purposes. She also used the oral contraceptive pill in 2002 as well as condoms in 2005 for contraceptive purposes. She experienced no adverse effects. She reported no problems with sexual function except that during sexual intercourse she would occasionally experience a painful sharp, shooting pain up the pelvis. There was much dryness of the vagina, which made penetration painful. The frequency and timing of sexual intercourse was about three to four times a week and was described as normal. Vulvovaginal symptoms included the vaginal dryness as well as a discharge which was a dark cream colour and smelt of ammonia. She and her husband made use of KY jelly lubrication.
She had been made to feel humiliated and embarrassed by her family members because of her body and inability to have a child. She felt happiest when at home with her husband and son. She explained that after her miscarriage and subsequent dilation and curettage, she felt that she would struggle to fall pregnant again.
The participant and her husband decided to try to conceive five and a half years prior to the trial. The participant explained that she didn’t feel that her infertility had any emotional connections. Her husband did not pressurise her regarding her falling pregnant. She described herself as vibrant, outgoing and lively. She felt emotionally stable and was tearless.
Review of Systems
She explained that her finger nails did not grow whereas her toenails grew fast, and were very brittle, and split easily. The participant described intense itching in the ear canal as well as the auricle. Scratching ameliorated the itching slightly. Application of vinegar or methylated spirits ameliorated the intense itching. The participant also mentioned sharp and stabbing pains just under the right side of her rib cage which were worse for eating chocolate. This pain started about a month prior to the first consultation, and was described to have been extremely painful. She also reported tachycardia at night when sleeping on her sides.
Family History
Mother: Deceased 80 - Ovarian Cancer Father: Deceased 54 - Tuberculosis
76 Grandparents: Deceased - Heart failure Siblings: Spinal and digestive ailments Children: Good health Family history: Heart disease, tuberculosis, arthritis, cancer, hypertension and genetic disorders (Dandy-Walker variant: the participant and both siblings)
Medication
The participant was taking FoodState Multivitamin & Mineral Formula®, Folic Acid supplementation and Omega 3 supplements.
Physical Examination
Vital Signs:
Blood Pressure: 124/82 mmHg (Right arm, sitting upright) Heart Rate: 84 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.0ºC Weight: 100kg
General Examination:
Slight pitting oedema of both lower limbs was observed during examination.
Focused Physical Examination:
The participant’s skin was observed and small red spots as well as scratch marks were observed on the abdomen. Tiny sores from scratching were also noted. Abdominal examination was performed. Bowel sounds were normal and there was tenderness on palpation of both left and right iliac fossae. A positive Murphy’s sign was elicited as well as guarding over the liver region.
77 Motivation for Remedy Selection
The researcher decided to prescribe Calcarea carbonica after repertorisation. The participant presented with symptoms similar to those of Calcarea carbonica such as ‘sweats easily particularly over the head’, ‘worse for the least exertion’, ‘sour odour’, ‘night sweats over the head, neck and chest’, ‘sensitivity to cold’, she also experienced ‘ravenous hunger particularly in the mornings’, ‘gallstone colic’ and ‘sensitivity to slight pressure on the abdomen’ which are prominent features of the Calcarea carbonica symptom picture (Murphy, 1988; Vermeulen; 2001; Tyler, 1988). Her menses were ‘too profuse and too long’, and she experienced ‘hot, tender and swollen breasts before menses’. Other menstrual features that were synonymous with those of the Calcarea carbonica symptom picture were ‘sterility and copious menses’, ‘general weakness in women with exaggerated desires’ and ‘membranous dysmenorrhoea’. She appeared to be content provided she had security and friendship. She was not conscious of her appearance and appeared fleshy with a tendency to obesity with light brown hair and a chalky complexion with rosy cheeks. According to Bailey (1995) these characteristics are strong features of the Calcarea carbonica symptom picture. The 12th potency was prescribed twice a day, because of the mental and physical presentation of the case as well as to avoid any possible aggravations.
The participant appeared to be presenting with acute cholecystitis which was discovered on history taking and on examination. She was referred accordingly for ultrasound and appropriate treatment. The researcher felt that exclusion was not necessary as treatment would not affect the trial.
Prescription
Calcarea carbonica 12cH, one powder taken twice a day for one month.
4.2.2 Second Consultation – April 2008
General History
At the second consultation the participant reported that the brown blotches and itching had cleared completely. She now added that her skin was dry and itchy particularly on her back at night. Scratching ameliorated this symptom. The participant had eaten pork which resulted in one episode of asthma which was easier and shorter than previous episodes.
78 Her energy levels were greatly improved but her appetite was still ravenous. She had been craving pork, viennas and tomato juice, and had felt hungrier than the previous month. She had been eating more fruits such as pears, pineapples and oranges. She had not been feeling thirsty and said that her perspiration had significantly improved and was now no longer present. Her sleep was good and she would awake feeling refreshed. She was also urinating significantly less at night and frequently during the day. Her stool was regular and normal.
The participant explained that her menstrual cycle was usually very regular and that she would normally begin menstruating on day twenty-five or twenty-six of her cycle. This had not been the case. She had experienced breast tenderness, skin eruptions and bloating before the consultation. At the second consultation the participant explained that her menstrual period was late by seven days.
She explained that she had experienced a feeling as if something were in her uterus and a tingling sensation. At times she felt that menstrual bleeding would commence when it had not. She explained this to be a dull feeling which came and went. The last time she missed a menstrual cycle was seventeen years prior to the trial when she fell pregnant with her first child. She had not experienced the sharp pain during intercourse and the dryness of her vagina had significantly improved and was now rated five out of ten. She had a vaginal discharge which was creamy, sticky and wet, like cottage cheese. She explained that it still smelt of ammonia and that there was slight itching of the pudenda which started a week before the second consultation. The participant recalled that she had also experienced an episode of thrush when she first fell pregnant with her son seventeen years ago. Mentally and emotionally she had felt good and had been experiencing nausea after eating certain meals.
Review of Systems
The intense itching in the ear canal as well as auricle was still present. The participant explained that the sharp and stabbing pains just under the right side of her rib cage were still present but greatly improved. She had not yet consulted with a doctor regarding her acute cholecystitis because of financial difficulties.
79 Physical Examination
Vital Signs:
Blood Pressure: 130/74 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.3ºC Weight: 100kg
General Examination:
Slight pitting oedema of both lower limbs was observed during examination.
Focused Physical Examination:
Abdominal examination was performed. Bowel sounds were increased and the abdomen was found to be tympanitic on percussion. There was no tenderness on palpation of either left or right iliac fossae. A positive Murphy’s sign was elicited but was greatly reduced and not as pronounced as in the first consultation. Guarding and itching was observed over the liver region and solar plexus.
Discussion
The participant showed significant improvement in her general symptoms as well as presenting complaints. The researcher and the participant were pleased with the participant’s progression over the previous month. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month.
Owing to the absence of her menstrual period pregnancy was suspected. A βhCG urine pregnancy test was performed at the University of Johannesburg Health Clinic with a negative result. The participant was advised to continue monitoring the days of her cycle and record her basal body temperature and midcycle mucus changes.
80 Prescription
Calcarea carbonica 12cH, one powder taken twice a day for one month.
4.2.3 Third Consultation – May 2008
General History
At the third consultation the participant explained that she had been feeling good and that the itchiness on her back and abdomen had improved. She explained that when she was eighteen years old she had experienced a bad taste in her mouth. She noted that this symptom had returned and she was now experiencing that same bad taste in the last month.
Her energy levels were good and she continued to have a ravenous appetite. She was craving sugars and salts as well as green vegetables. She was feeling thirstier and was drinking larger quantities of water. She now experienced perspiration under her arms which was offensive and came without exertion. She had experienced this symptom last as a teenager. Her sleep was good, and she was urinating less frequently but in greater volumes. Her stool was firmer and had increased in amount.
The participant reported that she had experienced a fluttering sensation in her uterus three days prior to this consultation. She could sometimes feel a mass in her right iliac fossa which seemed to move. She had been experiencing severe breast tenderness. Her menses had not yet commenced. She was experiencing a vaginal discharge that was copious, creamy, slimy and ammonia-like in odour. She had previously experienced this symptom in her teenage years.
Mentally and emotionally she was feeling good within herself and concerned as she was planning to emigrate with her husband and son. She felt excited. She explained that the last time she had felt like this and experienced these symptoms had been when she had conceived her first child. She was excited about the possibility of being pregnant and for the ability to give her husband the child they had both wanted.
Review of Systems
The participant explained that the intense itching in the ear canal as well as auricle had completely cleared. The participant had still not consulted with her doctor regarding her acute cholecystitis
81 because of financial difficulties. Her cholecystitis had, however, resolved. She also reported that her tachycardia and heart palpitations had not returned since starting the trial.
Physical Examination
Vital Signs:
Blood Pressure: 120/78 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 35.8ºC Weight: 100kg
General Examination:
Slight pitting oedema of both lower limbs was observed during examination.
Focused Physical Examination:
Abdominal examination was performed. Bowel sounds were normal and there was tenderness and an “uncomfortable feeling” on palpation of the right iliac fossa. There was no Murphy’s sign as well as no guarding over the liver region.
Discussion
The participant continued to show significant improvement in general symptoms as well as presenting complaints. The participant was feeling better within herself. The occurrence of the bad taste in her mouth, offensive underarm perspiration and vaginal discharge was accepted as a return of old symptoms, in accordance with Hering’s Law of Cure. The researcher and participant were pleased with the participant’s progression over the last two months. The researcher decided to repeat the prescription for the following month.
Further testing of her S-Quantitative βhCG and βhCG Pregnancy Screen-S test, and abdominal and pelvic ultrasound were sent for. The participant was advised to continue monitoring the days of her cycle and continue recording her basal body temperature and midcycle mucus changes.
82
Prescription
Calcarea carbonica 12cH, one powder taken twice a day for one month.
4.2.4 Overview of Case Two
Owing to the continued absence of her menstrual cycle the participant was advised to visit a testing laboratory for blood tests to test possible pregnancy before the third consultation. The S- Quantitative βhCG (APPENDIX I) showed a result of < 5.0 mIU/ml which suggested pregnancy. Because of the low reading, the participant was advised to repeat the S-Quantitative βhCG and the βhCG Pregnancy Screen-S test. This test showed (APPENDIX J) a result of < 5.0 mIU/ml for the S- Quantitative βhCG and was negative for the βhCG Pregnancy Screen-S test. Owing to the presentation and results of the case, the researcher decided that ectopic pregnancy needed to be ruled out. The participant was thus referred to a gynaecologist who was requested to perform an abdominal and pelvic ultrasound on the participant. The results showed a normal gall bladder and no intrauterine pregnancy was identified (APPENDIX K). A complex solid/cystic mass lesion was identified in the right adnexa. An ectopic pregnancy could not be excluded.
The participant underwent surgery and laparoscopy to remove the complex solid/cystic mass lesion which, after histology analysis, proved to be a benign cyst. No foetal cells were observed in the cyst. This ultimately resulted in her exclusion from the study.
Shortly after her surgery, the participant, her husband and son emigrated to New Zealand. Over telephonic conversation a month after surgery, she reported that she no longer suffered with itchy skin and that her energy levels were very poor. Her perspiration symptoms had disappeared and her sleep quality had deteriorated significantly. After surgery, her menses had persisted for one month and she had experienced severe menstrual cramping. The blood was clotted and dark in colour as well as stringy and had an odour of ammonia. She had still not experienced any heart palpitations or symptoms of cholecystitis.
The participant showed an exceptional response to Calcarea carbonica. Figure 4.4 shows the basal body temperatures of the participant over the treatment period. The participant appeared to have ovulated on day fourteen of her cycle. Her cycle continued for fifty-eight days as her menses was absent. Figure 4.5 shows general well-being scores over the treatment period for the participant.
83 The greatest improvement was noted in the first month of the trial. This was maintained at a high level in the second month. The participant underwent surgery thus bringing her general well-being score down. Figure 4.6 shows the ratings of the individual questions of the General Well-being Questionnaire. When comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the third month of the trial it was noted that improvement had occurred in her general well-being, health, depression, nervousness and anxiety, worry, happiness as well as energy levels. After surgery all ratings per question were not scored as high as the second and third month. Table 4.2 shows midcycle mucus changes over the treatment period. It was evident that her midcycle mucus changes were ideal (clear, stretchy and slippery) on days 12, 13 and 14 of her cycle. Although the participant showed overall improvement, pregnancy was not achieved during the treatment period.
84
Participant 2 - Basal Body Temperature over the Treatment Period
37.2 37 36.8 36.6 Cycle 1 36.4 36.2 36 Temperature reading 35.8 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 Day of cycle
Figure 4.4: Basal Body Temperature of Participant 2 over the Treatment Period
Participant 2 - General Well-Being Questionnaire Scores
over the Treatment Period
40 36 34 35 30 25 25 19 20 15
Total Scores Total 10 5 0 1 2 3 4 Consultation
Figure 4.5: General Well-Being Scores of Participant 2 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5
Have you been ill or unwell in 4 the past month? Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? Have you felt worried or upset 0 during the past month?
1 2 3 4 5 6 7 How often have you felt happy during the past month? Month
Figure 4.6: Individual Question Ratings of Participant 2 over the Treatment Period
85 Table 4.2: Midcycle Mucus Changes of Participant 2 over the Treatment Period Cycle 1 Cycle 1 Cycle1 Day 1 Day 22 Clear, Day 42 Yellow, Thick, Thick, Wet Wet Day 2 Day 23 Clear, Day 43 Yellow, Thick, Thick, Sticky Wet Day 3 Day 24 Clear, Day 44 Yellow, Thick, Thick, Wet Wet Day 4 Day 25 Clear, Day 45 Yellow, Thick, Thick, Wet Wet Day 5 Day 26 White, Day 46 Yellow, Thick, Thick, Wet Wet Day 6 Day 27 White, Day 47 Yellow, Thick, Thick, Wet Dry Day 7 Day 28 White, Day 48 Yellow, Thick, Thick, Wet Dry Day 8 Day 29 White, Day 49 Yellow, Thick, Thick, Wet Wet Day 9 Day 30 White, Day 50 Yellow, Thick, Thick, Wet Wet Day 10 Day 31 White, Day 51 Yellow, Thick, Thick, Wet Wet Day 11 Clear, Day 32 Clear, Day 52 Yellow, Thick, Thick, Thick, Wet Wet Wet Day 12 Clear, Day 33 Clear, Day 53 Yellow, Thick, Thick, Thick, Wet Dry Wet Day 13 Clear, Day 34 Clear, Day 54 Yellow, Thick, Thick, Thick, Slippery Dry Wet Day 14 Clear, Day 35 Clear, Day 55 Yellow, Stretchy, Thick, Thick, Slippery Dry Wet Day 15 Clear, Day 36 Clear, Day 56 Yellow, Stretchy, Thick, Thick, Slippery Dry Wet Day 16 Clear, Day 37 Clear, Day 57 Yellow, Stretchy, Thick, Thick, Slippery Dry Wet Day 17 White Day 38 Clear, Day 58 Yellow, Sticky, Thick, Thick, Slippery Dry Wet Day 18 Clear, Day 39 Clear, Thick, Thick, Wet Dry Day 19 Clear, Day 40 Yellow, Thick, Thick, Wet Wet Day 20 Clear, Day 41 Yellow, Thick, Thick, Wet Wet
86 4.3 CASE THREE
Age: 39 (1969) Gender: Female Race: White Occupation: Self-employed Marital Status: Married Weight: 66kg Height: 1,71m BMI: 22.6 Menarche: 14 years of age History of Pregnancy: Three pregnancies, one live birth in 2002, one miscarriage in 1996 and one abortion in 2003 after a vehicle accident.
The participant and her partner had been trying to conceive without the use of contraceptives for more than five years and had consulted with a gynaecologist, infertility specialist and homoeopath concerning their infertility. The participant had undergone an extensive infertility evaluation. This included confirmation of ovulation as well as assessment of ovarian reserve in 2004. Both showed normal findings. A hysterosalpingogram and a laparoscopy were also performed in 2004, both of which showed normal findings. Other tests that were conducted included postcoital tests in 2004 which were normal. The participant’s husband underwent semen analysis in 2004 as well as a test of sperm function. These results showed normal morphology and function. The couple underwent three intrauterine inseminations and an in vitro fertilization in 2004, both of which were unsuccessful. The infertility specialist’s diagnosis was unexplained infertility.
The couple have a daughter of six years who was conceived through assisted conception. The participant contracted chicken pox, whooping cough and measles as a child and had had German measles, MMR and polio vaccinations. She had sought psychological/psychiatric help after a serious vehicle accident in which she lost her third pregnancy in 2003 at four months gestation.
87 4.3.1 First Consultation – June 2008
General History
At the first consultation the participant reported no main complaints. She reported that her energy levels could have been better and that she generally felt more tired in the evenings. The participant had no particular sensitivity to hot or cold but preferred warm weather to cold wet weather. Her appetite was good and she enjoyed food. She enjoyed savoury foods and had been craving oysters in particular. She described herself as thirstless and only had about two cups of tea a day.
The participant reported that she had no problems with her sleep. She awoke at about 1am to urinate and had dreams of abductions and hijackings as well as of her father who had already passed away. She generally slept on her left side and woke feeling refreshed. There were no complaints as far as her perspiration, urination and stool was concerned.
The participant’s menses typically lasted five to six days and she sometimes experienced breast tenderness which was better for pressure. A few hours before her menses began she experienced lower abdominal pain. This pain was felt in the back and across the lower abdomen. Although she did not experience this pain every month, on occurrence it was ameliorated by warmth as well as after a few hours of bleeding. She also experienced irritability and impatience before and during her menses. Her menses was usually bright red and clotted. She described her flow as heavy. Previously she had felt a very sharp pain in the region of her uterus which was so severe she would have to hold her breath and keep as still as possible. This pain was experienced a few days into her period and usually lasted between ten to twenty seconds. She also noted that around day seven of her cycle, when she thought that her menses had ceased, she would experience a discharge of blood described as a “gush of blood”. She used sanitary towels during menses.
She had made use of the oral contraceptive pill twenty-two years ago for a period of two months. Her reason for use was for severe dysmenorrhoea and she experienced adverse effects such as headaches and breast swelling. She had no problems with sexual function. Intercourse occurred about four times a week. She also noticed a normal physiological discharge throughout her cycle, especially at ovulation.
Mentally and emotionally the participant reported that everything was fine and she was happy. She avoided discussing serious issues or the loss of her second pregnancy. She described her personality
88 as being cheerful, happy and outgoing. She explained that she bottled up emotions when she was faced with grief or shock. She also described herself as tearless but when explaining the accident she was involved in, in 2003, she became emotional. The participant cried and expressed her frustration at the man who caused the accident and she said that she felt hurt, with a sense of injustice that “her little girl” was taken away from her.
Review of Systems
The participant reported that she bit her nails out of habit. No other complaints were noted
Family History
Mother: Aged 83 - Cancer survivor Father: Deceased 68 - Stroke Grandparents: Pneumonia Siblings: Good health Children: Age 6 - Good health Family history: Cancer and arthritis
Medication
The participant was taking FoodState Pregnancy Formula® as well as a Calcium and Magnesium supplement.
Physical Examination
Vital Signs:
Blood Pressure: 134/84 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.3ºC Weight: 66kg
89 General Examination:
No findings were observed on physical examination.
Motivation for Remedy Selection
The researcher decided to prescribe Natrum muriaticum after repertorisation, the key note of which was suppression of emotional pain (Bailey, 1995). Natrum muriaticum is the top ranking medicine in homoeopathy for sterility (Kandpal et al, 2004). During the first consultation the participant showed much suppression of emotional pain, particularly over the loss of her second pregnancy. She also came across as being very controlled and showed an inability to let go of her emotions and of the baby she lost. She did not like talking about her feelings and appeared to find difficulty in crying. She would thus avoid her feelings by smiling and laughing (Bailey, 1995). The participant also showed ‘craving for oysters’, ‘dreams of robbers’, ‘irritability before menses’ and ‘biting of nails’ all of which are Natrum muriaticum symptoms (Schroyens, 2001; Vermeulen, 2001). The 30th potency was prescribed because of the mental and physical presentation of the case.
Prescription
Natrum muriaticum 30cH, one powder taken twice a day for one month.
4.3.2 Second Consultation – August 2008
General History
At the second consultation the participant reported that her energy levels were good throughout the day but tended to be poor in the evenings. She still craved oysters and found that she enjoyed seafood. Her sleep had not been of a good quality and she would wake up between 4am and 5am and would be unable to fall asleep again. At this time she would generally need to urinate and she reported that she had not been having any strange dreams. She had been sleeping on her back.
Her menses had commenced earlier this cycle. Before her menses began, the participant experienced slight abdominal discomfort that disappeared as soon as her menses began. Her menses lasted five days and appeared to be bright red in colour, more fluid in nature and with less clots. It became darker as she approached the end of her menses. She experienced no breast tenderness, no
90 backache or abdominal pain and no irritability before or after her menses. The flow was more even throughout the five days and there was no “gush” of blood on day six as there had been in previous months. The participant had been very surprised at the improvement in her menstrual symptoms. No sharp pain had been experienced.
Mentally and emotionally the participant described herself as being “fine”. She avoided questions relating to her emotions and seemed uncomfortable when discussing her feelings and experiences.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 110/72 mmHg (Right arm, sitting upright) Heart Rate: 76 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.0ºC Weight: 64kg
General Examination:
Slight yellow discolouration of the sclera was observed as well as slight pitting oedema in both lower limbs.
Discussion
The researcher was pleased with the participant’s results after the first month. The participant was still closed and did not volunteer any emotional symptoms. Although her menstrual and general symptoms had improved, the researcher felt that the remedy needed more time to work, thus the prescription was repeated.
91 Prescription
Natrum muriaticum 30cH, one powder taken twice a day for one month.
4.3.3 Third Consultation – September 2008
General History
The participant reported that her energy levels were very poor and that she was feeling exhausted. She found that her appetite had increased and related this increase in appetite to a stressful situation at work. She had also found that she had become hungry at night. There was no time in particular at night that she noticed this hunger. Her thirst had increased slightly and she reported that she was drinking a lot more tea than before as well as about 1-1.5 litres of water per day.
Her sleep had still been poor and she noted that she would fall asleep easily but would awake between 12pm and 2am. During this time she would toss and turn and she found that her mind would be very busy. She would typically think about the stresses at work. She would awake in the morning feeling tired and unrefreshed.
She was constipated and found that she experienced a bowel movement every third day. She related the constipation to a poor diet over the last few weeks due to stress at work. She experienced much bloating and flatus that was worse in the morning and between 6pm and 7pm at night. It was very difficult to pass a stool.
Once again her menses had been early and appeared on day twenty-three of her cycle. There had been no pain experienced; this included no backache and no abdominal pain. Her menses had begun in the early hours of the morning and lasted for six days. She described the six days as three days of bleeding followed by three days of discharge. The blood had been red in colour and was more fluid than previous months with very few clots. The discharge was described to be “watered down” with no noticeable odour. There was very slight breast tenderness that was worse for pressure and the participant reported not feeling irritable before or during her menses. The flow of blood was constant and there was no “gush” of blood or sharp pain experienced.
92 Mentally and emotionally the participant was more open. She described her worry at losing her job as well as her fear of the unknown. She was worried about financial issues and became tearful when discussing her problems and appeared to be despondent and concerned.
Review of Systems
The participant reported no desire to bite her nails.
Physical Examination
Vital Signs:
Blood Pressure: 110/78 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC Weight: 64kg
General Examination:
Pitting oedema of both lower limbs was observed which was more noticeable than the previous month.
Discussion
The researcher and the participant were happy with the progress thus far. Her menstrual and general symptoms continued to improve gradually and the participant was also becoming more open emotionally. The researcher felt that the remedy needed yet more time to work, thus the prescription was repeated.
Prescription
Natrum muriaticum 30cH, one powder taken twice a day for one month.
93 4.3.4 Fourth Consultation – October 2008
General History
The participant reported that her energy levels had been very good before she had become sick with gastroenteritis a few days prior to the fourth consultation. While sick the participant felt very tired and weak. When asked about her appetite she described herself as starving with a craving for oysters and boiled eggs. She felt exceptionally thirsty and attributed this to being dehydrated.
She felt very tired although she was no longer waking up as much during the night. She would awake in the mornings feeling tired. She also explained that before becoming ill with gastroenteritis her sleep had greatly improved.
The participant described her stool as very watery and pale green to yellow in colour. As soon as the participant ate she would have an episode of diarrhoea. She experienced cramps mostly at night that were worse on the left side yet when passing a stool there was no pain. There had not been as much bloating and gas as there had been in previous months. She reported that before becoming ill with gastroenteritis her bowel movements had improved and were regular.
Her menses had lasted a total of six days and had started on the twenty-fourth day of her cycle. Before her menses commenced she had not experienced any irritability, backache or abdominal pain. Flow had commenced at night. She described the blood as dark with no clots and the flow was medium. She had not experienced a discharge at the end of her menses, nor was there any sharp pain or gush of blood at this time. She had, however, experienced severe breast tenderness and swelling. She described this as the worst breast tenderness she had ever experienced. It had been worse at night and for pressure and better for taking off her clothes and undergarments. Mentally and emotionally she felt very weak and tired as she had not yet recovered from the gastroenteritis.
Review of Systems
No complaints were reported during the review of systems.
94 Physical Examination
Vital Signs:
Blood Pressure: 88/68 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.5ºC Weight: 64kg
General Examination:
Very slight pitting oedema in both lower limbs was observed, which was improved from the previous month.
Motivation for Remedy Selection
The researcher noted the participant’s low blood pressure and attributed this to her gastroenteritis which had left her feeling weak and unable to eat. Although Natrum muriaticum had improved mental and general symptoms, the researcher felt that Natrum muriaticum was no longer the similimum remedy for the case and thus decided to change the prescription.
The researcher re-analysed the case and after repertorisation decided to prescribe Calcarea carbonica. The following symptoms are found in the symptom picture of Calcarea carbonica that match the participant’s symptom picture; ‘desire for hard boiled eggs’, ‘thirsty’, ‘desire for oysters’, ‘breasts swollen and tender before menses’, ‘menses too early’ (Vermeulen, 2001). ‘Ailments from the death of a child’ is also a feature of the remedy and was seen in the participant’s case (Schroyens, 2001). The remedy was prescribed in low potency and frequently due to the physical nature of the case.
Prescription
Calcarea carbonica 6cH, one powder taken twice a day for one month
95 4.3.5 Fifth Consultation – November 2008
General History
At the fifth consultation the participant reported that the gastroenteritis had completely cleared. Her energy levels had improved, however, she was still worse in the mornings. She had been feeling warmer lately and she had no longer felt excessively hungry. She craved sweets before her menses and was averse to potatoes.
Her sleep had improved but she would awake at 1am because she was worried about work-related issues. Once waking she struggled to fall asleep again and would wake in the mornings feeling unrefreshed. She slept on her left side, her right side and then on her back. Bowel function had been normal except on the day her menses commenced, where she experienced constipation.
Her menses commenced on the twenty-seventh day of her cycle and lasted three to four days. She had felt irritable before her menses and had experienced a dull ache in her lower abdomen on the day her menses commenced. Flow had commenced in the morning and was described to be a normal red colour with no clots and heavy flow. No discharge was noted after menses. There was no breast tenderness before or during her menses and she had not experienced the gush of blood after her menses. The participant noticed a slight decrease in her breast size. Generally she noted that her menses had been a lot better than previous months and that the pain was greatly decreased as was her general bloating during her menses. Mentally and emotionally she was feeling better than the last month and was feeling more positive and happy.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 102/72 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 9 breaths per minute
96 Temperature: 36.4ºC Weight: 63kg
General Examination:
Very slight pitting oedema was observed in both lower limbs.
Discussion
The participant showed significant improvement in her menstrual and general symptoms. The researcher was pleased with the participant’s progression over the last four months. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month.
Prescription
Calcarea carbonica 6cH, one powder taken twice a day for one month.
4.3.6 Sixth Consultation – December 2008
General History
The participant presented with a cough at the sixth consultation. The cough was worse at night and had started three nights prior to the consultation. The cough was tickling and irritating in nature. The participant said that the cough disappeared after 8am. There was a small amount of expectoration that was white, thick and had an offensive taste.
Her energy levels were good except after eating, when she felt tired. In general she still felt warmer than before, and her appetite was normal. She had craved nuts and was averse to bread and potatoes. The participant reported that her cough had disturbed her sleep. She awoke at 1am to urinate although this was no longer due to work-related worries. She awoke in the morning feeling alternately good or tired. Stool and urination were reported to be normal and regular.
The participant explained that her menses had begun on the twenty-seventh day of her cycle and had lasted three to four days. There had been a general dull ache experienced a few hours before her
97 menses commenced. She described the blood to have been a normal red colour, free of clots and heavy to medium in flow. Flow commenced in the morning and it was noted that when urinating, flow increased. There had been no pain throughout her menses. No discharge was present after her menses. She had experienced no breast tenderness and no decrease in breast size. She also commented on the absence of any bloating or constipation.
Mentally and emotionally she had noted slight irritability due to work-related issues, but in general she had been feeling much better and mentioned that she was happy to have seen further improvement in her menstrual symptoms.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 100/70 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.0ºC Weight: 64kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant continued to show significant improvement in her menstrual and general symptoms. The participant was starting to experience normal menstrual cycles. She was pleased with the progress thus far. The researcher however decided to continue with the same prescription owing to the chronicity of the case.
98 Prescription
Calcarea carbonica 6cH, one powder taken twice a day for one month.
4.3.7 Seventh Consultation – January 2009
General History
At the final consultation the participant reported that her menses had been twelve days overdue. During this time she reported that she had experienced breast tenderness which was aggravated by touch and better for removing her undergarments. She had become very thirsty and she noted that her urination had increased significantly. During this time she had been feeling much hotter and her appetite had increased significantly. She had been craving bacon, eggs and nuts, while being averse to bread and potatoes. She had also noted that she had put on weight. The participant explained that her energy levels had been very poor especially during the time her menses was overdue. She felt extremely tired. The participant explained that all she had wanted to do was sleep. She recalled the last time she had experienced these symptoms of lethargy and tiredness was when she was pregnant with her first child.
During the time her menses was overdue the participant had become ill with a cough and sore throat. She described the sore throat as a dry sensation with a grating pain that was worse for eating and better for sipping water. Her cough was dry and produced an expectoration that was thick and mucus-like. The participant had visited a general practitioner who had prescribed a course of antibiotics.
On the eleventh day after her menses was supposed to have commenced, the participant experienced severe backache that was rated nine out of ten. This pain was worse for movement and better for hot application as well as being immersed in the swimming pool. On the night of the eleventh day the participant started experiencing pain in her lower abdomen which was described as a continuous and aching pain. Nothing ameliorated this pain except for lying down on her left side in the foetal position which offered slight amelioration. The following morning the pain was still present and had increased in severity. The pain had been so severe that the patient had to hold her abdomen. She described the pain to be “like a knife cutting across her abdomen”.
99 She had begun bleeding on the twelfth day and her menses lasted six days. The severe abdominal pain was continuous over these six days. The participant described the blood as dark or “ox blood” in colour. There had been very little blood on the first day of bleeding. The next day the participant explained that the blood had been the most clotted it had ever been and there were stringy membranes in between the clots. The flow had been the heaviest it had ever been. While urinating the participant explained that large lumps of clotted blood were passed. She had also experienced severe bloating.
Mentally and emotionally the participant felt very disappointed. She believed that she had been pregnant and explained that physically she had felt the same symptoms she had in her previous pregnancies. During her first and second pregnancies the participant had experienced the exact same symptoms. She did not go for blood test to confirm pregnancy as she had been unable to go over the festive season. The participant explained that there was a part of her that was excited and happy that she had fallen pregnant and that she felt it could happen again. Two weeks after the completion of the study the participant reported to the researcher that her menses began again indicating a cycle of fourteen days after her last menses.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 120/80 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.3ºC Weight: 64kg
General Examination:
Slight light pitting oedema was observed in both lower limbs.
100 Discussion
The participant was pleased with the results of the last month of treatment, and the researcher was satisfied with the prescription change. Owing to the severity of the participant’s last menstrual cycle the script was repeated for another month.
Prescription
Calcarea carbonica 6cH, one powder taken twice a day for one month.
4.3.8 Overview of Case Three
The participant showed a favourable response to the Natrum muriaticum and responded even better to the Calcarea carbonica. Figure 4.7 demonstrates that the participant was estimated to have ovulated between days ten and thirteen of her cycle. Figure 4.8 showed a gradual decrease in general well-being from month zero to month three and slight improvement on month four. This occurred while the participant was treated with Natrum muriaticum. The participant showed much amelioration on a mental level but it was felt by the researcher that the case had progressed and a new remedy was required. The researcher changed the remedy to Calcarea carbonica and observed a slight increase in general well-being scores from month four to six. The participant reported significant improvement in her menstrual and general symptoms while treated with Calcarea carbonica. A decrease in general well-being was experienced from month six to seven which was described by the participant to be due to suspected pregnancy and subsequent miscarriage. Figure 4.9 shows the ratings of the individual questions of the General Well-being Questionnaire. It was noted that when comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial, the participant felt worse at the end of the trial. Table 4.3, showing midcycle mucus changes, indicates that conditions appeared to be ideal (clear, stretchy and slippery) on day 17 of the first cycle, on days 11, 12 and 15 of the third cycle, and on days 13 to 15 of the sixth cycle. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated as were her general symptoms. Pregnancy is suspected to have been achieved during the last month of the trial. The participant presented with increased frequency of urination, breast swelling and tenderness, nausea, fatigue and amenorrhoea. Also, on observation of Figure 4.5 it is evident that the participant’s basal body temperature was elevated in the luteal phase of the last cycle of the trial. This sustained elevation in basal body temperature is also an indication of conception.
101 Participant 3 - Basal Body Temperature over the Treatment Period
38.5 Cycle 1 38 Cycle 2 37.5 Cycle 3 Cycle 4 37 Cycle 5 36.5 Cycle 6 Temperature reading Temperature 36 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Day of cycle
Figure 4.7: Basal Body Temperature of Participant 3 over the Treatment Period
Participant 3 - General Well-Being Questionnaire Scores over the Treatment Period
38 40 36 37 32 35 30 30 28 25 21 20 15
Total Scores Total 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.8: General Well-Being Scores of Participant 3 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5 Have you been ill or unwell in 4 the past month? Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? Have you felt worried or upset 0 during the past month?
1 2 3 4 5 6 7 How often have you felt happy during the past month? Month
Figure 4.9: Individual Question Ratings of Participant 3 over the Treatment Period 102 Table 4.3: Midcycle Mucus Changes of Participant 3 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Day 1 Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses Day 5 Menses Menses Menses Menses Menses Menses Day 6 No Discharge Menses Menses No Discharge Menses Menses Day 7 No Discharge No Discharge Menses No Discharge No Discharge No Discharge Day 8 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 9 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 10 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Clear, Stretchy, No Discharge No Discharge No Discharge Day 11 Slippery No Discharge No Discharge Clear, Stretchy, No Discharge No Discharge White, Sticky, Day 12 Slippery Slippery No Discharge No Discharge White, Sticky, No Discharge No Discharge Clear, Stretchy, Day 13 Wet Slippery No Discharge White, Sticky, White, Sticky, No Discharge Clear, Clear, Stretchy, Day 14 Wet Slippery Thick, Slippery Slippery Clear, Thick, White, Sticky, White, Thick, White, Sticky, Clear, Clear, Stretchy, Day 15 Slippery Wet Wet Dry Thick, Slippery Slippery White, Thick, White, Sticky, No Discharge White, Sticky, Clear, No Discharge Day 16 Slippery Wet Dry Thick, Slippery Clear, Stretchy, White, Sticky, No Discharge White, Sticky, No Discharge No Discharge Day 17 Slippery Wet Dry Clear, Thick, White, Sticky, No Discharge White, Thick, No Discharge No Discharge Day 18 Slippery Wet Dry No Discharge No Discharge No Discharge White, Thick, No Discharge No Discharge Day 19 Dry Day 20 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 21 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 22 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 23 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 24 No Discharge No Discharge No Discharge No Discharge No Discharge Day 25 Day 26 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 27 Day 28 No Discharge No Discharge No Discharge Day 29 No Discharge No Discharge Day 30 No Discharge No Discharge Day 31 No Discharge No Discharge No Discharge Clear, Day 32 Thick, Slippery No Discharge White, Thick, Day 33 Slippery No Discharge White, Thick, Day 34 Slippery Day 35 No Discharge No Discharge Day 36 No Discharge No Discharge Day 37 No Discharge No Discharge Day 38 No Discharge
103 4.4 CASE FOUR
Age: 35 (1973) Gender: Female Race: White Occupation: Accountant Marital Status: Single Weight: 80kg Height: 1,76m BMI: 27.1 Menarche: 14 years of age History of Pregnancy: One pregnancy and one spontaneous miscarriage.
This participant was single and was not in a sexual relationship. In 2006 she decided to go for intrauterine insemination and has thus been trying to conceive for two years. She had consulted with a general practitioner and a gynaecologist about her infertility. The participant had undergone an extensive infertility evaluation. This included confirmation of ovulation in 2006, the findings of which were normal. A hysterosalpingogram and a laparoscopy were also performed in 2007, and showed normal findings as well as patent fallopian tubes. The sperm bank where sperm was obtained guaranteed normal motility, morphology and function of the sperm. The participant underwent thyroid testing which was normal in 2007. In 2006 the participant underwent one intrauterine insemination. In 2007 the participant underwent another intrauterine inseminations, and in 2008 another two intrauterine insemination. All attempts at conception were unsuccessful. The same sperm donor was used in 2006 and 2007. Two different donors were used in 2008. The gynaecologist’s diagnosis was unexplained infertility.
The participant had contracted chicken pox and measles as a child. She had also received the BCG, hepatitis, yellow fever and polio vaccinations. She was currently taking Tetralysal® 150mg daily for prediagnosed rosacea. Tetralysal® is contraindicated in pregnancy and may result in candida overgrowth. The participant was notified of this and decided that she would stop her rosacea medication so as to take part in the study.
104 4.4.1 First Consultation – April 2008
General History
At the initial consultation the participant volunteered that she tended to be emotional. She explained that she was like a valve, as soon as she had “blown her lid” she would be fine straight afterwards. She would cry when extremely stressed and described crying as a stress relief. She generally took long to trust people and found it difficult to become close to a man when in a relationship. She loved her independence and loved travelling. She explained that she had a poor self-esteem.
Her energy levels were worst between 3pm and 4pm and she would get very hot easily. She loved the sea and was craving popcorn, salts, cheese, biscuits and savoury foods. She felt thirsty but was averse to drinking. She experienced profuse perspiration under her arms, under her breasts and at the back of her neck which soaked her clothing. She experienced good sleep but would awake unrefreshed. She slept on her left side and urinated twice a day. She had regular bowel habits, but experienced bloating which felt better after stool. Occasionally she would experience discomfort on passing a stool as well as slight bleeding.
The participant explained that her menstrual cycle was typically twenty-three days and her menses would last five to seven days. The participant experienced much bloating as well as menstrual cramps before menses. She also experienced increased breast tenderness before her menses. At this time she would feel very emotional and would cry easily which ameliorated her premenstrual symptoms as did commencement of flow. She experienced increased sexual desire before and during her menses and described this as a “craving for sexual intercourse”. The participant experienced severe cramps and profuse flow particularly on the second day of her cycle. The participant described the blood as bright red in colour and clotted while flow was heavy. After flow she experienced a brown vaginal discharge with a slight odour. The participant used sanitary towels, tampons and panty liners.
She had made use of the oral contraceptive pill in 1989 for a period of six months. Her reason for use was for severe acne and she experienced no adverse reactions. She was not sexually active and recalled experiencing pain on intercourse a year before as well as much vaginal dryness. The participant would be consulting with her gynaecologist on a monthly basis for timely ultrasound and monitoring of follicles and subsequent artificial insemination with donor sperm. The participant had noticed a normal physiological discharge throughout her cycle and at ovulation.
105
The participant explained that she still struggled to accept and deal with the loss of her pregnancy two years ago. Conception had occurred naturally. Although unplanned, she was distraught when she miscarried a few weeks into gestation. Thereafter she decided to try fall pregnant again. She explained that she feared taking the “next step” with a man as well as the possible loss of independence. She felt sad that there wasn’t anyone there to “hold her hand and go through the process of falling pregnant with her”. She felt that the process of collecting the donor sperm and being inseminated as lacking the emotional support she would like. She added that not having a child affected her negatively but she feared what would happen to the child if something happened to her. She was tearful while discussing this. She explained her personality as extroverted. She feared heights and added that she experienced an “urge to jump” when at a height. She mentioned that she was tearful and laughs or cries during times of grief or shock.
Review of Systems
The participant reported that she experienced rosacea and that the skin on her cheeks was red, dry and flaky. These symptoms were worse for spicy foods and chillies as well as excessive exercise. She added that her toes were always cold.
Family History
Mother: Aged 61 - Type II Diabetes Father: Aged 68 - Type II Diabetes Grandparents: Good health Siblings: Good health Family history: None
Medication
The participant had been taking Tetralysal® 150mg daily for prediagnosed rosacea. She was to stop its use while on the trial.
106 Physical Examination
Vital Signs:
Blood Pressure: 118/76 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 35.7ºC Weight: 80 kg
General Examination:
Marked pitting oedema of both lower limbs was observed on examination.
Focused Physical Examination:
The participant’s skin was observed. It appeared red, dry and flaky. Two eruptions were noted on the right cheek.
Motivation for Remedy Selection
After repertorisation the researcher decided to prescribe Pulsatilla pratensis. The participant showed symptoms such as a ‘amelioration from weeping’, ‘sexual desires increased during menses’, ‘discolouration of the face on excitement’, ‘weeps easily when disturbed at work’, ‘aversion to drinking accompanied by thirst’, ‘sterility’ which were all prominent symptoms in the symptom picture of Pulsatilla pratensis (Schroyens, 2001). Other rubrics which were used included ‘menses bright red and clotted’, ‘fear of high places’, ‘mammae aggravated before menses’, ‘swelling of the lower limbs’, ‘weeping when telling others of her sickness’, ‘weeping before and during her menses’ and ‘weeping easily’ (Schroyens, 2001). These rubrics featured Pulsatilla pratensis. The participant also showed a craving for cheese, she was worse for warmth and worse before menses. She was easily moved to laughter or tears and appeared to be of an affectionate, mild and gentle disposition (Vermeulen, 2001; Tyler, 1988; Bailey, 1995). The 30th potency was prescribed owing to the combination of mental and physical symptoms in the case.
107 Prescription
Pulsatilla pratensis 30cH, one powder taken once a day for one month.
4.4.2 Second Consultation – May 2008
General History
At the second consultation the participant reported a thick green to white nasal discharge which had been worse in the mornings. She added that she had felt this mucus moving down the back of her throat. Her energy levels were unchanged and her appetite decreased. On waking in the mornings she had experienced a taste of bile in her mouth which was better after eating. The participant recalled that she had noticed a slight improvement in her perspiration since last month.
Her sleep had been restless owing to work related issues which she had been worried about. The participant’s urination had been unchanged while the odour had improved. Her bowel function had not been as regular as it had been the first week after the first consultation. She explained that she had not been constipated or bloated in the last month and had not experienced discomfort or bleeding on passing a stool.
The participant explained that she had not experienced any breast tenderness or swelling before her menses. No bloating before menses was noted either. She reported that she had not experienced any menstrual cramps throughout the duration of her menstrual cycle. She described the menses as dark in colour with dark clots. This was most prominent on day three of her cycle. She had not experienced a brown discharge this month and added that she had not felt as emotional and had not felt like crying. She explained that her menses had not been as heavy as it usually had been. Mentally and emotionally she explained that she was feeling positive but was worried about work related issues.
Review of Systems
The participants rosacea had improved and had not been as red as it had been previously. She had not experienced any skin eruptions over the past month.
108 Physical Examination
Vital Signs:
Blood Pressure: 100/68 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 35.8ºC Weight: 80kg
General Examination:
Pitting oedema of both lower limbs was observed on examination but was greatly improved from the previous month.
Focused Physical Examination:
The participant’s skin was observed. The appearance had improved and was not as red and flaky as it had been last month. No eruptions were noted.
Discussion
The researcher was pleased with the participant’s progress after the first month. The researcher felt that the remedy needed more time to work as mild symptoms were still present, thus the prescription was repeated at the same potency and frequency.
Prescription
Pulsatilla pratensis 30cH, one powder taken once a day for one month.
109 4.4.3 Third Consultation – June 2008
General History
The participant presented at the third consultation feeling exceptionally emotional. The participant cried while discussing her troubles. She explained that she longed for support and company and that she felt like she was always alone.
Her sleep had been disturbed as she was waking at about 3am and struggled to fall asleep again. At this point she would lie awake and think about her problems. Her energy levels were described as low and she had felt hungry all the time. She had been craving chocolate at 3pm while her thirst had increased particularly in the mornings. Although her perspiration had generally improved over the treatment period, she noticed profuse perspiration the day before the third consultation.
She had been constipated for an estimated two weeks. She had experienced bloating and discomfort. Her stools had been solid and dark in colour. She added that her stool was in the shape of small balls and was odourless.
Her menstrual flow had been lighter than before and no breast tenderness or menstrual cramps were experienced. The blood was described as bright red in colour and with fewer clots. At the time of her menses she felt good and had not been tearful, frustrated or angry.
Review of Systems
The participants explained that her rosacea had become worse and was exceptionally red and flaky. As she had previously mentioned, this symptom had been worse for eating spicy foods as well as for stress, both of which she had either consumed or experienced in the last few days.
Physical Examination
Vital Signs:
Blood Pressure: 116/70 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 16 breaths per minute
110 Temperature: 36.3ºC Weight: 80kg
General Examination:
Pitting oedema of both lower limbs was observed on examination.
Focused Physical Examination:
The participant’s skin was observed. The appearance was red and flaky.
Discussion
The researcher noted the sensitivity of the participant and was concerned that the participant was proving Pulsatilla pratensis which rarely but sometimes happens in sensitive cases. The researcher thus decided to stop the prescription and wait as no other remedy was better indicated.
Prescription
Nil
4.4.4 Fourth Consultation – July 2008
General History
The participant explained that she was feeling better than the last month and that she noted that when not taking the medication she felt less emotional. Her sleep had improved and she was now able to fall asleep easily and had not been waking during the night. She would awake feeling less tired than she had previously. Her energy levels were improved and she had been feeling more positive. The participant had not been craving chocolates or sweets and was not as thirsty as before. Her perspiration had greatly improved, and was no longer experienced. Her bowel movements were regular and improved.
The participant explained that menstruation commenced on day eighteen of her cycle and the duration of her menstrual cycle had been three days. She had not experienced breast tenderness
111 before her menses. Her menses had been very clotted and bright red in colour. No discharge was noted before or after her menses and the flow was described to have been light. No pain or heaviness was noted during her menses.
Review of Systems
The participant explained that her rosacea had improved.
Physical Examination
Vital Signs:
Blood Pressure: 118/78 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.4ºC Weight: 80kg
General Examination:
Slight pitting oedema of both lower limbs was observed on examination.
Focused Physical Examination:
It was evident that the participant’s skin had improved.
Discussion
The participant appeared to be coping well and was no longer experiencing intense emotional symptoms. Because the participant felt better, the researcher decided to continue to wait and watch the participant’s progress.
Prescription
Nil
112 4.4.5 Fifth Consultation – August 2008
General History
The participant described her emotional state as being “in a good space”. She explained that she felt composed and in control of her life. She also added that felt hopeful for the future and had been enjoying her daily activities. She felt excited about her next artificial insemination. Her energy levels had fluctuated recently and she had been feeling “over heated”. The participant had been feeling thirstier between 4pm and 5pm, as well as at night. During these times of thirst she had wanted cold water. She described increased perspiration under her arms, and said that her sleep patterns had not been good. Her urination and her bowel function were normal.
Her menses had been very short and only lasted three days. One heavy day of bleeding followed by light flow was reported with mild breast tenderness, bloating and emotional symptoms being reported before menstruation. The participant experienced mild lower back pain during menses. No menstrual pains were experienced and her menses was described as having been bright red in colour with few small clots. She added that it had appeared to be more liquid in consistency while no discharge was noted before or after menses.
Review of Systems
She had experienced slight pain in the areas were her rosacea had presented. The skin was no longer as red as it had been previously. She had noted pustular skin eruptions before commencement of her menses.
Physical Examination
Vital Signs:
Blood Pressure: 108/70 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 35.8ºC Weight: 80kg
113 General Examination:
Slight pitting oedema of both lower limbs was observed on examination.
Focused Physical Examination:
A few eruptions were noted on the forehead. Her skin appeared to be less red.
Discussion
The researcher was pleased with the participant’s results. Although she was experiencing mild symptoms, the researcher felt that no prescription was needed as she was feeling generally well.
Prescription
Nil
4.4.6 Sixth Consultation – September 2008
General History
The participant had had her artificial insemination which had not worked. She was not upset when she realised that the artificial insemination was unsuccessful. She felt averse to her occupation, and had not felt as emotional as she had previously. She had been attending church services more regularly and explained that she had felt confused and guilty about receiving artificial insemination. She questioned whether what she was doing was correct and whether it was seen as wrong within her church.
Her energy levels had continued to improve and she still felt hot. Her thirst had decreased and her perspiration was unchanged. The participants sleep had significantly improved and she felt refreshed on waking. Her bowel movements had been normal and regular.
Before commencement of her menses the participant experienced no emotional symptoms, no bloating and no breast tenderness. Her menses lasted three to four days. Heavy flow was consistently noted throughout this duration. The menses was described as bright red and with very
114 few clots. Lower back pain was noted on the first day of flow while no menstrual pain was experienced throughout the rest of the menstrual cycle. The participant experienced a constant headache on top of her head during her menses. Nothing ameliorated or aggravated this symptom.
Review of Systems
The participants explained that her rosacea had been its worst while on the trial. Her back, forehead and cheeks had presented with pustular eruptions before and during her menses. This had cleared after completion of her menses.
Physical Examination
Vital Signs:
Blood Pressure: 104/70 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC Weight: 84kg
General Examination:
Marked pitting oedema of both lower limbs was observed on examination.
Focused Physical Examination:
The participant’s skin had worsened. Pustular eruptions were noted on the above mentioned areas.
Discussion
The participant appeared to be asymptomatic and the researcher felt that there were not enough prominent symptoms present that would warrant the prescription of a remedy. The researcher decided to wait and watch the participant’s progress.
115 Prescription
Nil
4.4.7 Seventh Consultation – October 2008
General History
At the final consultation the participant reported that she had been exercising more which had made her feel good. Her appetite had increased and she had craved chocolate and had been averse to cheese. She felt thirsty for cold water and her perspiration had worsened. It was now most evident under her arms, on her upper lip and nape of her neck. There had been an offensive odour to the perspiration. Her sleep had been of a poor quality and she felt tired and unrefreshed on waking. She had been dreaming considerably about people in her past and would awake at 3am, and had found it difficult to fall asleep again. Her urination had been normal and her stool had been darker and looser than previous months. Her movements had been irregular and smaller amounts at a time. She added that there had been increased bloating and flatus experienced over the previous month.
The participant experienced no premenstrual symptoms. She reported that her menses had lasted four days. She noted slight cramping pains on the left side of her lower abdomen during menses as well as slight lower back pain. The blood was described as being dark red and very clotted. The participant described a continued aversion to her occupation, and described her indifference when she realised that the artificial insemination had again failed.
Review of Systems
The participants explained that her rosacea had improved. She reported a headache which was worse on the left side and for bright lights. Sleep ameliorated her headache.
Physical Examination
Vital Signs:
Blood Pressure: 98/66 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute
116 Respiratory Rate: 13 breaths per minute Temperature: 36.0ºC Weight: 88kg
General Examination:
Marked pitting oedema of both lower limbs was observed on examination.
Motivation for Remedy Selection
The researcher repertorised the case once again and a new remedy was selected. Sepia officinalis fit the case as the participant demonstrated symptoms such as ‘aversion to her occupation’, ‘weeps when telling symptoms’ and ‘indifference’ (Vermeulen, 2001; Bailey, 1995). Sepia officinalis is a well known remedy in cases of sterility. The participant also experienced ‘amelioration from physical exertion’, ‘desires chocolate’, ‘frequent flushes of heat with sweat from least exertion’, ‘distension of the abdomen as from flatulence’, ‘dreams when lying on her left side’, ‘worse for the left side’ (Synthesis, 2001; Vermeulen, 2001; Tyler, 1988; Kandpal et al, 2004). The participant also presented with a headache which was mostly on the left side of her head and better after sleeping. These symptoms fit the Sepia officinalis symptom picture. Owing to the participant’s sensitivity to previous prescriptions, a low potency was prescribed and repetition was reduced so as to avoid aggravations. The case showed physical and mental symptoms so the 12th potency was prescribed.
Prescription
Sepia officinalis 12cH, one powder taken once a week for one month.
4.4.8 Overview of Case Four
The participant showed a favourable response to Pulsatilla pratensis which was followed by aggravation. She showed improvement when the remedy was stopped and was then prescribed Sepia officinalis in the final month of the treatment period. Figure 4.10 showing basal body temperatures of participant four revealed that the participant did not experience ideal basal body temperature patterns during her ovulatory cycles. Figure 4.11 showed the general well-being over the treatment period. The participant showed a steady decline in her general well being between
117 consultations one to three, thereafter an increase in general well being was noted in the fourth month. This occurred while the participant was treated with Pulsatilla pratensis for the first two months and then aggravated in the third month. A thirteen point improvement was noted when the prescription was stopped. A decrease in well-being occurred in the final month and was followed with a prescription of Sepia officinalis. Figure 4.12 shows the ratings of the individual questions of the General Well-being Questionnaire. The ratings per question at the beginning of the trial were compared to the ratings per question at the end of the trial. It was noted that ratings at the beginning of the trial were the same or similar to those at the end of the trial. Table 4.4 shows that participant four experience an ideal ovulatory discharge (clear, stretchy and slippery) on day nineteen of cycle five and days thirteen and fourteen of cycle seven during the treatment period. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated as were her skin symptoms. Pregnancy was not achieved during the treatment period. The reduction in distress in response to artificial insemination could be interpreted as an amelioration due to the inherent complexities of her situation as a potential mother.
118
Participant 4 - Basal Body Temperature over the Treatment Period
37.2 37 Cycle 1 Cycle 2 36.8 Cycle 3 36.6 Cycle 4
36.4 Cycle 5 Cycle 6 36.2
Temperature reading Cycle 7
36 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 Day of cycle Figure 4.10: Basal Body Temperature of Participant 4 over the Treatment Period
Participant 4 - General Well-Being Questionnaire Scores over the Treatment Period
39 40 35 32 32 29 27 30 25 26 25 20 15
Total Scores 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.11: General Well-Being Scores of Participant 4 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5
Have you been ill or unwell in the 4 past month?
Have you felt depressed in the 3 past montth? Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels? 1 Have you felt healthy enough to do the things you want/had to?
0 Have you felt worried or upset 1 2 3 4 5 6 7 during the past month? How often have you felt happy Month during the past month?
Figure 4.12: Individual Question Ratings of Participant 4 over the Treatment Period
119 Table 4.4: Midcycle Mucus Changes of Participant 4 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Cycle 7 Day 1 Menses Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses No Discharge No Discharge Menses Menses Day 5 Menses Menses Menses No Discharge No Discharge No Discharge No Discharge Day 6 No Discharge Menses Menses No Discharge No Discharge No Discharge No Discharge No Discharge Menses Menses No Discharge No Discharge No Discharge Day 7 No Discharge Menses No Discharge No Discharge No Discharge No Discharge Day 8 No Discharge Menses No Discharge No Discharge No Discharge No Discharge Day 9 White, Sticky, Yellow, Thick, No Discharge No Discharge No Discharge Yellow, Sticky, Day 10 Wet Dry Slippery White, Sticky, Yellow, Thick, No Discharge No Discharge No Discharge Yellow, Sticky, Day 11 Wet Dry Slippery White, Sticky, Yellow, Thick, No Discharge No Discharge No Discharge Yellow, Sticky, Day 12 Wet Dry Slippery Clear, Sticky, Yellow, Thick, No Discharge No Discharge No Discharge Clear, Stretchy, Day 13 Wet Dry Slippery Clear, Sticky, White, Thick, No Discharge No Discharge No Discharge Clear, Stretchy, Day 14 Wet Dry Slippery Clear, Sticky, Yellow, Thick, White, Thick, No Discharge White, Thick, No Discharge Day 15 Wet Dry Wet Sticky Clear, Sticky, Yellow, Thick, White, Thick, No Discharge White, Thick, No Discharge Day 16 Wet Dry Wet Sticky Clear, Sticky, White, Stretchy, White, Thick, No Discharge White, Thick, No Discharge Day 17 Wet Sticky Wet Sticky White, Stretchy, Yellow, Thick, White, Thick, No Discharge White, Thick, Yellow, Stretchy, Day 18 Slippery Dry Wet Sticky Slippery White, Stretchy, Yellow, Thick, White, Thick, Clear, Stretchy, White, Thick, Yellow, Stretchy, Day 19 Slippery Dry Wet Slippery Sticky Slippery White, Stretchy, Yellow, Thick, White, Thick, Yellow, Sticky, White, Thick, Yellow, Stretchy, Day 20 Slippery Dry Wet slippery Sticky Slippery Yellow, Thick, Yellow, Thick, White, Thick, Yellow, Sticky, White, Thick, Yellow, Stretchy, Day 21 Wet Dry Wet slippery Sticky Slippery Yellow, Thick, Yellow, Thick, White, Thick, No Discharge White, Thick, Yellow, Stretchy, Day 22 Wet Dry Wet Sticky Slippery Yellow, Thick, White, Thick, No Discharge No Discharge No Discharge Day 23 Dry Wet Yellow, Thick, White, Thick, No Discharge No Discharge No Discharge Day 24 Dry Wet Yellow, Thick, White, Thick, No Discharge No Discharge Day 25 Dry Wet Yellow, Thick, No Discharge Day 26 Dry Yellow, Thick, Day 27 Dry Yellow, Thick, Day 28 Dry Yellow, Thick, Day 29 Dry Yellow, Thick, Day 30 Dry Yellow, Thick, Day 31 Dry Yellow, Thick, Day 32 Dry
120 4.5 CASE FIVE
Age: 39 (1969) Gender: Female Race: White Occupation: Personal Assistant Marital Status: Married Weight: 66kg Height: 1,60m BMI: 25.8 Menarche: 15 years of age History of Pregnancy: No pregnancies.
The participant and her partner had been trying to conceive for more than five years and had consulted with a general practitioner, gynaecologist and infertility specialist. The participant had undergone an extensive infertility evaluation. In 2005 endometrial biopsy showed findings of mild endometriosis and she was sent for laparoscopy and treatment. In 2005 the participant was given Clomiphene citrate over three months, with artificial insemination each month. All three attempts where unsuccessful. Thyroid function tests in 2005 showed normal function. Postcoital tests performed in 2006 were found to be normal. Confirmation of ovulation in 2007 showed normal findings. The laparoscopy in 2007 found normal findings. The diagnosis of the infertility specialist was unexplained infertility.
She had mumps, chicken pox and measles as a child and had not had any immunizations. She sought help from a psychologist in 2007 for difficulties dealing with her infertility.
4.5.1 First Consultation – April 2008
General History
At the first consultation the participant reported that she felt generally unwell. She reported a lot of sneezing as well as phlegm in her throat due to a postnasal drip that was worse in the mornings and difficult to expectorate. The participant described this as a choking sensation. The mucus was white in colour, thick and worse for eating sugar and dairy products.
121 The participant explained that her energy levels were very poor. She felt that she had “nothing in her anymore”. Her energy levels were better in the mornings and while walking around and worse after 2pm. She described herself as a chilly person. She preferred summer but did not like to sit in the sun. Her appetite was good and she preferred savoury foods, particularly salty foods. She craved sweet food during her menses, especially dark chocolate. Although the participant described herself as thirsty, she did not drink much water because it “did not appeal to her”. No symptoms were reported as far as perspiration was concerned. Her sleep was good. She occasionally experienced burning on urination which typically occurred before and after her menses. No problems were reported regarding bowel function.
Before commencement of menses she experienced lower back pain. She also suffered from breast tenderness before and during her menses and said that her breasts felt swollen. She would become very irritable and would have an aversion toward men. Once her menses had commenced she would experience bloating and “terrible” cramps which were worse for eating cold foods and drinks and better for pressure, exercise, warmth, lying down and for hot drinks. These cramps were felt across the lower abdomen from side to side and were rated seven out of ten in intensity. When she experienced these cramps she liked to be alone. Her menses generally lasted six to seven days. The menses was described as dark in colour and clotted, and the flow profuse. She reported that it would “feel like everything was about to come out”. She experienced heavy menstrual flow during the first three days, and at night. She reported that she noticed that her physical symptoms would alternate with her mental symptoms from month to month. She made use of sanitary towels as well as tampons. The contraceptive pill was used in 1997 for purposes of contraception. Adverse effects including nausea and a general “unwell” feeling were experienced.
The participant explained that her sexual function had been “fine” yet she experienced pain on intercourse. She also noticed vaginal dryness before her menses during which time intercourse was painful. The frequency and timing of intercourse was once every two weeks. The participant made no use of lubricants and reported no vulvovaginal symptoms other than vaginal dryness.
Mentally and emotionally the participant felt “drained”. She and her husband had experienced two robberies twelve years prior, and the participant reported that she still felt fearful and anxious about these two events. She felt better after speaking about her problems.
It was difficult for her to discuss her thoughts and feelings about her infertility. She could not relate to people who had children. She felt that her infertility has set her back. She was not able to watch
122 any injustices directed toward children and would get angry and emotional, and cried when she saw children hurt or harmed. She felt that her infertility had affected her relationship negatively and explained that she felt inadequate. She said that she could not show people that side of her life and found that she was better for crying when alone. She felt that her husband didn’t understand the severity of the problem.
The participant described her personality as conservative and quiet. She feared insecurity and felt insecure about the future, her relationship and her job. She disliked change and was better for consolation yet she would not cry in front of people.
Review of Systems
The participant said that her feet were often cold.
Family History
Mother: Good health Father: Good health Grandparents: Diabetes, heart disease Siblings: Good health Family history: Heart disease and mental illness
Medication
The participant was taking a garlic supplements, a vitamin B complex supplement and a prenatal multivitamin supplement.
Physical Examination
Vital Signs:
Blood Pressure: 120/86 mmHg (Right arm, sitting upright) Heart Rate: 62 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 35.6ºC
123 Weight: 66 kg
General Examination:
No findings were observed on physical examination.
Motivation for Remedy Selection
After an in depth analysis and repertorisation had been conducted by the researcher, Cimicifuga racemosa was selected. Characteristic features of Cimicifuga racemosa include symptoms such as ‘depression of the mind and low spirits’, ‘cramping pain extending down the thighs’, ‘pain in the uterus extending from side to side’ or ‘extending across the pelvis from side to side’, ‘pain during menses the more profuse the flow, the greater the suffering’, ‘pains bearing down as if everything would come out’ and ‘mental symptoms alternate with physical symptoms’. These characteristic symptoms were features in the participant’s case. Other symptoms matching the Cimicifuga racemosa symptom picture include ‘menses profuse, dark, clotted’, ‘worse for cold’, ‘better for warmth’, ‘pain in the lumbar region going down the thighs’ (Synthesis, 2001; Vermeulen, 2001). The 12th potency was selected.
Prescription
Cimicifuga racemosa 12cH, one powder taken twice a day for one month.
4.5.2 Second Consultation – May 2008
General History
At the second consultation, the participant reported feeling a lot better mentally and emotionally. She explained that she felt happier within herself. She said that her “spirits had been lighter” and that she felt positive. She no longer felt drained and appeared to be more enthusiastic. She had suffered from influenza and had taken a broad spectrum antibiotic, Coryx® and Sinutab®.
Her energy levels were much better since being on the homoeopathic medication and she no longer felt drained. She felt chilly because of her up coming menses. Her appetite and thirst were unchanged. She recalled craving coffee during her last menses. Her sleep was still good but she
124 found that she would wake up in the middle of the night due to work related stress. There was no longer burning on urination.
The participant experienced much change with her menses. No abdominal pain was experienced at all. Some bloating, backache and breast tenderness were experienced and the flow of blood was still heavy. She mentioned that “it was amazing to feel like that!”. The menstrual blood was unclotted. There was no sensation as if everything would come out and she rated the general discomfort of her menses as between three and four out of ten. The flow had been continuous and there had been less flow at night compared to the previous months.
Review of Systems
The participant reported that her chest had been feeling “blocked up” at night and that nothing ameliorated this sensation. Her feet were not feeling cold and there was a sore pain under the ball of each foot that was worse for walking.
Physical Examination
Vital Signs:
Blood Pressure: 126/88 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 37.1ºC Weight: 65kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant showed much improvement. She was very pleased with the results and showed positive changes on a mental, emotional and physical level. The researcher was pleased with the progress and decided to repeat the prescription owing to the chronicity of the case.
125
Prescription
Cimicifuga racemosa 12cH, one powder taken twice a day for one month.
4.5.3 Third Consultation – June 2008
General History
The participant explained at the third consultation that she had felt very distressed and emotional as she was changing jobs and was also premenstrual. She started discussing her emotional state immediately and cried when she spoke of the injustices committed against her. She said that she had been hurt in the past by other people’s actions and selfishness. She explained that she had suffered the affects of their hurtful actions until today and she felt that it was because of this hurt that she had not been able to fall pregnant. She felt very strongly about this and mentioned that she felt bitter toward family members because of this.
She reported indifference toward her husband and an aversion toward him and his actions. She felt rejected by him and jealous of the affection he showed others. She explained that she craved his affection and asked the question “why can’t he do it to his wife?”. Because of his lack of interest and support she could not be affectionate toward him and explained that she did not even want to try. She cared for him and was however, dedicated to the commitment she had made to him in marriage. She had a tendency to become depressed when thinking of her problems and wanted a child so that her husband would want to spend more time with her. She explained that she longed for the company a child would give her and that her husband had not given her.
Her energy levels were good, yet she had felt stressed and drained in the late afternoon. Her appetite had been normal but because of her high levels of stress she had not been eating correctly. The participant had still been craving chocolate and had not felt very thirsty. Her sleep had been fine except that she had found it difficult to get out of bed in the mornings as she felt tired. She would wake up at 2am and found it difficult to fall asleep thereafter. Her urination had been normal but had increased in frequency to about six to eight times a day. The participant also woke up twice at night to urinate despite unchanged drinking habits.
126 There had been further improvement in her menstrual symptoms. There had been no cramps at all and the flow had not been as heavy as before. The bloating symptoms had improved, as had the backache. Her breast tenderness had been unchanged. The participant described the blood as being bright red in colour, with no clots. There had been no sensation “as if all would fall out” and the menses lasted for four days.
Review of Systems
The participant had been waking with a headache located over the temples which was throbbing in nature. This headache was worse in the mornings. There had also still been phlegm present in the participant’s throat which was due to a postnasal drip. A slight stabbing pain was reported in her abdominal region before her menses. The pain was ameliorated by a hot bath and aggravated by mental irritation. Her feet had not felt cold and the pain under her feet was no longer present.
Physical Examination
Vital Signs:
Blood Pressure: 128/88 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 35.7ºC Weight: 65kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant continued to show improvement and amelioration on a physical level especially her menstrual symptoms. She was now able to express and describe her emotional and mental turmoil. The researcher felt that it was too soon to change the remedy, especially in light of the improvement experienced thus far. The prescription was therefore repeated.
127 Prescription
Cimicifuga racemosa 12cH, one powder taken twice a day for one month.
4.5.4 Fourth Consultation – August 2008
General History
During the past month the participant’s father had undergone surgery. The participant was distraught during this time and had found her day to day experiences exhausting both emotionally and physically. Her energy levels and general well-being were negatively affected during the last month. This was ameliorated by sleeping. The participant’s appetite had increased. She was craving chocolate and had been averse to fatty foods. Her thirst had increased and had been more pronounced in the mornings and late afternoons. She craved fizzy drinks and fruit juices. There had been a burning pain on urination in the mornings.
The participant had experienced two menstrual cycles since the last consultation. The first of the two menstrual cycles had started on the day her father was admitted to hospital. The menses had been very heavy and profuse yet no pain was experienced. The blood had been dark red with no clots and had lasted for five days. The participant experienced no premenstrual symptoms.
The second menstrual cycle was very heavy and lasted for five days. There was more pain experienced but only on the day of and before her menses. The pain was described as a cramping pain in the lower abdomen. Breast tenderness was marked as was the backache and irritability. The blood was red, heavy and clotted and there had been much bloating before her period began. The participant had requested that her fourth consultation be postponed, and subsequently she ran out of medication for approximately three weeks. She attributed her deteriorating menstrual symptoms to the lack of medication during that time. Mentally the participant felt tired but relieved that her father’s surgery had gone well. She felt that the situation took all her energy from her. The participant felt depressed and demotivated.
128 Review of Systems
The participant’s skin had felt dry. No headache had been experienced during the previous month but the participant had recently suffered from an ear infection which had resolved. There was also no tight sensation in the chest.
Physical Examination
Vital Signs:
Blood Pressure: 130/86 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.6ºC Weight: 65kg
General Examination:
Slight yellow discolouration of the sclera as well as slight pitting oedema of both lower limbs was observed.
Discussion
The participant’s father was admitted to hospital and she thus missed her follow up consultation. Another appointment was made, however she ran out of medication for about three weeks. While on the medication the participant continued to improve. During the time the participant was not taking medication, her symptoms seemed to deteriorate. The researcher thus repeated the prescription for the next month.
Prescription
Cimicifuga racemosa 12cH, one powder taken twice a day for one month.
129 4.5.5 Fifth Consultation – September 2008
General History
At the fifth consultation the participant showed much aversion to her husband and family members. Her energy levels were generally improved. She explained that she had been getting hot and cold chills in the early hours of the morning. Her appetite was normal and she had been craving chocolate and coffee. She was still averse to fatty foods. Her thirst had increased considerably in the mornings. On waking she noted that her mouth was very dry. She sometimes struggled to fall asleep and said that during the day all she wanted to do was sleep.
Her menstrual period lasted five days and she had experienced very little pain in her lower abdomen. This pain had been better for exercise and worse for drinking cold water or eating cold foods. The flow had been heavy and the blood was described to have been bright red in colour with no clots. No breast tenderness or backache had been experienced before her menses. The only premenstrual symptom she had experienced was abdominal bloating.
Review of Systems
The participant reported that her skin had still been dry.
Physical Examination
Vital Signs:
Blood Pressure: 132/76 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 35.7ºC Weight: 65kg
General Examination:
No findings were observed on physical examination.
130 Motivation for Remedy Selection
The researcher felt that Cimicifuga racemosa no longer applied to the case. The participant’s case had moved and new symptoms were now evident. Her mental symptoms were now prominent. The researcher repertorised the case once again and a new remedy was selected. Sepia officinalis matched the case as the participant demonstrated symptoms such as ‘aversion to husband’, ‘aversion to family’, ‘dwells on past disagreeable occurrences’, ‘averse to occupation’, ‘weeps when telling symptoms’, ‘easily offended’ and ‘very sad’ (Vermeulen, 2001). The participant also experienced ‘cold sweats at night’, ‘desires chocolate and coffee’, ‘averse to fat and bread’, ‘distension of the abdomen’ (Synthesis, 2001; Vermeulen, 2001; Tyler, 1988). Sepia officinalis is a well known remedy in cases of sterility. There is great sadness and a dread of men (Kandpal et al, 2004). The participant also loved dancing which ameliorated her symptoms and she appeared to have compromised her true nature for so long that she was beginning to lose her spirit for life. Her emotions appear blunted and she was thus indifferent to everything (Bailey, 1994). Vermeulen (2001) states that the Sepia officinalis symptom picture is better for dancing and indifferent to those she loves. Owing to the combination of physical and mental symptoms the researcher decided to prescribe the 30th potency.
Prescription
Sepia officinalis 30cH, one powder taken twice a day for one month.
4.5.6 Sixth Consultation – October 2008
General History
At the sixth consultation the participant reported very low energy levels that were better for sleep. Her appetite had decreased. Her thirst had increased due to the heat. The participant mentioned that she no longer felt as thirsty in the mornings. Her perspiration, particularly over the face, neck and axilla areas had increased. The participant’s sleep had improved and was no longer waking at night to urinate.
Before and during the participant’s menstrual period, she reported being considerably irritable. She had also noted bloating before and during her menses. Her menses lasted four days during which time she had experienced “excruciating” lower abdominal pain. This pain was better for sleep and
131 worse for drinking cold drinks. She described the flow as very heavy and the appearance of menses to have been clotted, and dark red in colour. She experienced no breast tenderness and only slight backache before menses. A brown discharge was present for two days after menses.
Mentally and emotionally she had felt depressed and demonstrated much aversion to her occupation as well as indifference to her family. She also showed an aversion toward her husband. She mentioned her hurt from the past and how people’s actions had caused her infertility and prevented her from having the family and life she had always wanted.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 122/80 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.3ºC Weight: 62kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant showed little improvement in her symptoms. The researcher decided to repeat the prescription as it was felt that the remedy fit the symptom picture of the participant and more time was necessary for a response to occur.
132 Prescription
Sepia officinalis 30cH, one powder taken twice a day for one month.
4.5.7 Seventh Consultation – November 2008
General History
The participant reported that she felt very depressed. She had lost weight and had no appetite. She wanted to be alone to cry. The only thing which ameliorated her depression was dancing. Her energy levels had improved slightly, and she had been thirsty and craving chocolate in the middle of the night. This was pronounced when she was feeling depressed or when she was menstruating. She explained that she had wanted to sleep more and related this to her depression. She felt that she was not getting enough sleep and would wake feeling unrefreshed.
The participant’s menses lasted five days and she had experienced bloating, backache and breast tenderness before and during her menses. This pain had been worse for cold foods, and better for drinking hot drinks, and for hot applications. She had experienced lower abdominal pain on the day her menses commenced which was better than the previous month. She described a sensation of “everything wanting to come out”. The flow was heavy, and the blood bright red and clotted.
Review of Systems
The participant explained the presence of pains all over her body “like something pushing down”. These pains started when her troubles started and she started feeling depressed. These pains felt worse when she was anxious or when she was feeling depressed.
Physical Examination
Vital Signs:
Blood Pressure: 110/84 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 11 breaths per minute Temperature: 36.8ºC
133 Weight: 59kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant presented with depression owing to marital problems. Her mental symptoms had not yet improved, thus the researcher decided to prescribe Sepia officinalis in the 200th potency.
Prescription
Sepia officinalis 200cH, one powder taken once a day for one month.
4.5.8 Overview of Case Five
The participant showed a favourable response to Cimicifuga racemosa. The participant experienced severe symptoms of depression and it was felt that Cimicifuga racemosa no longer fit matched the case. The remedy was changed to Sepia officinalis. Although well indicated, she experienced little amelioration while on Sepia officinalis. Figure 4.13 demonstrates erratic basal body temperatures throughout the treatment period. Figure 4.14 shows general well being scores over the treatment period. The greatest improvement was observed in general well-being in the first month of the treatment period with Cimicifuga racemosa. This was maintained in the second month but a marked decrease in general well being was observed in the third month. This coincided with the participant’s aggravation of marital troubles which were expressed with intense mental and emotional symptoms. Over months four and five a slight increase in general well-being was noted. This occurred while being treated with Sepia officinalis. In the final month of the treatment period yet another drop in general well-being occurred. Once again the drop in score of general well-being coincided with further complications in her marital problems. It should be noted that during months four to six the participant’s father had experienced traumatic back surgery, which was a further stressor on the participant. Figure 4.15 shows the ratings of the individual questions of the General Well-being Questionnaire. When comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial it was noted that improvement had occurred in her health and energy levels. No significant change or decreased in well being was noted in the other
134 individual questions. Table 4.5 shows that at no point during the treatment period did the participant’s midcycle mucus changes ever take the appearance of the ideal ovulatory discharge (clear, stretchy and slippery). The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated in the first five months. As her personal problems became more severe, so did her menstrual symptoms. However her general symptoms ameliorated over the treatment period. Although the participant showed overall improvement, pregnancy was not achieved during the treatment period.
135
Participant 5 - Basal Body Temperature over the Treatment Period
37.4 37.2 Cycle 1 37 Cycle 2 36.8 Cycle 3 36.6 Cycle 4 36.4 Cycle 5 36.2 Cycle 6
Temperature reading 36 35.8 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Day of cycle
Figure 4.13: Basal Body Temperature of Participant 5 over the Treatment Period
Participant 5 - General Well-Being Questionnaire Scores over the Treatment Period
40 35 31 31 27 29 30 24 26 25 25 20 15
Total Scores Total 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.14: General Well-Being Scores of Participant 5 over the Treatment Period
Individual Question Rating
How are you feeling in 5 general? Have yo u been ill or unwell in 4 the past month? Have yo u felt depressed in the past montth? 3 Have yo u felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have yo u felt healthy enough to do the things you want/had to? 0 Have yo u felt worried or upset during the past month?
1 2 3 4 5 6 7 How often have you felt happy during the past month? Month
Figure 4.15: Individual Question Ratings of Participant 5 over the Treatment Period
136 Table 4.5: Midcycle Mucus Changes of Participant 5 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Day 1 Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses White, Sticky, Menses Yellow, Stretchy, Menses Day 5 Slippery Sticky White, Sticky, White, Sticky, Clear, Thick, Yellow, Stretchy, Yellow, Thick, Day 6 Wet Slippery Dry Sticky Slippery White, Sticky, White, Sticky, Clear, Thick, Yellow, Stretchy, Yellow, Thick, Day 7 Wet Slippery Dry Sticky Slippery Yellow, Stretchy, White, Sticky, Clear, Thick, Yellow, Stretchy, Yellow, Thick, Day 8 Slippery Slippery Dry Sticky Slippery Yellow, Stretchy, White, Sticky, Clear, Thick, White, Thick, Yellow, Thick, Day 9 Slippery Slippery Dry Dry Slippery Clear, Thick, Yellow, Stretchy, White, Sticky, Clear, Thick, White, Thick, Yellow, Thick, Day 10 Wet Slippery Slippery Dry Dry Slippery Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, White, Thick, Yellow, Thick, Day 11 Wet Dry Slippery Dry Dry Slippery White Sticky, Clear, Thick, White, Sticky, Clear, Thick, White, Thick, Yellow, Thick, Day 12 Slippery Dry Slippery Dry Dry Slippery White Sticky, Clear, Thick, White, Sticky, Clear, Thick, White, Thick, Clear, Thick, Day 13 Slippery Dry Slippery Dry Dry Dry Yellow, Stretchy, Clear, Thick, Yellow, Sticky, Clear, Thick, Clear, Thick, Clear, Thick, Day 14 Slippery Dry Slippery Dry Dry Dry Yellow, Stretchy, Clear, Thick, Yellow, Stretchy, Clear, Thick, Clear, Thick, Clear, Thick, Day 15 Slippery Dry Slippery Dry Dry Dry Yellow, Stretchy, Clear, Thick, Yellow, Stretchy, Clear, Thick, Clear, Thick, Clear, Thick, Day 16 Slippery Dry Slippery Dry Dry Dry Clear, Thick, Clear, Thick, Yellow, Stretchy, Clear, Thick, Clear, Thick, Clear, Thick, Day 17 Dry Dry Slippery Dry Dry Dry Clear, Thick, Clear, Thick, Yellow, Stretchy, Clear, Thick, Clear, Thick, Clear, Thick, Day 18 Dry Dry Dry Dry Dry Dry Clear, Thick, Clear, Thick, Yellow, Stretchy, Clear, Sticky, Clear, Thick, Clear, Thick, Day 19 Dry Dry Dry Slippery Dry Dry Clear, Thick, Clear, Thick, Yellow, Stretchy, Clear, Stretchy, Clear, Thick, Clear, Thick, Day 20 Dry Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, Clear, Thick, Day 21 Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, Clear, Stretchy, Clear, Thick, Clear, Thick, Day 22 Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, Clear, Thick, Day 23 Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, Clear, Thick, Day 24 Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, Clear, Thick, Day 25 Dry Dry Wet Dry Dry Clear, Thick, Clear, Thick, White, Sticky, Clear, Thick, Clear, Thick, Day 26 Dry Dry Wet Dry Dry Clear, Stretch, White, Sticky, Clear, Thick, Clear, Thick, Day 27 Slippery Wet Dry Dry White, Thick, White, Sticky, Clear, Thick, Day 28 Wet Wet Dry White, Thick, White, Sticky, Day 29 Wet Wet White, Thick, White, Sticky, Day 30 Wet Wet White, Thick, Day 31 Wet White, Thick, Day 32 Wet White, Thick, Day 33 Wet
137 4.6 CASE SIX
Age: 35 (1973) Gender: Female Race: Black Occupation: Department Manager Marital Status: Married Weight: 75kg Height: 1,65m BMI: 27.5 Menarche: 15 years of age History of Pregnancy: One pregnancy, one live birth in 1994 and two spontaneous miscarriages.
The participant and her partner had been trying to conceive for between three to four years. The participant had consulted with a gynaecologist who diagnosed unexplained infertility. The participant had undergone a basic fertility evaluation. Confirmation of ovulation was found to be normal in 2007. Laparoscopy and hysterosalpingogram in 2007 found normal findings and thyroid function tests showed normal functioning. Other tests that were conducted included postcoital tests in 2008 which were found to be normal. The participant’s husband underwent semen analysis in 2008 as well as a test of sperm function. These results showed normal morphology and function.
Childhood illnesses she had experienced included chicken pox and measles. The participant had received the polio and BCG vaccinations.
4.6.1 First Consultation – May 2008
General History
At the initial consultation the participant reported feeling ill. She explained that she was experiencing coryza which was clear and jelly like. The flow of coryza was worse at night and would wake her from sleep.
Her energy levels were average and she felt most energetic in the mornings. She would get hot easily especially at night. She liked sunny weather and experienced episodes of extreme hunger. She craved fish and sweet foods and was averse to broccoli. She was thirstless and explained that
138 the more water she drank the thirstier she would become. She reported no symptoms of perspiration and added that she slept a lot. She had a tendency to talk and on occasions scream out in her sleep. Urination was frequent throughout the day. She experienced difficult stool with ineffectual urging, and added that she had been constipated.
The participant’s menses were irregular and lasted only three days. Before menses commenced she would experience breast tenderness as well as nipple pain. After three days of bleeding she would experience a brown discharge which lasted for some days. The discharge was foul smelling and large in amount. She described the blood as dark in colour, clotted and light in flow. She would experience lower abdominal cramps particularly on the first day of flow. Itching and burning of the vagina was experienced for a few days after menses. This was an uncomfortable soreness. Nothing ameliorated or aggravated this. Her choice of sanitary wear was sanitary towels and tampons.
She used the oral contraceptive pill fifteen years ago and the contraceptive injection seven years prior for contraceptive purposes. She experienced no adverse effects. She reported no problems with sexual function. The frequency and timing of sexual intercourse was about four times a week. She had no vulvovaginal symptoms and did not make use of lubricants.
Mentally and emotionally she explained that she felt happy. She added that she was very easily offended, and found it difficult to accept her husbands apologies if he had offended her. At this point she would normally want to be alone. With regard to her infertility the participant explained that she felt that she owed her husband a child as she already had a son from a previous marriage. She felt that he deserved a child of his own. She explained her personality as introverted and that she did not want to have too many friends. She had no fears and explained that she tended to cry easily even if she was angry.
Review of Systems
The participant had a skin rash where her skin had come into contact with metal. The rash was itchy and better for scratching. Her eyes would become red infrequently and she experienced burning in her mouth on eating oranges. This burning was better for washing her mouth out with water.
Family History
Mother: Deceased - Cerebral Malaria
139 Father: Good health Grandparents: Hypertension Siblings: Healthy Family history: Hypertension
Medication
The participant was taking FoodState Pregnancy Formula®.
Physical Examination
Vital Signs:
Blood Pressure: 150/98 mmHg; 140/92 mmHg; 152/92 mmHg (Right arm, sitting upright) Heart Rate: 70 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.5ºC Weight: 75kg
General Examination:
Slight discolouration around the iris of both eyes was noted on examination.
Motivation for Remedy Selection
Nitricum acidum was chosen for this participant by the researcher after repertorisation and analysis of the case. The participant presented with ‘irregular menses’, ‘scanty menses’ and ‘brown leucorrhoea after menses’ as well as ‘offensive odour of leucorrhoea after menses’. These symptoms are a feature in the Nitricum acidum symptom picture. Other symptoms of the participant which matched Nitricum acidum included ‘burning pain in the vagina after menses’, ‘desire for fish’, ‘constipation with hard stool’, ‘ ineffectual urging and straining at stool’, ‘thirst after eating’, ‘nasal discharge worse at night’ as well as ‘mammary pain before menses’ (Vermeulen, 2001; Tyler 1988). Her symptoms were generally worse at night, and she would experience great hunger and cravings for sweets. She experienced anxious, unrefreshing sleep with frequent waking and an inability to fall asleep again. These symptoms are marked features in the symptom picture of
140 Nitricum acidum (Vermeulen, 2001; Murphy, 1988). She expressed symptoms which were worse for a loss of sleep and explained that she was easily offended and quarrelsome at times. She was ‘unmoved by apologies’ (Vermeulen, 2001). Owing to the physical nature the researcher decided to prescribe the 6th potency so as to avoid aggravations.
Prescription
Nitricum acidum 6cH, one powder taken once daily for one month.
4.6.2 Second Consultation – June 2008
General History
At the second consultation the participant reported that her previous flu symptoms had cleared and that she had been feeling generally better. Her energy levels were unchanged and her appetite decreased. Her cravings and aversions were unchanged and she felt thirstier. She had been waking up at 3am and would fall asleep again at 6am. She felt refreshed on waking and had dreamt of deceased family members and corpses. Her bowel movements had improved since the last consultation and she had up to two bowel movements a day.
Two days prior to the commencement of her menses she had experienced lower abdominal pain which was described it as “like giving birth”. This pain was worse than previously. Her menses had been heavier than before. She had not experienced any breast tenderness before her menses. The menstrual blood had been composed of dark clots and dark blood. On the fourth day the discharge was noted and disappeared only to return again a day or two later. The discharge had had a very bad smell. She had not experienced any burning or itching of the vagina after her menses.
Review of Systems
The rash symptoms were unchanged but the itching was now worse for scratching. She had not experienced a headache over the past month and no redness of the eyes had been noted. The burning in her mouth when eating oranges had improved. She had experienced heart palpitations at times of anxiety. It was added that she had experienced this infrequently while driving or thinking about anxious situations.
141 Physical Examination
Vital Signs:
Blood Pressure: 154/100 mmHg; 150/96 mmHg; 150/92 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC Weight: 75kg
General Examination:
On examination slight discolouration around the iris of both eyes was noted.
Discussion
Very slight amelioration had occurred over the first month. The researcher felt that Nitricum acidum was still well indicated. The researcher thus decided to continue with the 6th potency of the Nitricum acidum so as to continue to stimulate the vital force further and allow for the remedy to work.
Prescription
Nitricum acidum 6cH, one powder taken twice daily for one month.
4.6.3 Third Consultation – July 2008
General History
The participant reported episodes of heart palpitations that were worse in the evenings. She had experienced stiffness in the right arm as if from strain. She had experienced a sore throat at night on waking. Nothing ameliorated or aggravated this symptom. Her energy levels were unchanged and her appetite still diminished. Her thirst symptoms were unchanged while her sleep had improved and she felt refreshed on waking. She had not experienced an increase in frequency of urination before menses and bowel movements had improved to once a day.
142 Her menses lasted five days with light pink blood on the first day and dark red blood on the second day. The blood was generally thick with small clots. On the third day, no blood was observed, while on the fourth day light coloured blood was noted which was not as heavy as previous menstrual cycles. On the fifth day the participant noted the brown discharge which had improved in amount and odour. The participant was happy to report that she had not experienced any premenstrual symptoms. She also experienced no menstrual pains throughout her menses. She was pleased with this and added that she had still not experienced any itching of the vagina after menses. Mentally and emotionally the participant said that she was feeling good.
Review of Systems
The participant reported that the rash symptoms were still unchanged. Her headache symptoms had improved. The burning in her mouth when eating oranges was no longer present.
Physical Examination
Vital Signs:
Blood Pressure: 144/90 mmHg; 140/90 mmHg; 140/94 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.5ºC Weight: 75kg
General Examination:
Slight discolouration around the iris of both eyes was noted
Focused Physical Examination:
Cardiovascular examination found normal contour and amplitude of pulses. All other findings were normal. A musculoskeletal exam also showed normal findings. On examination of the participant’s throat no signs of inflammation were noted.
Discussion
143
Continued improvement was noted in the participant’s case. The researcher was pleased with the progress thus far and felt that further improvement could be achieved using the selected remedy. The researcher thus decided to increase to the 30th potency of the Nitricum acidum so as to stimulate the vital force further.
Prescription
Nitricum acidum 30cH, one powder taken once daily for one month.
4.6.4 Fourth Consultation – August 2008
General History
At the fourth consultation the participant reported improvement in her main complaints. She had only experienced heart palpitations once in the last month, her right arm stiffness had resolved and she no longer experienced throat symptoms. Her energy levels had improved and her appetite was increased. Stool and urination was normal and regular.
Her menstrual cycle had commenced a few days later than the participant had expected. She reported no premenstrual symptoms except slight breast tenderness and no menstrual pains. Menses lasted five days and was dark red in colour. She explained that the consistency had been thick and the flow heavy. She explained that she still had the discharge after her menses, but that it was continually improving. Once again, no itching of the vagina was reported.
Review of Systems
Her skin symptoms had cleared.
Physical Examination
Vital Signs:
Blood Pressure: 140/90 mmHg (Right arm, sitting upright) Heart Rate: 70 beats per minute
144 Respiratory Rate: 15 breaths per minute Temperature: 36.5ºC Weight: 75kg
General Examination:
Slight discolouration around the iris of both eyes was noted.
Discussion
Both the researcher and the participant were pleased with the participant’s response to the remedy as well as to her asymptomatic state. The researcher decided to stop the prescription and wait and watch the participant’s progression over the next month.
Prescription
Nil
4.6.5 Fifth Consultation – September 2008
General History
The participant’s energy levels were very good. She had been feeling hot at night. She had been craving pizza and was still averse to broccoli. Her thirst symptoms were unchanged and her sleep was good.
About three days before her menses she experienced lower abdominal pain that was cramping in nature. She also experienced breast tenderness that was worse for pressure before her menses. Her nipples were especially painful during this time. Her menstrual flow lasted for five days. There were no menstrual pains during menses. The blood was described as medium flow and dark red with few clots. She had a brown discharge on the fourth day of her cycle which had an offensive odour.
Mentally and emotionally the participant reported that she was stressed and she felt anxious because of work-related issues. She experienced tightness in the chest during this anxiety.
145
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 130/86 mmHg (Right arm, sitting upright) Heart Rate: 70 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.6ºC Weight: 73kg
General Examination:
Slight discolouration around the iris of both eyes was noted.
Discussion
Besides minimal discomfort at time of menstruation, the participant had maintained an asymptomatic state. The researcher felt that her progress thus far was good and decided to allow the participant to continue without a prescription.
Prescription
Nil
4.6.6 Sixth Consultation – October 2008
General History
The participant had been feeling very hot at night and felt better when opening the window. She had experienced breast tenderness about three days before her menses. There was no nipple pain but
146 there was breast swelling and the pain was worse for touch and better for commencement of menses. Her menses lasted for four days during which time there was no menstrual pain. There had been heavy flow during the first two days of menses, with lighter flow on days three and four as well as a brown discharge on day four of her cycle. The discharge had been less than the last month. The blood was a brighter red than before and had no clots. She had not experienced pain on intercourse.
Mentally and emotionally the participant felt stressed because of work related issues but she had not felt anxious in the last month. She had not experienced tightness in the chest.
Review of Systems
The participant explained that she had experienced heart palpitations once during the last month. She felt better when relaxing and for breathing deeply.
Physical Examination
Vital Signs:
Blood Pressure: 122/80 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.6ºC Weight: 75kg
General Examination:
A brown discolouration of the sclera was noted as was slight pitting oedema of both legs.
Discussion
The participant presented with nervous palpitations from the slightest mental excitement. She also showed very mild symptoms. The researcher decided to prescribe a single dose of Nitricum acidum in a high potency. It was felt that the remedy was still well suited to the case and a high potency would have the desired effect.
147
Prescription
Nitricum acidum 200cH, stat dose.
4.6.7 Seventh Consultation – November 2008
General History
At the final consultation the participant reported energy levels which had improved significantly. She had not experienced any heat at night and her appetite had increased. She felt especially hungry in the mornings and found that she could eat broccoli without feeling ill. She experienced recurrent dreams of being bitten by a dog but explained that her sleep was of a good quality and she would awake feeling refreshed. Urinary and bowel movements were normal and regular.
About eight days before menses she had breast tenderness which was worse for pressure and better for commencement of menses. At the time of the consultation she was on day four of her cycle and reported no menstrual cramping, no pain on intercourse and no irritability before menses. The menses were bright red in colour and had membranes and very small clots. The brown discharge was not as noticeable, while the menses was medium in flow. During the month she had felt nodules in her breasts.
Mentally and emotionally the participant reported no anxiety, nor accompanying tightness of the chest. She felt generally better since taking part in the study.
Review of Systems
The participant reported no palpitations over the last month.
Physical Examination
Vital Signs:
Blood Pressure: 132/90 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute
148 Respiratory Rate: 9 breaths per minute Temperature: 36.8ºC Weight: 75kg
General Examination:
No discolouration of the sclera was noted while both lower limbs showed pitting oedema.
Focused Physical Examination:
A breast examination was conducted on both breasts. A nodule was palpated in the inner lower quadrant of the right breast while two nodules were palpated in the outer upper quadrant and inner upper quadrant of the left breast. The participant was instructed on how to perform self examinations and was advised to consult with her gynaecologist for a second opinion.
Discussion
The researcher was pleased with the participant’s progress. It was decided that another prescription was not necessary.
Prescription
Nil
4.6.8 Overview of Case Six
The participant showed a favourable response to Nitricum acidum. Figure 4.16 demonstrates the participant’s basal body temperature over the treatment period. Estimated days of ovulation can not be made owing to the uncharacteristic pattern of her temperatures. Figure 4.17 shows the participant’s general well-being scores over the treatment period. An initial increase in well being was noted in the first month, which was continued in the second month. A slight decrease was noted in general well being in the third month while in the fourth month the greatest improvement was noted. This occurred when the participant was not taking the remedy. Thereafter, the level of general well-being was maintained over the fifth month where a stat dose of the remedy was administered. A slight decrease was then noted in the sixth month of the treatment period. Figure
149 4.18 shows the ratings of the individual questions of the General Well-being Questionnaire. The ratings per question at the beginning of the trial were compared to the ratings per question at the end of the trial. It was noted that no significant improvement had occurred except where her level of happiness over the treatment period was concerned. The participant reported significant improvement in her menstrual and general symptoms while treated with Nitricum acidum. Table 4.6 shows that midcycle mucus changes appeared to have been ideal (clear, stretchy and slippery) on days sixteen and seventeen of the first cycle, on days sixteen, seventeen and eighteen of the second cycle and on days eighteen to twenty-one of the third cycle. In the fourth cycle mucus changes appeared ideal on days sixteen to twenty while days fifteen to nineteen showed ideal mucus changes in the fifth cycle. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly improved as were her general symptoms. Although improvement was noted on all spheres of the participant’s being, pregnancy was not achieved.
150 Basal Body Temperature
37.25
Month 1 37 Month 2 Month 3 36.75 Month 4 Month 5 36.5 Month 6 Temperature reading Temperature 36.25 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 Day of cycle
Figure 4.16: Basal Body Temperature of Participant 6 over the Treatment Period
Participant 6 - General Well-Being Questionnaire Scores over the Treatment Period
40 32 32 33 33 35 31 30 31 30 25 20 15
Total Scores Total 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.17: General Well-Being Scores of Participant 6 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5
Have you been ill or unwell in the 4 past month?
Have you felt depressed in the 3 past montth? Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels? 1 Have you felt healthy enough to do the things you want/had to?
0 Have you felt worried or upset 1 2 3 4 5 6 7 during the past month? How often have you felt happy Month during the past month?
Figure 4.18: Individual Question Ratings of Participant 6 over the Treatment Period 151 Table 4.6: Midcycle Mucus Changes of Participant 6 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Day 1 Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Day 5 Menses Menses Menses Menses Menses Clear, Stretchy, Menses White, Thick, No Discharge No Discharge Day 6 Sticky Dry White, Thick, White, Thick, White, Thick, No Discharge No Discharge Day 7 Sticky Sticky Dry White, Thick, White, Thick, White, Thick, No Discharge No Discharge Day 8 Sticky Sticky Dry White, Thick, White, Thick, White, Thick, White, Thick, No Discharge Day 9 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, No Discharge Day 10 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 11 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 12 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 13 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 14 Sticky Sticky Sticky Dry Sticky White, Thick, White, Stretchy, White, Thick, White, Thick, Clear, Stretchy, Day 15 Sticky Slippery Sticky Dry Slippery Clear, Stretchy, Clear, Stretchy, White, Thick, Clear, Stretchy, Clear, Stretchy, Day 16 Slippery Slippery Sticky Slippery Slippery Clear, Stretchy, Clear, Stretchy, White, Thick, Clear, Stretchy, Clear, Stretchy, Day 17 Slippery Slippery Slippery Slippery Slippery White, Thick, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 18 Sticky Slippery Slippery Slippery Slippery White, Thick, White, Thick, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 19 Sticky Sticky Slippery Slippery Slippery White, Thick, White, Thick, Clear, Stretchy, Clear, Stretchy, White, Thick, Day 20 Sticky Sticky Slippery Slippery Sticky White, Thick, White, Thick, Clear, Stretchy, White, Thick, White, Thick, Day 21 Sticky Sticky Slippery Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 22 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 23 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 24 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 25 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 26 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 27 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 28 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 29 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, White, Thick, Day 30 Sticky Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, Day 31 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, Day 32 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, Day 33 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, Day 34 Sticky Sticky Sticky Sticky White, Thick, White, Thick, White, Thick, White, Thick, Day 35 Sticky Sticky Sticky Sticky
152 4.7 CASE SEVEN
Age: 32 (1976) Gender: Female Race: Indian Occupation: Housewife Marital Status: Married Weight: 60kg Height: 1,57m BMI: 24.3 Menarche: 11 years of age History of Pregnancy: Three pregnancies and three spontaneous miscarriages.
The participant and her husband had been trying to conceive for ten years. They had consulted a gynaecologist as well as an infertility specialist regarding their inability to conceive. The diagnosis given by both specialists was that of unexplained infertility. The participant had conceived naturally ten years ago and had miscarried at six weeks gestation. In 1999, intrauterine insemination was conducted and was successful. The participant, however, miscarried once again at six weeks gestation. She underwent a basic infertility evaluation which included confirmation of ovulation and thyroid function test in 2005. Both were found to be normal. Laparoscopy and hysteroscopy were performed in 2005, both of which showed normal findings. Semen analysis and sperm function were tested in 2005 both showing normal structure and function. In 2005 the participant underwent in vitro fertilization which too was successful, however she miscarried at eight weeks gestation.
4.7.1 First Consultation – May 2008
General History
The participant presented with pain in her right hip. She described the pain as if “there was cold in the bone”. The pain was better for rubbing and worse for cold. It had started two days prior to the first consultation.
Her energy levels had been very low and made it difficult to get out of bed. She felt worse in the mornings and at night. She felt cold all the time, even with the slightest breeze. Her toes, feet and hands were cold all the time and she was better for warmth. Her appetite was good and she craved
153 sour foods and was averse to meat. She described herself as thirstless. Her sleep had been poor and she would wake at night and find it difficult to fall asleep again. She felt tired and unrefreshed on waking. Generally she was worse in the mornings. Urination and stool were found to be normal.
The participant experienced very painful periods. This pain would start the day before her menses making her very irritable and uncomfortable. The pain radiated from her back to her thighs and lower legs. There would also be pain across the lower abdomen, and leg stiffness which was better for hot application. She would experience these symptoms for about two days and described the pain as a “pulling downward” pain and said that it felt like everything was “loose inside”. There was also a pulling down sensation in the navel and in the uterus. Her menstrual blood was described as being dark red with few clots. She experienced skin eruptions on her face before her menses that would clear as soon as her menses had finished. These eruptions presented typically on the chin and cheek area. The duration of her period was seven days. On the first day flow would be light. It became heavier by day two of her menses. From days three to seven, there would only be a slight discharge of blood. The participant experienced breast tenderness which was better for flow and worse for walking down stairs. The participant made use of sanitary towels. She used the oral contraceptive pill for a month ten years ago, for contraceptive purposes. No adverse effects were experienced.
No problems during sexual intercourse were reported except for a sharp pain that was experienced occasionally during intercourse. Intercourse occurred three times a week. A normal vaginal discharge had been noted and no other vulvovaginal symptoms were reported.
Mentally and emotionally the participant sometimes felt depressed and worried that she would not fall pregnant. She felt despondent when her menses commenced. She cried easily for reasons such as not having children or if her husband shouted at her. She said that she could not fight him back and therefore she cried and would then fall asleep, which ameliorated her. She felt lonely as her husband did not show his emotions regarding their infertility. She described herself as being quiet when in company. She would rather listen and felt more comfortable talking in her own surroundings. She feared not falling pregnant.
Review of Systems
The participant complained that her hair had been falling out a lot, particularly before her menses.
154 She also added that when she worried she would get a headache in the region of the temples. This sharp headache was worse for stress and worry. The participant also experienced hay fever which was aggravated by grass or dust exposure. Her eyes would begin to water and her nose would get blocked. The sides of her nose would get itchy and red. If she got a fright she experienced heart palpitations. She would get pain in her joints which was worse for winter.
Family History
Mother: Aged 60 - Hypercholesterolaemia Father: Aged 60 - Diabetes Grandparents: Diabetes, heart disease and arthritis Siblings: Good health Family history: Heart disease, arthritis and infertility
Medication
The participant was not taking any medication or supplementation
Physical Examination
Vital Signs:
Blood Pressure: 110/72 mmHg (Right arm, sitting upright) Heart Rate: 76 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.4ºC Weight: 60kg
General Examination:
Slight discolouration of the sclera was observed.
155 Focused Physical Examination:
Musculoskeletal examination was performed on the hip joints. There was no pain on palpation and all ranges of motion were normal.
Motivation for Remedy Selection
After repertorisation the researcher decided to prescribe Pulsatilla pratensis. The participant showed symptoms such as a ‘tendency to take cold’, ‘aversion to meat’, ‘thirstless’, ‘weeps easily’, ‘ailments from fright’ and ‘desires sour foods’ which were all prominent symptoms in the symptom picture of Pulsatilla pratensis (Schroyens, 2001). Her menstrual symptoms included irregular menses, with a bearing down sensation and irritability before menses. She described the menses as dark and clotted. She experienced ‘pain in the abdomen and small of her back’ during menstrual flow as well as acne before menses. She was worse for lying on one side and before menses, and better after a good cry and for lying on her back (Vermeulen, 2001). The participant was inclined to be submissive and appeared to have an affectionate, mild, timid and gentle disposition (Vermeulen, 2001; Tyler, 1988; Bailey, 1995). A low potency was prescribed due to the physical nature of the case.
Prescription
Pulsatilla pratensis 6cH, one powder taken twice a day for one month.
4.7.2 Second Consultation – June 2008
General History
At the second consultation the participant reported that the right sided hip pain had resolved four days after starting the homoeopathic medication. Her energy levels had improved significantly and thus she was feeling more energetic. There had been an improvement in her appetite. She no longer craved sour foods but was still averse to meat. She now craved junk food and sweets. Her thirst and sleep were unchanged. She found it had been easier to get out of bed in the mornings than she had previously.
156 Her menses lasted seven days and had been completely painless. The blood was much darker than before and was very membranous. The flow was heavier than before. Before and two days into her menses she experienced back pain which radiated downwards. This pain was greatly improved from the last. The pulling down sensation in the navel was no longer there but the sensation in the womb was still present. The breast tenderness was unchanged. She described her menstrual cycle as being a lot better and she did not feel as though everything was loose inside. She still experienced skin eruptions before her menses.
Mentally and emotionally she felt happy, but still became sad when thinking of pregnancy. In general she was feeling a lot more positive and had more hope to fall pregnant.
Review of Systems
The participant noted that her hair was not falling out as much. She was however still experiencing headaches when she worried. She reported that there were times when she experienced a tight pain as if a “bubble or wind were stuck behind the sternum”. This pain was better for sitting up and only lasted about half an hour. She had had this symptom in the past and it had now returned. She added that there was a constant sensation of being “ice cold” from the right hip until halfway down the thigh. She had always experienced this.
Physical Examination
Vital Signs:
Blood Pressure: 94/70 mmHg (Right arm, sitting upright) Heart Rate: 76 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.6ºC Weight: 59kg
General Examination:
No findings were observed on physical examination.
157 Focused Physical Examination:
Musculoskeletal examination was performed on the hip joints. There was no pain on palpation and all ranges of motion were normal.
Discussion
The researcher was pleased with the participant’s results after the first month. The participant’s menstrual symptoms improved slightly and she was able to deal more effectively with her emotions. Her hair was not falling out as much, she was feeling more energetic and the pain experienced in the right hip had now disappeared. The researcher felt that the remedy was still applicable to the case as it had worked effectively thus far. The researcher therefore repeated the prescription of Pulsatilla pratensis as it was felt that more could be gained from another month of treatment.
Prescription
Pulsatilla pratensis 6cH, one powder taken twice a day for one month.
4.7.3 Third Consultation – July 2008
General History
The participant reported a continued improvement in her energy levels. Her sleep had been very poor and it took her a long time to fall asleep. She would then get a headache from not sleeping and felt tired in the mornings.
Her menses had lasted seven days and it had been medium in flow. The blood had not been as dark as before and there were few clots and membranes. There was pain across the abdomen, back and legs which went from the back down to the thighs and was aching in nature. The pain was better for warm application and not as severe as before. She did not experience the pulling down sensation in her uterus. Her breast tenderness was unchanged.
158 Review of Systems
Only a small amount of hair had been falling out and the headache she had previously experienced still came and went. She had not experienced the “stuck wind” sensation again.
Physical Examination
Vital Signs:
Blood Pressure: 102/72 mmHg (Right arm, sitting upright) Heart Rate: 84 beats per minute Respiratory Rate: 16 breaths per minute Temperature: 36.6ºC Weight: 59kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant showed further improvement in her menstrual symptoms as well as in her general symptoms. The researcher was pleased with the participant’s progression over the last two months. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month.
Prescription
Pulsatilla pratensis 6cH, one powder taken twice a day for one month.
159 4.7.4 Fourth Consultation – August 2008
General History
At the fourth consultation the participant described feeling a pulling down sensation on the navel region. She also described an itching sensation on a small area above her left breast that had been worse at night and for scratching. This area bled when scratched.
Her energy levels had been very low and were worst in the mornings and in the late afternoon. She had not experienced any unusual cravings. Her thirst had increased and she found that her mouth would get dry especially in the mornings and evenings. She would drink small sips at a time, preferably of juice or cold drinks as she did not like water. Her sleep had not been good. She did, however, have intermittent nights of good sleep. She would wake at about 3am and would struggle to go back to sleep. She felt unrefreshed in the mornings.
Her menses had been very heavy, dark, membranous and clotted. She experienced pain over her abdomen and back. The pain moved from her back down her thighs and was better for hot application. Her menses lasted seven days and was accompanied by a pulling down sensation in the navel. She experienced irritability before and during her menses. She felt good mentally.
Review of Systems
The falling out of her hair had significantly improved. She had recently noticed vertical ridges on her nails which she had never noticed before. She still experienced a headache, over the frontal, occipital and cervical areas. The pain was heavy and sharp and aggravated by noise. She experienced a stiff pain behind the sternum that was worse for touch.
Physical Examination
Vital Signs:
Blood Pressure: 100/74 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.2ºC
160 Weight: 59kg
General Examination:
Vertical ridges were noted on all the participant’s fingernails.
Motivation for Remedy Selection
The participant presented with new symptoms. The researcher re-analysed the case and decided to change the remedy to a better suited and closer matching remedy. Special attention was placed on the reported history of three spontaneous miscarriages in her pregnancies, which occurred in the 6th week (two of the three miscarriages) and in the 8th week (one out of the three miscarriages) of gestation. After repertorisation, the researcher decided to prescribe Viburnum opulus. The participant reported symptoms such as ‘tendency to abortion in the early months’ or ‘frequent and very early miscarriage, causing seeming sterility’, ‘bearing down pains before menses’ and ‘membranous dysmenorrhoea’. The most characteristic symptom reported by the participant included ‘cramping pain begins in the back extending to uterus and ends in the thighs’ or ‘cramps radiate to the thighs’. She also reported ‘mouth is dry’ and ‘irritability’. These symptoms fit the symptom picture of Viburnum opulus, which was therefore prescribed for the following month in a low potency owing to the chronicity of the case.
Prescription
Viburnum opulus 6cH, one powder taken three times a day for one month.
4.7.5 Fifth Consultation – September 2008
General History
At the fifth consultation the participant reported that the itching she experienced over the left breast was still present but improved. Her energy levels were low during the day as she was fasting. She was not craving nor was she averse to anything in particular. She was feeling exceptionally thirsty and reported that her mouth felt very dry in the mornings and evenings.
161 Before her menses began she experienced bloating but no breast tenderness. Her menses were very dark. The menses were black in colour, very clotted and membranous. The flow was very heavy and the participant reported severe lower back and abdominal pain which radiated down the thighs. The pain was throbbing in nature and rated eight out of ten in intensity. Her menses lasted four days. There was no bearing down or pulling down pain reported. Mentally the participant felt good, except for feeling a bit tired and drained from the religious fast in which she was partaking.
Review of Systems
The vertical ridges on her nails were still present and unchanged. The participant had not experienced a headache in the last month. There was improvement of her joint pain.
Physical Examination
Vital Signs:
Blood Pressure: 104/72 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 11 beats per minute Temperature: 36.4ºC Weight: 60kg
General Examination:
Vertical ridges were noted on all the participant’s fingernails.
Discussion
The participant showed little improvement in her menstrual symptoms as well as in her general symptoms. Owing to religious customs and beliefs, the participant had been fasting over the last three weeks. The researcher viewed this as an obstacle to cure making any improvement of symptoms difficult to achieve. It was thus decided by the researcher that the remedy and potency still matched the totality of the case, and that more time was needed to allow the body to respond. Treatment was continued for the next month.
162 Prescription
Viburnum opulus 6cH, one powder taken three times a day for one month.
4.7.6 Sixth Consultation – November 2008
General History
The participant was concerned about her father as he had been admitted to hospital. She had also been involved in a car accident and was thus feeling fearful of driving again. She sustained injury to ligaments in the foot as well as whiplash.
The participant reported very low energy levels that were worse in the evenings. She had not been feeling as sensitive to cold as she had been previously. She experienced no cravings or aversions, and felt thirsty. Her throat felt dry, but this occurred less frequently. Her sleep was good and she was able to sleep throughout the night. She would wake feeling refreshed. Her bowel function and urination were normal and regular.
She had experienced two menstrual periods since her last consultation. The first menstrual cycle experienced was bright red and membranous, with very light flow. There was a pulling back pain in the abdomen and thigh pain rated three out of ten. Her cycle was twenty-eight days long and her flow lasted seven days. She experienced no premenstrual symptoms and no bearing down sensation. There was, however, a slight brown discharge after menses. Because of the vehicle accident the participant was unable to come to her following consultation and her medication had subsequently run out. This was followed by a second menstrual cycle which came on day thirty-three of her cycle with seven days of menstrual bleeding. The participant described the menses as very dark in colour, membranous, clotted and light in flow. Pain in the back region, thighs and right iliac fossa was experienced before and during menses, and was rated eight out of ten. No abdominal pain or premenstrual symptoms were experienced. The discharge after menses was noted again.
Mentally and emotionally the participant felt very emotional and was very concerned about her father’s well-being and health. The participant was felt depressed due to this.
163 Review of Systems
The vertical ridges on her nails were still present. The participant noted a frontal and occipital headache after her car accident that was throbbing in nature. This pain was worse for light and noise. No pain behind the sternum was experienced and her joint pain and stiffness had worsened.
Physical Examination
Vital Signs:
Blood Pressure: 108/70 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.5ºC Weight: 60kg
General Examination:
Tender submental lymph nodes were noted.
Discussion
The participant showed much improvement of her menstrual symptoms. However, when not taking the medication, her menstrual symptoms worsened. The researcher was confident in the selected remedy, but decided to increase the potency from 6cH to 30cH, to further stimulate the participant’s vital force. The researcher was confident that a higher potency would improve the case.
Prescription
Viburnum opulus 30cH, one powder taken once a day for one month.
164 4.7.7 Seventh Consultation – December 2008
General History
At the final consultation the participant reported energy levels which were still low but improved from the previous month. She had felt hot. The duration of her menstrual cycle for the last month was twenty-eight days with seven days of menstrual flow. She experienced pain across the abdomen, back and thighs on the first day of menstrual flow. This pain was rated eight out of ten and was absent on the days two through to seven of her menses. The participant described the menses as very dark in colour, clotted, membranous and very light in flow. The participant did not experience premenstrual symptoms and was no longer feeling emotional. The brown discharge after menses had improved.
Mentally and emotionally the participant felt better than the previous month. Her father’s health had improved and she felt positive. The participant added that over the duration of the trial she had noted much improvement in her menstrual symptoms as well as in her general well-being.
Review of Systems
The vertical ridges on the participant’s nails were still present and no headache was experienced. The participant reported a cough that had started two weeks prior to the seventh consultation. It was described to be a dry cough which was worse at night and produced no expectoration. She noted that no stiffness in the muscles had been experienced. Her joint pain remained unchanged.
Physical Examination
Vital Signs:
Blood Pressure: 98/70 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.6ºC Weight: 61kg
165 General Examination:
Slight yellow discolouration of the sclera was observed.
Focused Physical Examination:
Respiratory examination was performed on the participant. All breath sounds were found to be normal. No abnormalities were found.
Discussion
Both the participant and the researcher were very pleased with the results. Due to the good results of the remedy, the slight abdominal pain on the first day that radiated to her thighs, the membranous menses and the participant’s dry mouth, the researcher decided to continue with the same prescription.
Prescription
Viburnum opulus 30cH, one powder taken once a day for one month.
4.7.8 Overview of Case Seven
The participant showed a favourable response to Pulsatilla pratensis. After changing the remedy to Viburnum opulus, a greater response was noted as far as her menstrual symptoms were concerned. Figure 4.19, showing basal body temperatures of participant seven, revealed that the participant ovulated between days ten and thirteen of her cycle. Figure 4.20 shows the participant’s general well-being over the treatment period. The participant showed steady improvement in her general well being between consultations one to three, thereafter a decline in general well being was noted during the third month. This occurred while the participant was treated with Pulsatilla pratensis. The researcher noted stagnation in the progress of the case in the fourth month and decided, after in depth analysis of the case, to change the remedy to Viburnum opulus. Concurrently over the fifth month the participant was actively taking part in a religious fast which ultimately resulted in very low general well-being scores at consultation six. At this point a higher potency was prescribed which resulted in a significant eight point improvement in general well-being in the final month of the treatment period. Figure 4.21 shows the ratings of the individual questions of the General Well-
166 being Questionnaire. When comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial it was noted that improvement had occurred in her general well-being, health as well as energy levels. No significant change was noted in her depression, anxiety, level of worry or happiness. Table 4.7 shows that participant seven did not experience an ideal ovulatory discharge (clear, stretchy and slippery) during the treatment period. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated as were her musculoskeletal symptoms. Pregnancy was not achieved during the treatment period.
167
Participant 7 - Basal Body Temperature over the Treatment Period
37.2 Cycle 1 37 Cycle 2 Cycle 3
36.8 Cycle 4 36.6 Cycle 5 Cycle 6 36.4 Cycle 7 Temperature reading Cycle 8 36.2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 Day of cycle
Figure 4.19: Basal Body Temperature of Participant 7 over the Treatment Period
Participant 7 - General Well-Being Questionnaire Scores over the Treatment Period
40 34 35 31 30 29 30 27 23 25 22 20 15
Total Scores 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.20: General Well-Being Scores of Participant 7 over the Treatment Period
Individual Question Rating
How are you feeling in 5 general? Have you been ill or unwell in the past month? 4 Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? 0 Have you felt worried or upset during the past month? 1 2 3 4 5 6 7 How often have you felt happy Month during the past month?
Figure 4.21: Individual Question Ratings of Participant 7 over the Treatment Period
168 Table 4.7: Midcycle Mucus Changes of Participant 7 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Cycle 7 Day 1 Menses Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses Menses Day 5 Menses Menses Menses Menses Menses Menses Menses Day 6 Menses Menses Menses Menses Menses Menses Menses Day 7 Menses Yellow, Thick, Yellow, Sticky, No Discharge Menses Menses Menses Wet Dry Day 8 White, Thick, Yellow, Stretchy, Yellow, Sticky, No Discharge Menses Yellow, Thick, White, Thick, Dry Wet Dry Wet Wet Day 9 Yellow, Thick, Yellow, Stretchy, Yellow, Sticky, No Discharge White, Thick, Yellow, Thick, White, Thick, Dry Wet Dry Wet Wet Wet Day 10 Yellow, Thick, Yellow, Stretchy, Yellow, Thick, White, Stretchy, White, Thick, Yellow, Thick, White, Thick, Wet Wet Wet Slippery Wet Wet Wet Day 11 Yellow, Stretchy, Yellow, Thick, Yellow, Thick, White, Stretchy, White, Thick, Yellow, Thick, White, Thick, Slippery Wet Wet Slippery Wet Wet Wet Day 12 Yellow, Stretchy, Yellow, Thick, Yellow, Thick, White, Stretchy, White, Stretchy, Yellow, Thick, White, Thick, Slippery Wet Wet Slippery Wet Wet Wet Day 13 Yellow, Stretchy, Yellow, Thick, Yellow, Thick, White, Thick, White, Stretchy, White, Thick, White, Thick, Slippery Wet Wet Dry Wet Wet Wet Day 14 Yellow, Stretchy, Yellow, Thick, Yellow, Thick, White, Thick, White, Stretchy, White, Thick, White, Thick, Slippery Wet Wet Dry Wet Wet Wet Day 15 Yellow, Thick, Yellow, Thick, Yellow, Thick, White, Thick, White, Stretchy, White, Thick, White, Thick, Wet Wet Wet Dry Wet Wet Wet Day 16 Yellow, Thick, Yellow, Thick, Yellow, Sticky, Clear, Sticky, White, Thick, White, Thick, White, Thick, Wet Wet Dry Wet Wet Wet Wet Day 17 Yellow, Thick, Clear, Sticky, Yellow, Sticky, Clear, Sticky, White, Thick, White, Thick, White, Thick, Wet Wet Dry Wet Wet Wet Wet Day 18 Yellow, Thick, Clear, Sticky, Yellow, Sticky, Clear, Sticky, White, Thick, White, Thick, White, Thick, Wet Wet Dry Wet Wet Wet Wet Day 19 Yellow, Thick, Clear, Thick, Yellow, Sticky, Clear, Sticky, White, Thick, White, Thick, White, Thick, Wet Wet Dry Wet Wet Wet Wet Day 20 Yellow, Thick, Clear, Thick, Yellow, Sticky, Clear, Sticky, White, Thick, White, Thick, White, Sticky, Dry Wet Dry Wet Wet Wet Dry Day 21 Yellow, Thick, Yellow, Stretchy, Yellow, Sticky, Clear, Sticky, Yellow, Thick, White, Thick, White, Sticky, Dry Wet Dry Wet Wet Wet Dry Day 22 Yellow, Thick, Yellow, Stretchy, Yellow, Sticky, Clear, Sticky, Yellow, Thick, White, Thick, White, Sticky, Dry Wet Dry Wet Wet Wet Dry Day 23 Yellow, Thick, Yellow, Stretchy, Yellow, Sticky, Clear, Sticky, Yellow, Thick, White, Thick, White, Sticky, Dry Wet Dry Wet Wet Wet Dry Day 24 Yellow, Thick, Yellow, Stretchy, Yellow, Sticky, Clear, Sticky, Yellow, Thick, White, Thick, White, Thick, Dry Wet Dry Wet Wet Wet Dry Day 25 Yellow, Stretchy, White, Thick, White, Thick, White, Thick, Wet Wet Wet Dry Day 26 Yellow, Stretchy, White, Thick, White, Thick, White, Thick, Wet Wet Wet Dry Day 27 Yellow, Stretchy, White, Thick, White, Thick, Wet Wet Dry Day 28 White, Thick, White, Thick, Wet Wet Day 29 White, Thick, White, Thick, Wet Wet Day 30 White, Thick, Wet Day 31 White, Thick, Wet Day 32 White, Thick, Wet Day 33 White, Thick, Wet Day 34 White, Thick, Wet Day 35 White, Thick, Wet Day 36 White, Thick, Wet Day 37 White, Thick, Wet Day 38 White, Thick, Wet Day 39 White, Thick, Wet Day 40 White, Thick, Wet Day 41 White, Thick, Wet Day 42 White, Thick, Wet
169 4.8 CASE EIGHT
Age: 39 (1969) Gender: Female Race: White Occupation: IT Specialist Marital Status: Married Weight: 66kg Height: 1,65m BMI: 24.2 Menarche: 13 years of age History of Pregnancy: Two pregnancies and two abortions (one elective abortion and one dilation and curettage owing to a hydatidiform mole pregnancy).
The participant and her partner had been trying to conceive for three to four years and had consulted with an infertility specialist, who diagnosed unexplained infertility. The participant had undergone an extensive infertility evaluation. In 2006 the couple underwent intrauterine insemination which was unsuccessful, as well as in vitro fertilization in 2006 which also was unsuccessful. The participant underwent a hysterosalpingogram and laparoscopy in 2007 which showed normal findings. Other tests that were conducted included hysteroscopy in 2007 which showed that all was normal. The participant’s husband underwent semen analysis in 2008 as well as a test of sperm function. Both partners showed normal findings.
The participant experienced chicken pox and measles as a child and had had the DPT, MMR and polio vaccinations.
4.8.1 First Consultation – May 2008
General History
The participant presented with difficulty sleeping. Her position while sleeping was typically on her stomach with her head buried in her pillow. She didn’t feel tired at night and was waking at approximately 4am. She had been dreaming a lot in the last few days with the general theme being that of children.
170 She described her energy levels as normal as she was “on the go” all day. This was worse in the afternoons. She felt cold very cold easily. She reported that she was better for warmth. She felt better for the seaside and preferred sunny weather. Her appetite was good. She craved fresh fruit and vegetables as well as foods such as curries and stews. She was averse to cooked mushrooms, beans and lentils, and described herself as thirstless. Her perspiration was normal as was her urination and her bowel movements. She experienced bloating and flatulence and mentioned that she had never had a flat stomach because of this. She added that she very rarely got sick.
Her menses typically lasted four to five days and would begin with pain on the first day. The pain was dull and mostly in the abdomen and lower back. This pain was better for warm applications and ameliorated when her husband placed his hands on her abdomen. She also experienced a sensation as if everything would come out. She experienced heavy bleeding during the first two days which was worse in the evenings. The blood was typically bright red in colour with very dark clots. She experienced breast tenderness that was better for pressure, as well as irritability before her menses. Her choice of sanitary wear was sanitary towels.
She had used the oral contraceptive pill five years prior for contraceptive purposes and had experienced no adverse effects. The participant and her husband had no problems with sexual function although she had a very poor sexual drive and attributed their poor sexual relationship to this. The frequency and timing of sexual intercourse was about once a month. She had no vulvovaginal symptoms and did not make use of lubricants.
Mentally and emotionally the participant felt stressed because of work related issues. She described herself as a perfectionist and explained that she got irritated easily if things did not get done. She felt that there was something missing in her life and that she was trying to find the enjoyment in her life. Sometimes she felt lonely. She felt that having a child would fill this void. Her thoughts and feelings regarding her infertility elicited much emotion. She started crying when discussing her insecurity regarding not being able to have a child. She described the loneliness she would feel if she did not have a child, yet expressed her lack of maternal instinct and emotion. She rationalised this lack of maternal instinct as being because she was not over affectionate and she would shut out her feelings. She went on to describe a difficult childhood which had made her “hard”. She was sexually abused by her stepfather from an early age and did not share a close relationship with her mother. She felt that it was because of her sexual abuse that she had become increasingly body conscious, which may have added to difficulties with sexual relations. Her husband had been supportive throughout the process of seeking treatment.
171
She described her personality as being introverted as well as extroverted depending on the situation. She tended to be quiet in a crowd and described herself as being an “observer”. She was caring to those she let in and feared her husband would leave her if she did not fall pregnant. She became weepy when expressing her boredom and mentioned that she needed a challenge in her life. She did not cry easily in front of people and found that she over analysed everything too much. She cried for other people’s pain and suffering and would feel better afterward.
Review of Systems
The participant reported that she bit her nails, particularly when she was relaxed or bored. The review of systems revealed that she experienced a pain intermittently in her left ear. It was a sore pain which came once every three months. The pain was worse for touch and turning her head.
Family History
Mother: Aged 62 - Thyroid disorder Father: Aged 58 - Cancer Grandparents: Unknown Siblings: Good health Family history: Cancer and hypertension
Medication
The participant was taking Food State Multivitamin and Minerals®, folic acid supplementation and an Omega 3 supplements.
Physical Examination
Vital Signs:
Blood Pressure: 130/90 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC
172 Weight: 66kg
General Examination:
No findings were observed on physical examination.
Motivation for Remedy Selection
Owing to a suspected miasmatic block, the researcher decided to start the case with miasmatic treatment. Carcinosin was chosen as the participant demonstrated symptoms such as ‘biting of nails’, ‘suppressed anger from childhood abuse’ and a constant ‘striving for perfection’. She was very anxious about her health and had a conscious desire to please. She had a marked family history of cancer and had a café au lait complexion with numerous moles. Her sleeping position was on her abdomen with her face forced into her pillow. Her chronic sleeplessness was also a feature seen in the Carcinosin symptom picture (Vermeulen, 2001).
Prescription
Carcinosin 200cH, one powder taken every second day for one month.
4.8.2 Second Consultation – June 2008
General History
At the second consultation the participant reported that she had been sleeping a lot better and on waking felt refreshed. Her energy levels had improved. She craved fresh fruit and salads. Her stool symptoms had significantly improved. She had not experienced the usual frequency of bowel movements before her period as she usually had. She was currently experiencing a bowel movement every second day. She had not noticed any flatulence or bloating.
Her menstrual symptoms had improved as she experienced slight pain in the anterior thighs and no pain in the abdomen or back area. She did not need the pressure and warmth of her husband’s hands on her abdomen. On the first two days there was spotting and the flow was not as heavy as it had previously been. She did not experience the sensation as if “everything would come out”. The menses were not clotted and the colour was neither light nor dark. Her breast tenderness was slight
173 and her breasts felt heavier. The participant felt relaxed and not as irritable before her menses as she had been previously. Her sexual activity and low libido remained unchanged. The participant noted that after sexual intercourse, her husband’s semen was retained for much longer than it had been previously.
Mentally and emotionally she had improved. She had been thinking about her fertility a lot and was concerned that she was approaching menopause. She was feeling a lot more positive, yet still experienced anxiety about not giving her husband a child. She again mentioned that her sexual abuse had affected her self image negatively and she had recently started feeling more maternal and was surprised by this.
Review of Systems
The participant was still biting her nails. She reported experiencing the pain in her left ear three days prior to the consultation. She described it as a sore pain which was worse for touch and turning her head.
Physical Examination
Vital Signs:
Blood Pressure: 140/88 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC Weight: 66kg
General Examination:
No findings were observed on physical examination.
Motivation for Remedy Selection
Sepia officinalis is an excellent remedy in cases of infertility (Smith, 1989). It was selected to follow the miasmatic treatment of Carcinosin, as the participant showed significant improvement
174 on a mental and emotional level, as well as on a general level. The participant showed amelioration on these levels and presented with new symptoms. She continued to experience a ‘bearing down sensation’ and ‘aversion to coition’ (Vermeulen, 2001). There was a general loss of sexual interest and constipation (Smith, 1989). She craved fresh salads, fruits and vegetables and described an indifference to loved ones and to pleasures. Her lack of a “maternal feeling” may have improved but was still present (Vermeulen, 2001; Bailey, 1995). Low potency was selected owing to the chronicity of the case.
Prescription
Sepia officinalis 6cH, one powder taken twice a day for one month.
4.8.3 Third Consultation – August 2008
General History
At the third consultation the participant was feeling depressed. She also expressed a feeling of not knowing what she was doing in her life. Her energy levels were good and she had started doing more exercise on a daily basis. Her craving for fresh fruit and vegetables were more pronounced. She was also craving spicy food and was averse to mushrooms. She felt increasingly thirsty but had no desire to drink water to quench her thirst. Her sleep was good and she would wake feeling refreshed. She was urinating more often at night. Bowel movements were normal on a daily basis, and it was noted that she had increased bowel movements during her menses.
Her menses had significantly improved. They were not as heavy as they had been in previous months. The blood was bright red in colour and there were very few clots. The participant experienced no abdominal pain or lower backache during her menstrual cycle. There was slight breast tenderness before her menses and no abdominal bloating. The duration of her menses was four days and she did not experience the sensation of everything coming out. She did not experience irritability before her menses. The most marked and pronounced symptom was that of improvement of her sexual desire. Previously she noted that she had no sexual desire and that this month she had felt a change and improvement in this aspect of her life. Mentally and emotionally she felt very worried. She described feeling an alternation between happiness and sadness and found herself questioning where her life was going.
175 Review of Systems
The participant had not experienced any earache in the last month
Physical Examination
Vital Signs:
Blood Pressure: 110/70 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.4ºC Weight: 66kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant showed significant improvement in her menstrual symptoms as well as in her sexual desires. The researcher was pleased with the participant’s progression over the past two months. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month.
Prescription
Sepia officinalis 6cH, one powder taken twice a day for one month.
4.8.4 Fourth Consultation – September 2008
General History
At the fourth consultation the participant reported that she was no longer feeling depressed, and she appeared to be in good spirits. She explained that she was feeling a lot more loving toward her
176 husband, as well as to children who had previously annoyed her. She also mentioned that “even the dogs like being around me now”. She no longer kept quiet when in a crowd. She felt more affectionate and loveable toward her husband and had found herself thinking about participating and enjoying intercourse more. She noted that she also felt closer to her husband. Lastly, she mentioned that deep down she felt that she would have a child of her own and that she was feeling very maternal. She explained that there had been a definite improvement in this area of her life.
Her energy levels were good and she had noticed an improvement. She was still craving fresh fruits and vegetables. She was thirstless but was drinking more. Her bowel movements were regular. It was noted that her bowel movements decreased before and increased during menses.
Her menses presented over six days with two days of spotting initially and four days of bleeding. The day before her menses she reported experiencing a dull backache as well as irritability and tearfulness. There was bloating noted before menses as well as during ovulation. The blood itself did not have as many clots as before, but was stringy and mucusy and more red in colour. The flow was normal. She no longer experienced a bearing down sensation.
Review of Systems
It was noted that little skin eruptions she had previously had on her head had now disappeared. These bumps were of no significance to her thus she hadn’t mentioned it previously.
Physical Examination
Vital Signs:
Blood Pressure: 110/70 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.6ºC Weight: 65kg
General Examination:
No findings were observed on physical examination.
177
Discussion
The participant continued to show significant improvement in her menstrual symptoms and her sexual desires, as well as in her general symptoms. Mentally and emotionally the participant described much improvement and relief. Both the researcher and participant were pleased with the continued improvement in the participant’s health and well-being. Because of this, the researcher decided to continue with the chosen prescription for the following month, as the medication was still working and improvement on a mental, emotional and physical level was still being observed.
Prescription
Sepia officinalis 6cH, one powder taken twice a day for one month.
4.8.5 Fifth Consultation – October 2008
General History
She described her energy levels as good and consistent throughout the day. Her diet had not been good and consisted mostly of restaurant food, which had a bad effect on her digestion. She was still craving fresh fruits and vegetables. The participant’s thirst had greatly increased and was particularly pronounced in the mornings and at night. The participant’s sleep was reported to be very good. She was able to fall asleep easily, was not dreaming, and awoke feeling refreshed. She also mentioned that her sleep had not been that good in a long time. The frequency of urination had increased over the last month and she found that she would wake at 4am to urinate. She managed to fall asleep easily after urinating. She was also feeling very bloated because of the poor diet while travelling and because her menses was due to start within the next week. She had bowel movements every second day, and on the day her menses had begun. She still experienced decreased frequency of bowel movements before her menses and an increased during her menses.
Her last menses began at night and lasted for five days. On the first day there was a mucusy and bloody discharge. It was noted that the bleeding was not heavy, it was red in colour, and had no clots. There was no backache and no spotting as the period approached the end of the five days. She experienced no bearing down sensation. The participant noted that she had been irritable before her menses. When asked to reflect on her progression as far as her sexual desire was concerned, the
178 participant reported that there had been a dramatic improvement and that her libido had increased. When reflecting on the first consultation she rated her libido as a one out of ten whereas at the fourth consultation, she rated her libido as a five out of ten.
Mentally and emotionally the participant was doing well and was feeling positive and relaxed. She explained that she was still feeling affectionate and loving toward her husband and felt less preoccupied with work-related issues.
Review of Systems
The participant had not experienced a headache during the last month.
Physical Examination
Vital Signs:
Blood Pressure: 120/78 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 37.0ºC Weight: 67kg
General Examination:
No findings were observed on physical examination.
Discussion
Both the participant and the researcher were very pleased with the results and improvements. Due to the good results of the remedy and the participant’s libido, which was gradually improving, the researcher decided to continue with the same prescription.
Prescription
Sepia officinalis 6cH, one powder taken twice a day for one month.
179
4.8.6 Sixth Consultation – November 2008
General History
At the sixth consultation the participant reported that not eating correctly and the travelling had affected her energy levels negatively. She felt tired and had not taken her medication over the last two weeks because of the inconvenience of travelling. She had felt very hot over the last few days and was craving stews as well as fruits and vegetables. The participant explained that the more water she drank the thirstier she would get and that she was averse to cold water. The participant’s sleep was of a good quality and she was waking feeling refreshed. The participant reported that her urinary frequency had dramatically increased. She was urinating six to seven times in a day. She had been constipated, particularly before her menses and noted that she had experienced bloating although it was not as severe as the bloating experienced at the initial consultation.
At the onset of her menses she had experienced a severe migraine. While experiencing this pain the participant reported the desire to sleep which ameliorated the headache. During the first two days of her menses she had lower backache which was dull in nature. The blood was bright, no clots were present and the blood was not mucusy. During her menses there was heavy flow for four out of the five to six days her menses lasted. A dull abdominal pain was also noted which was better for warmth and pressure. She did not experience a bearing down sensation however she suffered from irritability before menses. The participant explained that there was an improvement in her libido and rated it six out of ten.
Review of Systems
During the month the participant had experienced an abscess on the right side of her mouth. There had been a throbbing pain. Nothing ameliorated or aggravated the pain. The participant had been prescribed Penicillin which treated the abscess. She was asymptomatic.
Physical Examination
Vital Signs:
Blood Pressure: 126/84 mmHg (Right arm, sitting upright)
180 Heart Rate: 64 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 37.0ºC Weight: 67kg
General Examination:
No findings were observed on physical examination.
Discussion
The researcher decided to increase the potency of the prescription and decrease the frequency of the remedy administration. This was because it was felt that the previous prescription was no longer active and the case had progressed. The remedy remained unchanged due to its similarity to the participant’s symptom picture.
Prescription
Sepia officinalis 30cH, one powder taken once a day for one month.
4.8.7 Seventh Consultation – December 2008
General History
At the seventh consultation the participant reported good energy levels and a good appetite. She craved fresh fruit and vegetables and was averse to strawberries. She was very thirsty, particularly in the mornings, but was averse to water. The participant’s sleep was poor as she was worried about moving house. She was able to fall asleep easily but would awake at 3am and would not be able to go back to sleep. Her bowel function had become very regular and no symptoms were reported. She still experienced bloating and constipation before her menses. The participant had not yet had her menstrual period since the last consultation. She experienced breast tenderness and had a vaginal discharge which was watery in nature. Her libido continued to improve.
Mentally and emotionally the participant was feeling very excited about the move. Her relationship with her husband was very good and she was still feeling very close to him.
181
Review of Systems
The abscess she had experienced a month before had completely resolved.
Physical Examination
Vital Signs:
Blood Pressure: 118/80 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.6ºC Weight: 66kg
General Examination:
No findings were observed on physical examination.
Discussion
The participant reported a positive difference in the final month’s prescription, and the researcher was pleased with the results. The researcher did not feel that it was necessary to repeat the prescription as the participant was now asymptomatic.
Prescription
Nil
4.8.8 Overview of Case Eight
The participant showed a favourable response to Carcinosin, and an even better response to Sepia officinalis. Figure 4.22 demonstrates that the participant was estimated to have ovulated around day ten of her cycle. Figure 4.23 shows an initial decrease, followed by a steady increase in general well-being from month one to month four. The participant’s general well-being decreased slightly
182 over the first month while on miasmatic treatment and then steadily increased over the next two months while treated with Sepia officinalis. During this time the participant showed great improvement on a mental level as well as in her libido and initial aversion toward sexual intercourse. The greatest decrease in general well-being was noted between consultations four and five. The participant attributed this decrease in general well-being to her travelling and its ill-effects on her diet and bowel movements and energy levels. A further improvement from month six to seven was noted. Figure 4.24 shows the ratings of the individual questions of the General Well- being Questionnaire. No significant change was noted when comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial. Table 4.8 shows midcycle mucus changes over the treatment period. These changes appeared to be ideal (clear, stretchy and slippery) on days ten to twelve of the fifth cycle, days ten to fourteen of the seventh cycle and days fifteen to eighteen of her eighth cycle. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated as had her general symptoms and bowel function over the treatment period however pregnancy was not achieved during the treatment period.
183 Participant 8 - Basal Body Temperature over the Treatment Period
37.2 Cycle 1 37 Cycle 2 Cycle 3 36.8 Cycle 4
36.6 Cycle 5 Cycle 6 36.4 Cycle 7 Temperature reading Temperature Cycle 8 36.2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Day of cycle
Figure 4.22: Basal Body Temperatures of Participant 8 over the Treatment Period
Participant 8 - General Well-Being Questionnaire Scores over the Treatment Period
40 37 32 35 29 30 30 29 30 26 25 20 15
Total Scores Total 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.23: Total General Well-Being Scores of Participant 8 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5
Have you been ill or unwell in the 4 past month? Have you felt depressed in the 3 past montth? Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels? 1 Have you felt healthy enough to do the things you want/had to?
0 Have you felt wo rried or upset 1 2 3 4 5 6 7 during the past month? How often have you felt happy Month during the past month?
Figure 4.24: Individual Question Ratings of Participant 8 over the Treatment Period
184 Table 4.8: Midcycle Mucus Changes of Participant 8 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Cycle 7 Day 1 Menses Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses Menses Day 5 Menses No Discharge Menses Menses Menses Menses Menses Day 6 Menses No Discharge No Discharge No Discharge Menses No Discharge No Discharge Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 7 Wet Clear, Thick, Clear, Sticky, No Discharge No Discharge No Discharge No Discharge No Discharge Day 8 Dry Slippery Clear, Thick, Clear, Sticky, Clear, Sticky, No Discharge No Discharge No Discharge No Discharge Day 9 Wet Slippery Wet Clear, Thick, Clear, Sticky, Clear, Sticky, Clear, Stretchy, Clear, Clear, Stretchy, No Discharge Day 10 Dry Slippery Slippery Slippery Thick, Slippery Slippery Clear, Thick, Clear, Sticky, Clear, Sticky, Clear, Stretchy, Clear, Clear, Stretchy, No Discharge Day 11 Dry Slippery Slippery Slippery Thick, Slippery Slippery Clear, Thick, Clear, Sticky, Clear, Sticky, Clear, Stretchy, Clear, Clear, Stretchy, No Discharge Day 12 Dry Slippery Slippery Slippery Thick, Slippery Slippery Clear, Thick, Clear, Sticky, Clear, Thick, No Discharge Clear, Clear, Stretchy, No Discharge Day 13 Wet Slippery Sticky Thick, Slippery Slippery Clear, Thick, Clear, Sticky, Clear, Sticky, No Discharge Clear, Clear, Stretchy, No Discharge Day 14 Wet Slippery Slippery Thick, Slippery Slippery Clear, Thick, No Discharge No Discharge No Discharge Clear, No Discharge Clear, Stretchy, Day 15 Wet Thick, Slippery Slippery Clear, Thick, No Discharge No Discharge No Discharge Clear, No Discharge Clear, Stretchy, Day 16 Wet Thick, Slippery Slippery Clear, Thick, No Discharge No Discharge No Discharge Clear, No Discharge Clear, Stretchy, Day 17 Wet Thick, Slippery Slippery Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge Clear, Stretchy, Day 18 Wet Slippery Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 19 Slippery Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 20 Slippery Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 21 Dry Clear, Thick, No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 22 Dry Day 23 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Day 24 No Discharge No Discharge No Discharge No Discharge Day 25 Day 26 No Discharge No Discharge No Discharge No Discharge Day 27 Day 28 No Discharge Day 29 No Discharge
185 4.9 CASE NINE
Age: 39 (1969) Gender: Female Race: Black Occupation: Sales Manager Marital Status: Married Weight: 59kg Height: 1,61m BMI: 22.8 Menarche: 14 years of age History of Pregnancy: One pregnancy and one live birth in 2002
The participant and her husband had been trying to conceive for more than five years. They had previously consulted with an infertility specialist as well as a traditional healer. The diagnosis of infertility specialist was that of unexplained infertility. The participant underwent a basic infertility evaluation. Confirmation of ovulation in 2002 was found to be normal as were hysterosalpingogram and laparoscopy testing in 2002. Postcoital testing in 2001 showed no abnormalities. The participant underwent three in vitro fertilisation attempts in 2002. The first two attempts were unsuccessful while the third attempt resulted in pregnancy. The participant’s husband underwent semen analysis in 2001. The results showed normal morphology and function.
The participant’s husband had four children from a previous marriage. She had received the BCG, DPT, hepatitis, yellow fever and polio immunizations.
4.9.1 First Consultation – May 2008
General History
A few days prior to the first consultation the participant fell and hit her chin on the floor. She had much pain in the region of the jaw which was worse for opening the mouth. There had been an associated ear pain and sensitivity to noises. At present she was experiencing low energy levels which were worse in the late afternoon and found that the use of Berocca® and green tea aided her energy levels greatly. She would get cold easily and her feet would get cold at night when sleeping. She described her appetite as poor. She was averse to shellfish and was thirstless. Perspiration only
186 occurred when she was sick, and it was isolated mainly to the thoracic region when she was sleeping at night. Her sleep was good and she could sleep at any time of the day unless something was worrying her. Sometimes she would find it difficult to wake up but generally she would sleep right through the night and was better for sleep. Urination and stool were normal.
She experienced pain before her menses. This pain was so severe that she would not be able to eat foods with fibre as she found that this would exacerbate the pain. She would not be able to sit or drive because of the severity of the pain. Her menses would then follow after the pain and she experienced a sensation as if she were carrying stones in her stomach. This pain was located in the flanks of the abdomen and was ameliorated by flow. After her menses were completed she would experience tenderness of the abdomen. The blood was thick, clotted and black in colour. The flow was profuse and would then get lighter each day. The duration of her menses was usually three to five days. She experienced no vulvovaginal symptoms at the time of the consultation. The participant used sanitary towels during menstruation. At times she experienced thrush symptoms before her menses and she would use an ointment for these symptoms.
Previously the participant made use of the contraceptive injection, as well as condoms for the purpose of contraception in 1994 and 1997 respectively. She did not experience any adverse effects from the use of contraceptive methods. Her and her husband’s sexual function was described as normal. Her libido was low and the frequency of intercourse was one to three times a week.
Mentally and emotionally she was not “feeling at her best”. She was very stressed at work and was finding certain work-related issues very demanding. She was also experiencing difficulties within her relationship with her husband. She mentioned that she did not want to go through the process of in vitro fertilization again as she found it emotionally and financially traumatising.
She described her need for a child because her daughter needing a sibling. Emotionally she described her inability to fall pregnant as having no impact on her. Her life had not been affected by her infertility and it had had no impact on her husband’s life at all.
She described her personality as outspoken and she liked to interact with other people. She also mentioned that she enjoyed talking about herself. She had a fear of cats and described herself as tearless and that she did not like crying in front of people. In times of grief or shock she liked to be alone. She was a very spiritual person and found she was better for crying when alone.
187 Review of Systems
The participant reported that she experienced a rash infrequently, all over the body which itched excessively. The more she scratched the more she would need to scratch. Nothing ameliorated or aggravated this symptom. The participant currently experienced a headache that was due to stress. It was located at the occiput and was better for sleep and closing her eyes. She experienced a slight postnasal drip which was worse at night. She was prediagnosed with hypertension.
Family History
Mother: Aged 68 - Good health Father: Aged 60 - Good health Grandparents: Unknown Siblings: Sister - Infertility Family history: Hypertension and infertility
Medication
The participant was taking antihypertensive medication for pre-diagnosed hypertension.
Physical Examination
Vital Signs:
Blood Pressure: 136/92 mmHg (Right arm, sitting upright) Heart Rate: 76 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 35.8ºC Weight: 59kg
General Examination:
Pain was elicited on palpation of cervical lymph nodes due to trauma to the jaw
188 Focused Physical Examination:
The participant had a pointy tongue which trembled on protrusion. There was a white coating on the tongue. A large bruise was observed on the left thigh.
Motivation for Remedy Selection
After repertorisation and analysis of the case, the researcher decided to prescribe Lachesis muta. The participant expressed symptoms similar to Lachesis muta. These symptoms include ‘loss of appetite’, ‘high blood pressure’, ‘no desire to mix with the world’, ‘makes mistakes in speaking’, ‘aversion to company’, ‘desires solitude’ as well as ‘religious affections’. The participant also experienced ‘paroxysms of sneezing’ and ‘stopped coryza’. On examination ‘trembling of tongue on protrusion’ was noted, and she added that her ‘menstrual pains were better at the onset of flow’ and that her ‘menses was black’ and ‘copious’ (Murphy, 1988; Vermeulen, 2005; Schroyens, 2001). The researcher decided to prescribe a low potency so that the remedy could be administered frequently so as to stimulate the vital force.
Prescription
Lachesis muta 6cH, one powder taken twice a day for one month.
4.9.2 Second Consultation – June 2008
General History
The participant showed much loquacity during the second consultation. She mentioned that she was feeling a lot more religious and spoke of her faith and Christianity. She described her husband’s actions as affecting her pride and she felt hurt by his words and actions. She recently discovered that her husband may have been cheating on her. She said that she dealt with his infidelity through prayer and knew that he still loved her. While talking her hand gestures were pronounced and she deviated from any questions directed at her emotions and rather focused on her husband’s actions and what he had been experiencing. She did however feel that she had conquered her situation and felt an improvement emotionally. She felt she could talk about these situations without crying and felt at peace within herself. She explained that a “heaviness” within her chest from the emotional hurt, “ had been released or taken from her chest”. She experienced what she described as a release
189 and a sense of peace. She felt irritated by her daughter’s attention deficit disorder (ADD), her husband’s possible ADD and felt stressed due to work-related deadlines.
Her energy levels still varied depending on whether she felt stressed or not. Generally she found that it would be worse in the mornings as well as late afternoon. This was ameliorated by sleep. Her appetite had not improved. She felt thirsty and noticed a marked thirst after eating. She had no difficulties falling asleep. She said that she enjoyed her sleep and would “sleep forever” if she could. The participant complained of constipation as evacuations were difficult. There was much bloating and flatus which was worse at night. She felt better after the passing of stool.
The participant explained that her last menses were pain free. She mentioned that she was shocked that she did not experience any pain whatsoever. She could eat food with fibre and there was still no pain. She did not experience the painful sensation of stones in her stomach and there was no tenderness of the abdomen after her menses. The blood was very black in the beginning and then got lighter later on. Her menses lasted four to five days and her flow was normal and not as heavy as it had been previously. There were no clots.
Review of Systems
No changes in skin symptoms were noted and no headache was experienced while on homoeopathic treatment.
Physical Examination
Vital Signs:
Blood Pressure: 130/90 mmHg (Right arm, sitting upright) Heart Rate: 80 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.6ºC Weight: 59kg
General Examination:
No findings were observed on physical examination.
190
Discussion
The researcher was pleased with the participant’s results after the first month. Her menstrual and general symptoms had improved, however, the researcher felt that the remedy needed more time to work. The prescription was therefore repeated.
Prescription
Lachesis muta 6cH, one powder taken twice a day for one month.
4.9.3 Third Consultation – August 2008
General History
The participant was experiencing marital problems at the time of the consultation and she felt depressed. She still felt at peace within herself and found that she was able to cope with her marital problems easily. Her energy levels varied and were worse after work. She was currently using Berocca® and drinking green tea to help with her energy levels.
She was urinating more often and related this to the amount of green tea she was consuming. Her stool symptoms had improved significantly. She was no longer constipated and experienced a bowel movement after every meal. It was noted that the participant experienced abdominal cramps particularly after eating. These cramps were better after the use of Buscopan® and were worse at night. She also experienced increased flatus after the use of Eno® or Buscopan®.
Her menses lasted five days and she experienced some discomfort during her menses. She experienced a slight sensation of a stone in her stomach. There was no tenderness after her menses and the pain experienced across her abdomen was not severe. Her menses were very dark in colour and became clearer toward the end of her menses. On the last day of her menses there was a brown discharge. The flow was normal to heavy and there were no clots. She also experienced large skin eruptions on her face during her menses which took about a week to heal. The participant commented that she felt that the homoeopathic medication was helping her as her menses had become much better.
191 Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 136/98 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 35.8ºC Weight: 59kg
General Examination:
Slight discolouration of the sclera of both eyes was noted on examination.
Discussion
The participant’s general symptoms were improved as were her stool symptoms. Her menstrual symptoms continued to improve gradually. The researcher was pleased with the participant’s progression over the last two months. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription.
Prescription
Lachesis muta 6cH, one powder taken twice a day for one month.
4.9.4 Fourth Consultation – September 2008
General History
On arrival at the fourth consultation the participant was very emotional and was crying. She was unable to complete a general well being questionnaire and could not speak due to her emotional
192 state. She was instructed to lie down by the researcher and after much time the participant explained to the researcher that her husband had filed for divorce that morning. She sobbed hysterically and sighed several times while explaining her story. She explained that her husband was leaving her for another woman. She concluded that she could no longer take part in the study.
She was briefly asked about her menstrual symptoms and explained that she had improved significantly while on the trial. She was no longer experiencing any pain or discomfort. Her menses were very heavy and dark in colour. The duration of flow was five days and she experienced skin eruptions before her menses.
The participant was too emotional and the researcher felt it inappropriate to complete the consultation in her state. The participant was allowed to rest and was given Ignatia amara 200cH every fifteen minutes for five doses for her emotional state. She eventually felt better, was able to communicate effectively and was no longer sobbing.
Physical Examination
Vital Signs:
Blood Pressure: 132/90 mmHg (Right arm, lying down on her back) Heart Rate: 84 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.3ºC Weight: 59kg
General Examination:
Tenderness of the submandibular lymph nodes was noted on examination.
Motivation for Remedy Selection
The researcher decided to not repeat the prescription of Lachesis muta as her menstrual symptoms had improved. Besides the situational shock she was experiencing at the time, she seemed to be asymptomatic.
193 The researcher, however, felt the need to prescribe Ignatia amara owing to the acuteness of the situation and presentation of the participant at hearing the news of her imminent divorce. The participant presented with ‘sighing and sobbing’, was ‘highly emotional’, showed ‘weeping alternating with laughing’, and was ‘not communicative’. There was ‘anger, followed by grief’, consolation appeared to aggravate, as did conversation. ‘Ailments from disappointed love’, ‘narrating her symptoms aggravates’ and ‘weeping ameliorates’ are symptoms expressed by the participant which were synonymous with the Ignatia amara symptom picture. The 200th potency was used due to the acuteness of the case and because of the mental picture which predominated.
Prescription
Ignatia amara 200cH, one powder taken every fifteen minutes for five doses.
4.9.5 Overview of Case Nine
The participant showed a favourable response to Lachesis muta. Much relief of menstrual symptoms was achieved and there was an improvement in general symptoms. Figure 4.25 shows the basal body temperatures of the participant over the treatment period. These temperature charts show possible ovulation on day ten of cycle one and day fifteen of cycle two. Figure 4.26 shows the general well-being scores of the participant over the treatment period. The participant showed minimal deterioration in general well-being over the treatment period. A questionnaire was not completed at the fourth consultation owing to the participant’s traumatised state. Figure 4.27 shows the ratings of the individual questions of the General Well-being Questionnaire. No significant change was noted when comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial. Table 4.9 demonstrates the participant’s midcycle mucus changes which show that at no point during the treatment period did she experience ideal ovulatory mucus changes (clear, stretchy and slippery). Although the participant showed overall improvement, pregnancy was not achieved during the treatment period.
194 Participant 9 - Basal Body Temperature over the Treatment Period
37
36.8
36.6 Cycle 1
36.4 Cycle 2
36.2 Temperature reading Temperature 36 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 Day of cycle
Figure 4.25: Basal Body Temperature of Participant 9 over the Treatment Period
Participant 9 - General Well-Being Questionnaire Scores over the Treatment Period
40 35 27 30 25 24 25 20 15 10 Total Scores Total 5 0 1 2 3 Consultation
Figure 4.26: General Well-Being Scores of Participant 9 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5 Have you been ill or unwell in the past month? 4 Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? 0 Have you felt worried or upset during the past month? 1 2 3 4 5 6 7 How o ften have you felt happy Month during the past month?
Figure 4.27: Individual Question Ratings of Participant 9 over the Treatment Period
195 Table 4.9: Midcycle Mucus Changes of Participant 9 over the Treatment Period Cycle 1 Cycle 2 Cycle 1 Cycle 2 Day 1 Menses Menses Day 19 Clear, White, Sticky, Thick, Slippery Slippery Day 2 Menses Menses Day 20 Clear, White, Sticky, Thick, Slippery Slippery Day 3 Menses Menses Day 21 White, White, Sticky, Sticky, Slippery Slippery Day 4 Menses Menses Day 22 White, White, Sticky, Sticky, Slippery Slippery Day 5 Menses Menses Day 23 White, Clear, Sticky, Sticky, Slippery Slippery Day 6 Clear, Clear, Day 24 White, Clear, Stretchy, Sticky, Sticky, Sticky, Wet Slippery Slippery Slippery Day 7 Clear, Clear, Day 25 White, Clear, Stretchy, Sticky, Sticky, Sticky, Wet Slippery Slippery Slippery Day 8 Clear, Clear, Day 26 White, Clear, Stretchy, Sticky, Sticky, Sticky, Wet Slippery Slippery Slippery Day 9 Clear, Clear, Day 27 Clear, Sticky, Sticky, Sticky, Dry Slippery Slippery Day 10 Clear, Clear, Day 28 Clear, Sticky Sticky, Sticky, Wet Slippery Slippery Day 11 Clear, Clear, Day 29 Clear, Sticky Sticky, Sticky, Wet Slippery Slippery Day 12 Clear, White, Day 30 Clear, Sticky Sticky, Sticky, Wet Slippery Slippery Day 13 Clear, White, Day 31 Clear, Sticky, Sticky, Sticky, Slippery Slippery Slippery Day 14 Clear, White, Sticky, Sticky, Slippery Slippery Day 15 Clear, Clear, Sticky, Sticky, Slippery Slippery Day 16 Clear, Clear, Sticky, Sticky, Slippery Slippery Day 17 Clear, Clear, Sticky, Sticky, Slippery Slippery Day 18 Clear, White, Sticky, Sticky, Slippery Slippery
196 4.10 CASE TEN
Age: 40 (1968) Gender: Female Race: Black Occupation: Service Manager Marital Status: Single Weight: 60kg Height: 1,60 cm BMI: 24.3 Menarche: 13 years of age History of Pregnancy: One pregnancy and one spontaneous miscarriage.
The participant and her husband had been trying to conceive for two to three years. They had consulted a gynaecologist as well as an infertility specialist regarding their infertility. The diagnosis given by both specialists was that of unexplained infertility. The participant had undergone a basic fertility evaluation in 2005. This evaluation included a hysterosalpingogram in 2005 which showed normal findings as well as laparoscopy in 2005 which, showed normal findings. Her husband underwent semen analysis as well as tests of sperm function in 2006. No abnormalities were found. In 2005 and 2006 the participant underwent in vitro fertilization. On both occasions the in vitro fertilization was unsuccessful. Thyroid function tests performed in 2008 showed normal results.
The participant’s partner had a child from a previous relationship. The participant had a history of gonorrhoea which she contracted at age eighteen, and she had experienced chicken pox as a child.
4.10.1 First Consultation – May 2008
General History
At the first consultation the participant described her energy levels as varying from day to day. Some days she felt energetic and other days she felt lethargic. She tended to get cold easily and described this tendency as getting cold from the slightest breeze which would make her have to wrap up warmly. She preferred summer months and being by the seaside.
197 She described her eating habits as eating little bits at a time. She also tended to be a fast eater and had been craving sweets. She explained that she had been thirsty and drank large quantities of water at a time. Her thirst was most marked in the mornings and she preferred her water at room temperature. Her sleep had been poor and she battled to fall asleep. She experienced restless sleep and felt tired on waking. During the night she awoke between 1-2am to urinate and found that at this time she drank a considerable amount of water. She was sleeping on her abdomen. There were no problems with her urination except frequency during the day. Bowel movements were normal and regular. She experienced a bowel movement once a day, usually in the mornings.
She described her menses as being very heavy on the first few days and typically lasting five to six days. The blood would start off pink in colour and eventually became red. The blood contained small clots. Pain was experienced during her menses and was located across the abdomen. The pain during menstruation was the same as the pain felt during ovulation. This pain was very severe for the participant and was rated six out of ten. Before her menses began she experienced abdominal pain that was cutting in nature and worse at night. She also experienced breast tenderness as well as irritability before her menses commenced. She used sanitary towels during her menses.
She had previously used the contraceptive pill from age eighteen to nineteen and had used condoms and the contraceptive injection more than ten years prior for purposes of contraception. The only adverse effect experienced from the use of the contraceptive pill was nausea.
The participant and her partner did not experience any difficulties during intercourse and did not make use of a lubricant. She described her sex drive as being normal. Frequency of intercourse was three to four times a week. She did not experience any vulvovaginal symptoms except for the monthly mucus changes over the time of ovulation.
On a mental and emotional level the participant explained that she felt sad that she was childless. She felt pressured to have a child. This would make her depressed but talking to someone about it made her feel better. She felt stressed because of financial concerns and described her relationship with her boyfriend as being very close. She described herself as having a very bad temper. If angered, she expressed her anger immediately and was very straight forward. She enjoyed entertaining and being around people as well as making friends. Her fears included not having a child, losing a loved one, not achieving in her life, and snakes. She tended to be tearful.
198 Her thoughts and feelings about her infertility included a fear that she was getting older and that she would not fall pregnant. Her partner was supportive of her and believed that she would fall pregnant. He consoled her when she felt sad.
Review of Systems
The participant complained of headaches which were pounding in nature and ameliorated by sleep and worse for concentration. The headache was located over the occipital and parietal region.
Family History
Mother: Aged 65 - Good health Father: Aged 67 - Good health Grandparents: Hypertension and diabetes Siblings: Good health Family history: Tuberculosis
Medication
The participant was not taking any medication or supplementation at the time of the consultation.
Physical Examination
Vital Signs:
Blood Pressure: 108/70 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.3ºC Weight: 60kg
General Examination:
Slight yellow discolouration of the sclera was observed as well as pitting oedema in both lower limbs.
199
Motivation for Remedy Selection
Owing to a suspected miasmatic block, the researcher decided to start the case with miasmatic treatment. Medorrhinum was selected as the participant showed a history of gonorrhoeal infection (Murphy, 1988). She also showed symptoms of ‘craving for sweets’, sleeps on her ‘abdomen which ameliorates’, ‘strong sex drive’, ‘worse for cold’, ‘better for the seaside’, ‘very thirsty with aversion to cold drinks’, ‘sensitive to drafts’ (Vermeulen, 2001). She made mistakes while talking, struggled to find the right words and was very slow in speaking. She experienced occipital headaches that were worse for mental efforts. She was very well groomed and wore expensive clothes and shoes. She appeared to be very secretive and hid her emotions and intentions. When angry she wanted everyone to see and liked drawing attention to herself (Vermeulen, 2001; Tyler, 1988). All of these symptoms fit Medorrhinum.
Prescription
Medorrhinum 200cH, one powder taken three times a week for one month.
4.10.2 Second Consultation – July 2008
General History
The participant described her energy levels as improved. She found that her appetite had decreased. She had been eating less food and had experienced a strong craving for sweets and an aversion to broccoli. She experienced great thirst particularly before going to bed. She said that she drank about two litres of water before going to bed and mentioned that the water had to be room temperature. This symptom was pronounced and had significantly increased since the last consultation. The participant woke during the night to drink water. This occurred between 1-2am. She noted that her thirst during the day was normal. As a result of her thirst at night she experienced difficulty falling asleep as well as restless sleep. She described not being completely asleep as her mind was very busy. The participant was still sleeping on her abdomen. She had experienced difficulty with bowel movements as well as increased flatus which was worse in the afternoons between 12-5pm as well as in the evenings. The stools were described as being large and green in colour as well as hard and dry.
200 Her menses lasted six days which was longer than usual. The participant experienced severe menstrual pains as well as a sensation as if something were pulling downward. The pain was located from the umbilicus to the pubis and was worse for walking. The participant also added that when she was ovulating she could feel the “egg coming out her ovary” and described this pain as a sharp pain which came and went. She experienced breast tenderness which was worse in the left breast and for touch. Her menses had been pink to light pink in colour and clotted. The flow had been extremely heavy and she mentioned that she had never experienced such a heavy menses before. She rated the pain as seven out of ten. She did not notice abdominal pain before her menses.
Mentally and emotionally she had felt very anxious and depressed because of possible retrenchment. She had found comfort in her religion and added that she felt more religious.
Review of Systems
No headache had been experienced in the last month.
Physical Examination
Vital Signs:
Blood Pressure: 94/62 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.1ºC Weight: 60kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
A random glucose test was performed because of her polydipsia and polyuria. Random glucose levels were 4.9 mmol/l
201 Motivation for Remedy Selection
After repertorisation it was decided that Sepia officinalis would be given following the miasmatic prescription of Medorrhinum. The participant fit the Sepia officinalis picture as she experienced a ‘dysmenorrhoea’, ‘bearing down sensation’, ‘desire for sweets’, ‘sleeplessness at night’, ‘anger from contradiction’ (Schroyens, 2001; Vermeulen, 2001; Tyler, 1988). Sepia officinalis is an excellent remedy in cases of infertility. The participant also experienced marked constipation which is seen in the Sepia officinalis symptom picture (Smith, 1989).
Prescription
Sepia officinalis 6cH, one powder taken three times a day for one month.
4.10.3 Third Consultation – August 2008
General History
At the third consultation the participant reported a sore throat which had started a few days prior to the third consultation as well as increased nasal discharge. This discharge had been clear and watery. She also reported a cough which was dry and spasmodic and worse during the day. She had felt hot and feverish.
Her energy levels had improved as she had not felt lazy and was more active. Her appetite had been normal and she was no longer craving sweets. She had not been as thirsty as before and was not experiencing the excessive thirst before going to bed. She drank an average of two litres of water throughout the day. She no longer woke during the night to drink water or urinate. As a result of this her sleep had significantly improved and she awoke feeling refreshed. Her previous complaint of constipation had improved. She had experienced a bowel movement once a day which was not difficult to pass and mentioned that there was increased flatus particularly in the mornings and during sleep. There had been no dryness or hardness of the stool.
The participant experienced a menstrual period that lasted five days. She described her last menstrual period as being a “different period”. There had been very slight breast tenderness that caused very little discomfort before her menses. Other than this slight breast tenderness, the participant did not experience any other premenstrual symptoms. No pain or discomfort was
202 experienced in any way throughout the period and she had not experienced the pulling downward sensation. She mentioned that this period came and went with her barely noticing it. She described her menses as having been red in colour and with very few clots. The flow had been heavy for the first two nights and then normal flow followed. Generally the flow of this period had not been as heavy as previous months. She had still experienced pain during ovulation that was sharp in nature and was most pronounced in the morning. This pain lasted three to four hours.
Mentally and emotionally the participant felt a happiness which she described to be coming from within. She felt optimistic and that “life was great”.
Review of Systems
No complaints were reported during the review of systems.
Physical Examination
Vital Signs:
Blood Pressure: 98/60 mmHg (Right arm, sitting upright) Heart Rate: 88 beats per minute Respiratory Rate: 16 breaths per minute Temperature: 36.0ºC Weight: 62kg
General Examination:
Slight pitting oedema in the left leg was observed as well as tenderness of the tonsilar and deep cervical lymph nodes
Discussion
The participant showed significant improvement in her menstrual and premenstrual symptoms. Mentally and emotionally she felt happier and more positive. Her general symptoms improved as did her stool symptoms. The researcher was pleased with the participant’s progression over the last
203 two months. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month.
Prescription
Sepia officinalis 6cH, one powder taken three times a day for one month.
4.10.4 Fourth Consultation – September 2008
General History
The participant explained that her energy levels had improved and she had not experienced any cravings or aversions. She had, however, enjoyed fresh fruits and vegetables more. The participant had not been as thirsty as previously and she had started perspiring slightly all over her body while sleeping at night. Her sleep quality had been very poor and she felt tired on waking. She reported dizziness on waking. Her bowel function had improved and less flatus was noted.
The participant reported that her menses had been completely pain free and had lasted five days. There had been no breast tenderness or a bearing down sensation during her menses. The blood had appeared light in colour and became progressively darker. The participant explained that there had not been any clots and the flow had been light. She also explained that about three hours before her menses had begun, she experienced a slight cramping pain which had disappeared as soon as menses commenced. The only premenstrual symptom she had experienced was irritability.
Mentally and emotionally the participant felt stressed due to work-related issues. However, she added that she had been feeling happier than she had previously and that she had noticed a definite improvement in her physical as well as mental symptoms.
Review of Systems
No complaints were reported during the review of systems.
204 Physical Examination
Vital Signs:
Blood Pressure: 88/58 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.5ºC Weight: 61kg
General Examination:
Yellow discolouration of the sclera was observed.
Discussion
The participant continued to show significant improvement in her menstrual and premenstrual symptoms. Mentally and emotionally she had been feeling even happier and more positive. Her general symptoms continued to improve. Her bowel function was now regular. The researcher and the participant were pleased with the continued progression and improvement. The researcher decided to not repeat the prescription for the following month as the participant was now asymptomatic.
Prescription
Nil
4.10.5 Overview of Case Ten
The participant demonstrated a favourable response to miasmatic treatment with Medorrhinum. Her response to Sepia officinalis was marked and she showed considerable improvement in her menstrual and general symptoms. Three months into the trial the participant requested to leave the trial owing to personal reasons. Figure 4.28 shows ovulation to have occurred between days eleven and fourteen on cycles one and two, as well as estimated ovulation between days thirteen and sixteen for cycles three and four. Figure 4.29 shows general well-being scores over the treatment
205 period. The greatest improvement in the participant’s general well being was noted between consultations two and three when the prescription was changed to Sepia officinalis. This was maintained in the fourth month. Figure 4.30 shows the ratings of the individual questions of the General Well-being Questionnaire. When comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial it was noted that improvement had occurred in her general well-being, depression, as well as her level of worry or happiness. No significant change was noted in her anxiety and energy levels. Table 4.10 shows that midcycle mucus changes appeared to be ideal (clear, stretchy and slippery) on days fourteen to seventeen of the first cycle, on days thirteen to seventeen of the second cycle, on days thirteen to fifteen of the third cycle, and on days fifteen to eighteen of the fourth cycle. The participant’s dysmenorrhoea and premenstrual symptoms had been greatly alleviated however, pregnancy was not achieved during the treatment period.
206 Participant 10 - Basal Body Temperature over the Treatment Period
36.9 36.8 36.7 Cycle 1 36.6 Cycle 2 36.5 Cycle 3 36.4 Cycle 4 36.3
Temperature reading 36.2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 Day of cycle
Figure 4.28: Basal Body Temperature of Participant 10 over the Treatment Period
Participant 10 - General Well-Being Questionnaire Scores over the Treatment Period 40 35 31 31 30 27 27 25 20 15
Total Score Total 10 5 0 1 2 3 4 Consultation
Figure 4.29: General Well-Being Scores of Participant 10 over the Treatment Period
Individual Question Rating
How are you feeling in general? 5
Have you been ill or unwell in 4 the past month? Have you felt depressed in the 3 past montth? Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels? 1 Have you felt healthy enough to do the things you want/had to?
0 Have you felt worried or upset during the past month? 1 2 3 4 5 6 7 How often have you felt happy Month during the past month?
Figure 4.30: Individual Question Ratings of Participant 10 over the Treatment Period
207 Table 4.10: Midcycle Mucus Changes of Participant 10 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Day 1 Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Day 5 Menses Menses Menses Menses Menses Day 6 No Discharge No Discharge No Discharge
Day 7 No Discharge No Discharge No Discharge No Discharge
Day 8 No Discharge No Discharge No Discharge No Discharge
Day 9 No Discharge No Discharge No Discharge No Discharge
Day 10 No Discharge No Discharge No Discharge No Discharge
Day 11 No Discharge No Discharge No Discharge No Discharge
Day 12 No Discharge No Discharge No Discharge No Discharge No Discharge Clear, Stretchy, Clear, Stretchy, Day 13 Slippery Slippery No Discharge Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 14 Slippery Slippery Slippery No Discharge Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Clear, Stretchy, Day 15 Slippery Slippery Slippery Slippery Clear, Stretchy, Clear, Stretchy, No Discharge Clear, Stretchy, Day 16 Slippery Slippery Slippery Clear, Stretchy, Clear, Stretchy, No Discharge Clear, Stretchy, Day 17 Slippery Slippery Slippery No Discharge Clear, Sticky, No Discharge Clear, Stretchy, Day 18 Wet Slippery No Discharge Clear, Sticky, No Discharge No Discharge Day 19 Wet No Discharge Clear, Sticky, No Discharge No Discharge Day 20 Wet
Day 21 No Discharge No Discharge No Discharge No Discharge No Discharge No Discharge Clear, No Discharge Day 22 Sticky Slippery No Discharge No Discharge Clear, No Discharge Day 23 Sticky Slippery No Discharge No Discharge Clear, No Discharge Day 24 Sticky Slippery
Day 25 No Discharge No Discharge No Discharge No Discharge
Day 26 No Discharge No Discharge No Discharge No Discharge
Day 27 No Discharge No Discharge No Discharge No Discharge
Day 28 No Discharge No Discharge No Discharge No Discharge
208 4.11 CASE ELEVEN
Age: 25 (1983) Gender: Female Race: White Occupation: General Manager Marital Status: Married Weight: 56kg Height: 1,63m BMI: 21.1 Menarche: 13 years of age History of Pregnancy: No pregnancies.
The participant and her partner had been trying to conceive for one to two years and had consulted with a general practitioner, gynaecologist as well as an infertility specialist concerning their infertility. The participant underwent a basic infertility evaluation. This included confirmation of ovulation in 2008 which was found to be normal as well as a hysterosalpingogram and laparoscopy which showed normal findings. Other tests that were conducted included a postcoital test in 2008 which was found to be normal. Thyroid testing showed normal function in 2008. The participant’s husband underwent semen analysis in 2008 as well as a test of sperm function. Both showed normal findings. The diagnosis of their infertility was unexplained infertility.
The participant had received the BCG, hepatitis, malaria, yellow fever, MMR and polio vaccinations. She had sought psychological/psychiatric help in 2001.
4.11.1 First Consultation – May 2008
General History
The participant reported that she had very low energy levels. She felt most energetic at night and in the mornings, while her energy levels were worse at 2pm. She explained that she got cold easily and that her hands and feet were always cold. She enjoyed winter as she felt most energetic during this time. Her appetite was good and she craved warm foods and savoury flavours and was averse to fish. She was very thirsty particularly at night but averse to water. Her perspiration was profuse on her hands and underarms. This was so severe that her clothes would become drenched. Calming
209 down ameliorated her profuse perspiration. Her sleep was very good except that she would awake feeling unrefreshed. Her urination and bowel function were normal and regular.
The participant explained that she experienced severe breast tenderness before her menses which was better for pressure. Her skin would break out in pustular eruptions particularly on her chin. Her skin symptoms were better for the flow of her menses. It was worse before and after her menses. She would be very emotional, irritable and angered easily. She would cry easily during this time. For the first two to three days of the five days of her menses, there was profuse flow of blood. She experienced lower back pain as well as pain in her flanks which was sore and cramping in nature respectively. This pain was better for warmth. She described the blood as dark red in colour and thick in consistency. For the first two days of flow there were clots as well as membranes. She made use of sanitary towels at night and tampons during the day.
She made use of the contraceptive pill and condoms in 2006 for purposes of contraception and suffered adverse effects including skin eruptions, tiredness, decreased libido and a feeling of general illness.
The participant explained that her sexual appetite had been “ravenous” and she experienced pain on penetration if she had not had sexual intercourse for at least a week. The frequency of intercourse was four times a week. The participant reported no vulvovaginal symptoms.
Mentally and emotionally the participant felt anxious as her husband was away on business. As a couple they decided to try fall pregnant soon into their marriage. She felt very depressed and despondent when thinking about her infertility. She explained that it was her dream to be a mother. Her husband was despondent about their difficulties in conceiving. She described her personality as easy going and someone who did not get angry easily. She got anxious when people hurt her family and explained that she did not cry easily. She explained that if she did cry she preferred to be alone.
Review of Systems
The participant reported that she experienced a vesicular skin eruption on the knuckles and in between her fingers. This eruption was worse for scratching, wetting her hands, perspiration and in summer. She also mentioned that she usually experienced sporadic nose bleeds with little bleeding which was bright red in colour.
210 Family History
Mother: Aged 53 - Fibromyalgia and depression Father: Aged 57 - Healthy Grandparents: Systemic Lupus Erythematosis, Emphysema, Diabetes Mellitus, Heart failure Siblings: Healthy Family history: Heart disease, Cancer
Medication
The participant was not taking any supplementation or medication.
Physical Examination
Vital Signs:
Blood Pressure: 100/70 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 15 breaths per minute Temperature: 36.2ºC Weight: 56kg
General Examination:
No findings were observed on physical examination.
Motivation for Remedy Selection
The researcher decided to prescribe Natrum muriaticum after repertorisation. Natrum muriaticum is the top ranking medicine in homoeopathy for sterility (Kandpal et al, 2004). After repertorisation, and according to Schroyens (2001), Natrum muriaticum features strongly in the rubrics ‘summer aggravates’, ‘profuse perspiration’, ‘sexual desires increased’, ‘weeping easily and irritability before and during menses’, ‘thirst accompanied by aversion to drinking’, ‘cold hands’, ‘aversion to water’, ‘skin eruptions before menses’ and ‘breast tenderness before menses’. These were symptoms that were strongly expressed by the participant. The participant also showed ‘menses
211 irregular and usually profuse’, ‘wants to be alone to cry’, ‘crusty eruptions on the bends of joints’, ‘skin is harsh and unhealthy’, ‘itching and burning of the skin’ and ‘itching worse for sweating’ (Schroyens, 2001; Vermeulen, 2001). Tyler (1988) also mentions that Natrum muriaticum experiences ‘large red blotches on the skin with violent itching’ as well as ‘oozing of an acrid substance’ and mentions the periodicity which corresponds with the participant’s main complaint and general symptoms. The 6th potency was prescribed twice a day because of the physical presentation of the case as well as because of the chronicity of the complaint.
Prescription
Natrum muriaticum 6cH, one powder taken twice a day for one month.
4.11.2 Second Consultation – June 2008
General History
The participant reported at the second consultation that her menses had been heavier than in the past. She had experienced sharp pains in the back and lower abdominal areas which was worse for cold. The menses were very dark in colour and were membranous and clotted. The blood had become brown toward the end of her bleeding. She had not experienced any emotional symptoms before her menses, only during flow. During this time she had felt sensitive and easily offended.
Her energy levels had been very low and she felt exceptionally cold over the last month. She had been averse to fruit but explained that she was constantly eating and craved food in general. She was very thirsty, which was most marked in the mornings. She was averse to water but forced herself to drink water. Her sleep had been poor. She would wake often during the night and awoke in the morning feeling unrefreshed. She described her sleep over the last month as restless.
Mentally and emotionally the participant was feeling very tired. She explained that due to work- related issues and deadlines she had been feeling very drained.
212 Review of Systems
The participant reported that her previous skin symptoms had improved. There was no longer any crusting between the fingers and only a few liquid filled vesicles remained on the right hand. She had not experienced any earache or nose bleeds over the last month.
Physical Examination
Vital Signs:
Blood Pressure: 110/60 mmHg (Right arm, sitting upright) Heart Rate: 60 beats per minute Respiratory Rate: 12 breaths per minute Temperature: 36.6ºC Weight: 56kg
General Examination:
Tenderness of the left and right submandibular lymph nodes was noted on palpation.
Discussion
The participant appeared to have experienced a slight aggravation in terms of her menstrual symptoms. Her chronic skin condition showed improvement. The researcher was still confident in the remedy and potency selection. It was felt that the remedy needed more time to work, thus the prescription was repeated at the same potency but less frequently.
Prescription
Natrum muriaticum 6cH, one powder taken once a day for one month.
213 4.11.3 Third Consultation – July 2008
General History
The participant had experienced two menstrual bleeds during the previous month. Prior to the first menstrual bleed the participant reported no emotional symptoms and no breast tenderness. The first menstrual bleed presented initially with spotting and severe back pain which was rated eight out of ten. She mentioned that there had not been as much abdominal cramping as before, and the flow had been light and had lasted six days. The blood was described to be dark in colour and clotted.
Her second menstrual cycle had been very heavy on the first two days and had lasted seven days. The blood was described to have been bright red in colour and without any clots. She experienced lower back pain which was rated five out of ten with no abdominal pain. She reported that she had felt exceptionally emotional and had been very easily angered and frustrated. Toward the end of her menstrual cycle she reported feeling nauseous as well as dizzy. The participant noted that she had observed that a painful menstrual cycle alternated with a less painful menstrual cycle. When her menstrual cycle was less painful she noted more prominent emotional symptoms.
Her energy levels had improved. She was averse to fruit and fish, and craved coffee. She felt thirstier since last month. This thirst was most pronounced at night. Her perspiration had improved significantly. Her sleep had improved, and mentally and emotionally she explained that she felt better than the last month.
Review of Systems
The participant reported that her skin symptoms had cleared. She had felt dizziness which she related to the amount of computer work she was required to do. She reported slight congestion of the nose as well as two episodes of epistaxis at night during the previous month.
Physical Examination
Vital Signs:
Blood Pressure: 120/78 mmHg (Right arm, sitting upright) Heart Rate: 64 beats per minute
214 Respiratory Rate: 14 breaths per minute Temperature: 36.0ºC Weight: 56kg
General Examination:
No findings were observed on physical examination.
Discussion
The researcher and the participant were happy with the progress thus far. Her menstrual and general symptoms as well as her skin symptoms continued to improve gradually. Because of the presence of symptoms closely related to the Natrum muriaticum symptom picture, the researcher decided to continue the prescription. It was felt that further improvement could be achieved.
Prescription
Natrum muriaticum 6cH, one powder taken twice a day for one month.
4.11.4 Fourth Consultation – August 2008
General History
At the fourth consultation the participant explained that she had been feeling very good in general. She had felt even better mentally and emotionally than the previous month. Her energy levels had continued to improve and she felt warmer than she had previously. Her appetite was more consistent and she was no longer craving coffee. She was very thirsty, and had not experienced any symptoms of perspiration.
Her menstrual cycle had been very good. She had experienced mild breast tenderness a week before her menses. Her menstrual cycle lasted two to three days and she had experienced mild lower back pain which was rated three out of ten. She had not experienced any bloating, dizziness or abdominal pain, and described the blood as dark in colour, thick and clotted. She had been emotional, irritable and weepy before her menses.
215 Review of Systems
The participant reported no skin symptoms and no episodes of epistaxis.
Physical Examination
Vital Signs:
Blood Pressure: 106/60 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 14 breaths per minute Temperature: 36.1ºC Weight: 56kg
General Examination:
Very slight pitting oedema was noted in both lower limbs.
Discussion
The participant continued to show significant improvement in her menstrual and general symptoms. The participant was starting to experience normal menstrual cycles. She was pleased with the progress thus far. The researcher however decided to continue and repeat the prescription owing to the chronic nature of the case.
Prescription
Natrum muriaticum 6cH, one powder taken twice a day for one month.
216 4.11.5 Fifth Consultation – October 2008
General History
The participant presented at the fifth consultation with energy levels which were normal, and increased thirst in the mornings. The quality of her sleep had been poor and she had been waking feeling tired. She had slept on her back over the last month which had caused lower back pain.
Her menstrual cycle had improved. She experienced no premenstrual symptoms such as abdominal bloating, breast tenderness or emotional symptoms. Her menstrual cycle lasted five to six days and was described to be very light in flow. The blood had been very clotted and coagulated. It had been very dark in colour and there had been no fluid blood in the menses. No menstrual cramps were reported.
Review of Systems
The participant reported that the skin eruption on her hands had returned. The eruption was on both hands and was very itchy. The itching was worse for water and scratching and better for the application of camphor cream. The participant was asked to refrain from using Camphor cream during the treatment period.
Physical Examination
Vital Signs:
Blood Pressure: 122/88 mmHg (Right arm, sitting upright) Heart Rate: 72 beats per minute Respiratory Rate: 13 breaths per minute Temperature: 36.5ºC Weight: 57kg
General Examination:
No findings were observed on physical examination.
217 Discussion
The researcher and the participant were happy with the progress thus far. Her menstrual and general symptoms continued to improve gradually. Owing to the presence of mild symptoms and the participant’s favourable response to the remedy, the researcher decided to repeat the prescription for the following month. It was felt that any change in remedy selection or potency would disturb the good progress thus far.
Prescription
Natrum muriaticum 6cH, one powder taken twice a day for one month.
4.11.6 Sixth Consultation – November 2008
General History
The participant explained that she had been craving junk food. She reported that she had been thirstless, and had found much difficulty waking up despite a good quality sleep. Mentally and emotionally she had felt irritable and anxious.
Her menstrual cycle had lasted five to six days and had commenced three days too early. She had felt emotional before her menses. On the first day she had noted spotting followed by flow. She had also experienced back pain and menstrual cramps which were rated nine out of ten. These symptoms were ameliorated after the first day. The blood was described to have been light red in colour, coagulated and heavy in flow.
Review of Systems
The participant reported that her skin symptoms had worsened. She described the sensation to be “as if on fire’. The eruption had been worse on the right hand and continued to be worse for touch and water. The participant explained that scratching seemed to spread the eruption. On observation it was noted that tiny fluid filled vesicles were present. The participant explained that the fluid in the vesicles crusted over the eruption resulting in the skin peeling off.
218 Physical Examination
Vital Signs:
Blood Pressure: 126/68 (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.3ºC Weight: 55kg
General Examination:
Tenderness of the left and right tonsilar lymph nodes was noted on palpation.
Focused Physical Examination:
The skin of both hands was observed. It was found that a rash was evident over the joints and cuticles of the fingers of the right hand. The eruption appeared crusty with red spots. Fluid-filled vesicles were scattered over the area. The left hand was clear of any eruption.
Discussion
The researcher decided that it was time to change the potency of the remedy to the 30th potency as the original improvement was not holding. The participant had shown good response to Natrum muriaticum, thus the remedy was not changed.
Prescription
Natrum muriaticum 30cH, one powder taken once a day for one month.
219 4.11.7 Seventh Consultation – January 2009
General History
At the final consultation the participant explained that her energy levels varied because of end of year deadlines and work-related stresses. She was no longer feeling as warm as she had the previous month and her thirst had returned to normal. The participant’s sleep was still bad and she mentioned that she felt hot at night and perspired on her neck. She also recalled that she had dreamt often over the past month but could not remember any of her dreams.
The participant had experienced two menstrual cycles since the last consultation and explained that she had felt irritable and tired before the commencement of her menses. She had also experienced marked breast tenderness before her menses. She experienced no lower back pain or menstrual cramps and described the flow as being light to medium. The blood was described to be bright red in colour with no clots.
The second menstrual cycle experienced by the participant presented with no premenstrual symptoms, mild lower back pain and no menstrual cramps. The flow was described to have been medium while the blood was described to have been dark in colour with no clots. This menstrual period lasted three days.
Review of Systems
The participant reported that her skin symptoms on her right hand had cleared completely. She had experienced a headache as if her head would explode. This headache was described to have been worse for light and at the end of the day.
Physical Examination
Vital Signs:
Blood Pressure: 110/70 mmHg (Right arm, sitting upright) Heart Rate: 68 beats per minute Respiratory Rate: 10 breaths per minute Temperature: 36.4ºC
220 Weight: 53kg
General Examination:
No findings were observed on physical examination.
Focused Physical Examination:
No skin eruption was observed and the cuticles were intact.
Discussion
Both the researcher and the participant were pleased with the results after the final month of treatment. It was evident that the participant was now asymptomatic as far as her main complaints were concerned. The researcher decided that no further treatment was necessary.
Prescription
Nil
4.11.8 Overview of Case Eleven
The participant showed a good response to Natrum muriaticum. According to Kent, Natrum muriaticum is a remedy which operates slowly and brings about its results after a long time. For this reason the remedy was repeated often and at the same potency and frequency (Tyler, 1988). Significant improvement was noted in the participant’s skin complaints as well as in her menstrual cycle. Figure 4.31 shows basal body temperatures over the treatment period for participant eleven. This shows that the date of ovulation is difficult to estimate due to the lack of typical ovulatory pattern in the participant’s basal body temperature readings. Figure 4.32 shows the participant’s general well-being over the treatment period. The scores show a decrease in general well-being in the first month of treatment. This may be due to the slight aggravation experienced due to the medication. A steady increase in general well-being was noted over the next two months followed by the greatest decrease in general well-being in the fourth month of treatment. After changing to the 30th potency, a gradual improvement was noted over the last two months of the treatment period. Figure 4.33 shows the ratings of the individual questions of the General Well-being
221 Questionnaire. No significant change was noted when comparing the ratings per question at the beginning of the trial to the ratings per question at the end of the trial. Table 4.11 shows that the participant experienced ideal (clear, stretchy and slippery) ovulatory discharges on days fourteen and fifteen of cycle three, and days eleven and twelve of cycle four. Although the participant showed overall improvement, pregnancy was not achieved during the treatment period.
222 Participant 11 - Basal Body Temperature over the Treatment Period
38 37.75 Cycle 1 37.5 Cycle 2 37.25 Cycle 3 37 Cycle 4 36.75 Cycle 5 36.5 Cycle 6 36.25 Temperature reading Temperature Cycle 7 36 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Day of cycle
Figure 4.31: Basal Body Temperature of Participant 11 over the Treatment Period
Participant 11 - General Well-Being Questionnaire Scores over the Treatment Period
40 35 30 30 27 28 24 25 25 21 21 20 15
Total Scores Total 10 5 0 1 2 3 4 5 6 7 Consultation
Figure 4.32: General Well-Being Scores of Participant 11 over the Treatment Period
Individual Question Rating
How are you feeling in 5 general? Have you been ill or unwell 4 in the past month? Have you felt depressed in the past montth? 3 Have you felt anxious or nervous in the past month?
Rating 2 How are your energy levels?
1 Have you felt healthy enough to do the things you want/had to? 0 Have you felt worried or upset during the past 1 2 3 4 5 6 7 month? How often have you felt happy during the past Month month?
Figure 4.33: Individual Question Ratings of Participant 11 over the Treatment Period
223 Table 4.11: Midcycle Mucus Changes of Participant 11 over the Treatment Period Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6 Day 1 Menses Menses Menses Menses Menses Menses Day 2 Menses Menses Menses Menses Menses Menses Day 3 Menses Menses Menses Menses Menses Menses Day 4 Menses Menses Menses Menses Menses Menses Day 5 Menses Menses Menses Menses Menses Menses No Discharge Menses No Discharge Menses Menses White, Sticky, Day 6 Slippery White, Stretchy, Menses No Discharge Menses White, Sticky, White, Sticky, Day 7 Sticky Slippery Slippery Clear, Stretchy, White, Stretchy, No Discharge Menses White, Sticky, White, Sticky, Day 8 Sticky Slippery Slippery Slippery Clear, No Discharge White, Sticky, Menses White, Sticky, Day 9 Stretchy, Wet Stretchy Slippery White, Stretchy, White, Stretchy, White, Sticky, Clear, Sticky, White, Sticky, Day 10 Sticky Slippery Stretchy Slippery Slippery Clear, Sticky, Clear, Sticky, Clear, Sticky, Clear, Stretchy, White, Sticky, Day 11 Slippery Slippery Slippery Slippery Slippery Clear, Sticky, Clear, Sticky, Clear, Sticky, Clear, Stretchy, White, Sticky, Day 12 Dry Slippery Slippery Slippery Slippery Clear, Sticky, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 13 Wet Stretchy Stretchy Slippery Slippery White, Stretchy, Clear, Sticky, Clear, Stretchy, White, Sticky, White, Sticky, White, Sticky, Day 14 Sticky Slippery Slippery Slippery Slippery Slippery Clear, Sticky, White, Sticky, Clear, Stretchy, White, Sticky, White, Sticky, White, Sticky, Day 15 Wet Stretchy Slippery Slippery Slippery Slippery Clear, Sticky, White, Stretchy, Clear, White, Sticky, White, Sticky, White, Sticky, Day 16 Wet Slippery Sticky, Slippery Slippery Slippery Slippery White, Sticky, White, Thick, Clear, White, Sticky, White, Sticky, White, Sticky, Day 17 Slippery Wet Sticky, Slippery Slippery Slippery Slippery Clear, Sticky, White, Sticky, White, Stretchy, White, Sticky, White, Sticky, White, Sticky, Day 18 Wet Stretchy Slippery Slippery Slippery Slippery Clear, Sticky, White, Sticky, Clear, White, Sticky, White, Sticky, White, Sticky, Day 19 Wet Stretchy Sticky, Slippery Slippery Slippery Slippery White, Stretchy, Clear, Sticky, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 20 Wet Slippery Slippery Slippery Slippery Slippery Clear, Sticky, Clear, Sticky, White, Sticky, Clear, Sticky, White, Sticky, White, Sticky, Day 21 Wet Slippery Slippery Slippery Slippery Slippery Clear, Sticky, Clear, Sticky, White, Sticky, Clear, Sticky, White, Sticky, White, Sticky, Day 22 Wet Slippery Slippery Slippery Slippery Slippery Clear, Sticky, Clear, Sticky, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 23 Wet Slippery Slippery Slippery Slippery Slippery Clear, Sticky, Clear, Sticky, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 24 Wet Slippery Slippery Slippery Slippery Slippery White, Sticky, White, Stretchy, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 25 Slippery Slippery Slippery Slippery Slippery Slippery Yellow, Sticky, White, Stretchy, White, Sticky, White, Sticky, White, Sticky, White, Sticky, Day 26 Slippery Slippery Slippery Slippery Slippery Slippery Clear, Sticky, White, Sticky, Yellow, Sticky, White, Sticky, White, Sticky, Day 27 Slippery Slippery Slippery Slippery Slippery White, Sticky, White, Sticky, Day 28 Slippery Slippery White, Sticky, White, Sticky, Day 29 Slippery Slippery
224 CHAPTER FIVE
RESULTS
5.1 INTRODUCTION TO THE RESULTS
In chapter five the researcher discusses the sample characteristics of the group, and analyses the related clinical fertility parameters, general parameters, related functional symptoms and concomitant symptoms experienced by the sample group over the treatment period. Achievement of pregnancy is discussed and as well as the difference between the statistical and clinical significance of the trial. Issues of compliance are also visited.
5.2 SAMPLE CHARACTERISTICS
The average age of the participants who took part in the trial was 35.7 years of age. Of the eleven participants three (27.3%) had been trying to conceive for between one to two years, one (9.1%) of the participants had been trying for between two to three years, and two (18.2%) participants had been attempting conception for between three to four years. A total of five (45.5%) participants had been trying to conceive for more than five years. Of the eleven participants, eight (72.7%) presented with at least one previously documented conception or secondary infertility. The remaining three (27.3%) participants presented with primary infertility.
It was found that participants had consulted general practitioners (18.2%), gynaecologists (45.5%), infertility specialists (31.8%), homoeopaths (4.5%) or traditional healers (4.5%) regarding their difficulties in conception.
Of the participants ten (90.9%) did not smoke while one (9.1%) smoked between one to five cigarettes per day. Eight (72.7%) of the participants had never smoked in the past, while three (27.3%) had smoked previously.
Seven (63.6%) of the participants did not drink alcoholic beverages, while three (27.3%) participants consumed one to two units of alcohol per week. One (9.1%) participant said that she consumed three to four units of alcohol per week. Eleven (100%) of the participants had not made
225 use of recreational drugs. When questioned about toxic exposures it was found that only one (9.1%) of the study group had experienced toxic exposure in the form of radiation.
When questioned on childhood illnesses it was found that four (19.0%) had experienced mumps, nine (42.9%) had experienced chicken pox, six (28.6%) had experienced measles and only two (9.5%) had experienced whooping cough. These participants were questioned on which immunizations they had received and it was found that five (14.7%) had received the BCG vaccination, four (11.8%) had received the DPT vaccination, four (11.8%) had received a hepatitis vaccination and two (5.9%) had received malaria vaccination. Four (11.8%) participants had received their yellow fever vaccination while another four (11.8%) had received the MMR vaccination. A total of nine (26.5%) participants had received the polio vaccination while two (5.9%) had received other vaccinations not listed on the questionnaire. Only one (2.9%) participant had received the German measles vaccination.
The participants were questioned on the prevalence of specific diseases in their family. It was found that five (17.2%) had a family history of cancer, while four (13.8%) participants had a family history of heart disease. Four (13.8%) participants had a family history of tuberculosis, four had a family history of hypertension and another four (13.8%) had a family history of arthritis. Of the participants that took part in the trial, three (10.3%) had a family history of infertility, two (6.9%) had a history of mental illness in their families, and two (6.9%) of the participants had a family history of genetic disorders. One (3.4%) participant had a family history of endocrine disease.
Five (45.5%) participants had undergone artificial insemination. Of this group a total of twelve attempts were made while the maximum amount of attempts made by one participant was four times. The minimum amount of times artificial insemination was attempted was once. None of the artificial insemination attempts were successful. Five (45.5%) participants underwent in vitro fertilisation therapy. Of this group a total of eight attempts were made. The maximum amount of attempts made by one participant was three, while the minimum amount was one. Three of the five participants that underwent in vitro fertilisation therapy had achieved successful conception. But only two of the three participants who had successful in vitro fertilisation had a live birth. None of the participants underwent GIFT, ZIFT or ICSI treatment. A minimum of two years before the trial six (54.5%) of the participants had used Clomid® for purposes of assisted conception. A total of five (45.5%) participants had not used Clomid® at any point during their fertility treatment.
226 5.3 ACHIEVEMENT OF PREGNANCY
No pregnancies were achieved during the treatment period. Participant two was suspected to have fallen pregnant during the treatment period but upon investigation a benign complex cyst was discovered on the right adnexa. This cyst explained the positive βhCG and three months of amenorrhoea. Participant three was also suspected to have fallen pregnant in the last month of the trial. Owing to unforeseen circumstances, testing could not be performed thus no test results are available to confirm if pregnancy was in fact achieved. After a brief period of illness the participant was suspected to have miscarried.
5.4 STATISTICAL ANALYSIS
Owing to the small size of the sample group and the nature of the study no inferential statistics could be made. However, graphs and frequencies were used to draw a conclusion.
5.5 CLINICAL ANALYSIS
5.5.1 Related Fertility Parameters
Sexual dysfunction, namely dyspareunia, low libido and vaginal dryness were experienced by eight (72.7%) of the participants. Six (54.5%) participants showed significant improvement in their sexual symptoms while one (9.2%) showed only slight improvement. One (9.2%) participant was unable to report whether improvement had occurred as she was not sexually active and was receiving artificial insemination at times of ovulation.
Observation of midcycle mucus changes showed that participants were not consistently experiencing ideal (clear, stretchy and slippery) midcycle mucus changes. Analysis of Basal Body Temperature Charts demonstrated that participants did not consistently experience normal changes in basal body temperature.
5.5.2 General Parameters
Figure 5.1 shows the mean values for the individual questions which make up the general well- being questionnaire.
227 General Well-Being Questionnaire
5 How are you feeling in general?
Have you been ill or unwell in the past 4 mont h?
Have you felt depressed in the past mont t h? 3
Have you felt anxious or nervous in the past mont h? 2 How are your energy levels? Average Rating Average
Have you felt healt hy enough to do the 1 t hings you want/had to?
Have you felt worried or upset during the 0 past month?
1 2 3 4 5 6 7 How of t en have you felt happy during the past month? Month
Figure 5.1: Mean values of the individual questions of the General Well-Being Questionnaire for all Eleven Participants over the Treatment Period
The plotted mean values demonstrate the progression of the eleven participants in terms of each question over the treatment period. Comparison of the mean values in Table 5.1 of the first consultation and the last consultation demonstrate that improvement was noted in questions one, two, four, five, six and eight. These improvements involve general well being, illness, anxiety or nervousness, energy levels, health and happiness respectively. A decrease in mean value was observed in question three and seven. The decreased readings involved the participant’s experiences of depression as well as worry and feeling upset.
Table 5.1: The Mean Scores of all Eleven Participants at Consultation One and Seven. Consultation One Consultation Seven 1. How are you feeling in general? 2.82 3.25 2. Have you been ill or unwell in the past month? 3.64 4.13 3. Have you felt depressed in the past month? 4.18 3.88 4. Have you felt anxious or nervous in the past month? 3.55 3.63 5. How are your energy levels? 2.73 3.63 6. Have you felt healthy enough to do the things you want/had to? 4.09 4.20 7. Have you felt worried or upset during the past month? 3.82 3.50 8. How often have you felt happy during the past month? 3.45 3.50
228 Figure 5.2 shows the progress of all eleven participants over the six month treatment period. The graph shows that the averages of the total scores for all the participants increased over months one, three and five. The most significant improvement occurred after the first month of treatment.
The graph also demonstrates a gradual improvement in the participants’ general well-being from the beginning of the treatment period to the end of the treatment period. This is demonstrated by a trend line.
Average General Well-Being Questionnaire Scores of all Eleven Participants over the Treatment Period
35
33
31 29.7 30.1 29.8 29 29.2 28.9 29 27.8 Total Scores Total 27
25 1 2 3 4 5 6 7 Consultation
Figure 5.2: Average Scores of the General Well-Being Questionnaire Scores of all Eleven Participants over the Treatment Period
5.5.3 Related Functional Symptoms
All eleven participants presented at the first consultation with symptoms of dysmenorrhoea. This included pelvic pain before or during menses with possible radiation to the lower back or legs, headache, nausea, constipation or diarrhoea, and urinary frequency.
Seven (63.6%) of the eleven participants reported complete amelioration of their symptoms of dysmenorrhoea by the end of the treatment period, while four (36.4%) of the eleven participants reported improvements in their dysmenorrhoea with continued mild symptoms by the end of the treatment period.
229 Premenstrual symptoms were experienced by all eleven participants. This included symptoms of irritability, anxiety, emotional lability, depression, oedema, breast pain and headaches. These symptoms would normally occur seven to ten days before menses and usually ended a few hours after the onset of menses. Eleven participants reported premenstrual symptoms at the first consultation. Of these four (36.4%) were no longer experiencing premenstrual symptoms by the end of the treatment period. Six (54.5%) participants experienced improvement in their premenstrual symptoms, but were still presenting with mild premenstrual symptoms. One participant (9.1%) only experienced slight amelioration and still experienced premenstrual symptoms at the end of the treatment period.
5.5.4 Concomitant Symptoms
Concomitant symptoms such as constipation, insomnia, skin complaints, profuse perspiration and poor energy levels were experienced by some participants.
Five of the eleven participants presented with symptoms of constipation at the first consultation. Four of the participants showed improvements in bowel function and experienced regular bowel movements on a daily basis by the end of the treatment period. One participant experienced no amelioration of her symptoms of constipation.
Six of the sample group experienced insomnia throughout the treatment period, with phases of amelioration and aggravation. By the end of the trial three of the participants were no longer experiencing insomnia and were able to have good quality sleep regularly. One participant experienced amelioration in her insomnia but was still experiencing mild symptoms and two participants showed no change in their symptoms of insomnia.
Five (45.5%) participants presented with skin complaints during the trial. Four participants showed improvement in their skin complaints while one (9.1%) participant showed slight improvement.
Four (36.4%) participants presented with profuse perspiration at the initial consultation. By the end of the treatment period three (27.3%) of the participants were no longer experiencing profuse perspiration while one (9.2%) participant was only experiencing mild symptoms of perspiration.
Energy levels were reported to be poor in six (54.5%) of the participants at the initial consultation. Improvement was noted in all six (54.5%) participants. High blood pressure was noted in five
230 (45.5%) participants at the initial consultation. A decrease in blood pressure was noted in four (36.4%) of the participants while no change was noted in one (9.2%) participant.
Mental symptoms such as depression, anger, irritability or emotional lability were noted in nine (81.8%) of the participants. Of the nine participants seven (63.6%) showed improvement in these symptoms and showed, thereafter, symptoms of positivity, contentment and happiness. Two (18.2%) participants continued to show symptoms of depression and emotional lability because of continued marital problems.
5.6 STATISTICAL vs. CLINICAL SIGNIFICANCE
Owing to the nature of the study it is important to consider the difference between the statistical significance and the clinical significance. Statistical significance occurs when the hypothesis is tested using the paired-t test. This test is used to test the differences in data from the beginning of the trial to the end of the trial. Owing to the small size of the study, this could not be performed.
The clinical significance is subjective and can be observed. It was evident from the clinical analysis of related fertility parameters as well as the general parameters that reactions to the treatment were positive. Positive reactions were also observed on analysis of the related functional symptoms and concomitant symptoms. The General Well-Being Questionnaire scores as well as the mean values for individual questions supported the positive reactions given by the participants. All the participants were pleased with the results. This supports the fact that although no documented pregnancy occurred, the overall outcome of the study shows that using homoeopathic similimum, related fertility parameters, general parameters as well as related functional symptoms and concomitant symptoms may be treated successfully.
5.7 COMPLIANCE
It is important to note that the compliance of the participants was 73%. Three (27%) participants did not finish the study. The second participant was excluded from the trial as she was required to undergo surgery and laparoscopy. Participant nine dropped out of the study as her husband filed for divorce and she felt it pointless to continue the trial. The tenth participant requested to leave the trial as she could not cope with the stresses that infertility treatment was causing her. The remainder (73%) of the participants were eager to attend all seven of their consultations. A total of eight participants completed the study.
231 CHAPTER SIX
CASE DISCUSSIONS, RECOMMENDATIONS AND CONCLUSION
6.1 CASE DISCUSSIONS
A brief retrospective analysis and discussion of each case is presented here, followed by a final conclusion. Table 6.1 shows the remedy and potency selection for each participant over the treatment period
Table 6.1: A Table Showing the Remedy and Potency Selection for each Participant over the Treatment Period Participant Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 1 Natrum Natrum Natrum Natrum Natrum Natrum Natrum Muriaticum Muriaticum Muriaticum Muriaticum Muriaticum Muriaticum Muriaticum 12cH 12cH 12cH 12cH 12cH 12cH 12cH 2 Calcarea Calcarea Calcarea Carbonica Carbonica Carbonica 12cH 12cH 12cH 3 Natrum Natrum Natrum Calcarea Calcarea Calcarea Calcarea Muriaticum Muriaticum Muriaticum Carbonica Carbonica Carbonica Carbonica 30cH 30cH 30cH 6cH 6cH 6cH 6cH 4 Pulsatilla Pulsatilla Nil Nil Nil Nil Sepia Pratensis Pratensis Officinalis 30cH 30cH 6cH 5 Cimicifuga Cimicifuga Cimicifuga Cimicifuga Sepia Sepia Sepia Racemosa Racemosa Racemosa Racemosa Officinalis Officinalis Officinalis 12cH 12cH 12cH 12cH 30cH 30cH 200cH 6 Nitricum Nitricum Nitricum Nil Nil Nitricum Nil Acidum Acidum Acidum Acidum 6cH 6cH 30cH 200cH 7 Pulsatilla Pulsatilla Pulsatilla Viburnum Viburnum Viburnum Viburnum Pratensis Pratensis Pratensis Opulus Opulus Opulus Opulus 6cH 6cH 6cH 6cH 6cH 6cH 6cH 8 Carcinosin Sepia Sepia Sepia Sepia Sepia Nil 200cH Officinalis Officinalis Officinalis Officinalis Officinalis 6cH 6cH 6cH 6cH 30cH 9 Lachesis Lachesis Lachesis Ignatia Muta Muta Muta Amara 6 cH 6cH 6cH 200cH 10 Medorrhinum Sepia Sepia Sepia 200cH Officinalis Officinalis Officinalis 6cH 6cH 6cH 11 Natrum Natrum Natrum Natrum Natrum Natrum Nil Muriaticum Muriaticum Muriaticum Muriaticum Muriaticum Muriaticum 6cH 6cH 6cH 6cH 6cH 30cH
232 6.1.1 Case One
Participant one was prescribed Natrum muriaticum 12cH twice a day for months one to six. During this time the participant experienced significant improvement in her dysmenorrhoea which would usually debilitating and would keep her from her daily duties. She also experienced significant improvement in her sexual function, premenstrual symptoms and energy levels. Other symptoms that were noted to have improved were her mental symptoms and general well-being, her insomnia, constipation and skin symptoms. The participant on examination, appeared to have experienced improvement in her blood pressure.
It was felt that because of the profound action of the Natrum muriaticum on the participant, stopping the remedy would have interfered with the action of the remedy and halted her progress. Toward the end of the trial the participant reported return of old symptoms. This was noted by the researcher and reinforced the fact that the correct remedy, potency and frequency of administration had been selected.
Although pregnancy was not achieved, the participant noted that the significant improvement in her health would make up for the lack of a child in her life. She indicated this when she said that if her period remained as pain free as it had been in the last six months she would not mind if she never fell pregnant.
6.1.2 Case Two
Participant two was prescribed Calcarea carbonica 12cH twice a day for two months and showed a favourable response to the remedy.
The participant experienced amelioration in her sexual function as well as premenstrual symptoms. Her insomnia and skin symptoms completely resolved as did the occurrence of acute cholecystitis. This was evident by the elicitation of a Murphy’s sign at the first consultation and subsequent abdominal ultrasound which found no signs of cholecystitis or cholelithiasis. Concomitant symptoms showed marked improvement namely her energy levels and perspiration. She also experienced fewer asthmatic attacks while on the remedy. She had previously experienced marked dysmenorrhoea however, her amenorrhoea during the trial made evaluation of this impossible.
233 Conception was suspected to have occurred as the participant presented with breast tenderness, increased frequency of urination and amenorrhoea. Necessary investigations were performed and the cause of these symptoms was found to have been a benign cyst of the right adnexa. The participant underwent surgery to remove the cyst and was thus excluded from the trial.
The researcher was pleased with the participant’s overall improvements and was confident that continued treatment after surgery may offer the participant continued improvements.
6.1.3 Case Three
Participant three was treated with Natrum muriaticum 30cH for the first three months. Thereafter she was prescribed Calcarea carbonica 6cH for the last three months of the trial. Good results were achieved with use of both remedies, however, the best results were seen while the participant was on Calcarea carbonica.
The participant experienced complete amelioration of her symptoms of dysmenorrhoea and premenstrual symptoms. A decrease in high blood pressure was noted and pregnancy was suspected to have been achieved in the final month of treatment. The participant presented with increased frequency of urination, breast swelling and tenderness, nausea, fatigue and amenorrhoea. Owing to circumstance, the participant was unable to go for relevant testing. Although pregnancy was suspected, no tests can confirm this.
The researcher also acknowledges that on retrospective analysis of the participant’s case, she appeared to have recurrent infections or illnesses which may suggest a weakened vital force.
6.1.4 Case Four
Participant four was prescribed Pulsatilla pratensis 30cH in the first two months. No prescription was made in months three, four, five and six. At the seventh consultation Sepia officinalis 12cH was prescribed. On re-analysis of the case of participant four the researcher felt that Pulsatilla pratensis should have been given less frequently and then stopped after the first month’s prescription. Continuing the remedy for the second month ultimately resulted in the participant proving Pulsatilla pratensis in the third month. She showed improvement after stopping the remedy.
234 The participant did, however, experience amelioration with her dysmenorrhoea, premenstrual symptoms and constipation. Only slight improvement was noted with her mental symptoms. Her rosacea showed improvement and continued to be aggravated by her eating habits and stress levels. No significant improvement was noted with her perspiration.
On retrospective analysis the researcher felt the incorrect remedy had been selected and that Lilium tigrinum was better suited to the case. The researcher felt that Lilium tigrinum would have brought about the most improvement because of its close match to the participant’s case. Symptoms which matched the Lilium tigrinum symptom picture include ‘tormented about her salvation’, ‘constant inclination to weep’, ‘sexual excitement alternating with apprehension of religious things’, ‘hurry in occupation’, ‘occupation ameliorates’, ‘menses early’, ‘increased sexual desire’, ‘brown leucorrhoea after menses’ and ‘bloating before and during menses’. Other symptoms which were experienced by the participant and which matched the Lilium tigrinum picture include ‘averse to warmth’, ‘history of miscarriage’, ‘better for lying on the left side’, ‘generally worse after 5pm’ and ‘thirsty’ (Vermeulen, 2001).
6.1.5 Case Five
Participant five was treated with Cimicifuga racemosa 12cH for the first three months. She experienced significant improvement of her dysmenorrhoea and premenstrual symptoms as well as in her sexual function. Her energy levels improved significantly and when referring to her menstrual cycle the participant explained that “it was amazing to feel like that”.
The participant’s prescription was then changed to Sepia officinalis owing to indicated pronounced mental symptoms and depression. No amelioration was noted and her dysmenorrhoea returned. Retrospective analysis shows that the researcher should have increased the potency of Cimicifuga racemosa as this remedy is also indicated for great depression. This would have been a better decision as the participant had already responded well to the remedy. Hence it is possible that increasing the potency would have alleviated her mental symptoms and depression as well as maintained the good results experienced with her menstrual symptoms.
6.1.6 Case Six
Participant six was prescribed Nitricum acidum 6cH for two months. The researcher then prescribed the remedy in the 30th potency as the progress had been minimal and very slow while on the
235 Nitricum acidum 6cH. The researcher felt confident in the remedy selection and ceased its use for two months. The well selected remedy, although bringing about improvement, did not hold after the two months. The researcher increased the potency to 200cH and good results were noted.
The participant noted marked improvement in her dysmenorrhoea as well as her symptoms of constipation. Improvement was noted in her high blood pressure.
Retrospectively, the researcher felt that the 200th potency should have been used initially as the remedy was well indicated. Also the researcher felt that Natrum muriaticum, which after repertorisation, was the second highest, should have been considered for the case.
6.1.7 Case Seven
Participant seven was prescribed Pulsatilla pratensis 6cH for the first three months. Good results were achieved while on this prescription. At month four the participant’s case appeared to have changed. Viburnum opulus 6cH was prescribed for the months four and five. Although well indicated the participant showed little amelioration. The researcher decided to increase the potency which proved successful.
The participant expressed improvement in her hip pain and dysmenorrhoea. Her sexual function was improved and she no longer experienced premenstrual symptoms. Mentally she showed improvement and she had good quality sleep. Her energy levels had improved significantly and she was able to perform her daily tasks.
The researcher felt that owing to the close match of the remedy to the case a higher potency of Viburnum opulus could have been used and repeated less frequently.
6.1.8 Case Eight
Participant ten was prescribed Carcinosin 200cH for the first month of the treatment. The purpose of this treatment was to clear a possible miasmatic taint and help the participant to respond to the chosen similimum remedy. The participant responded well to the Carcinosin which was followed by Sepia officinalis 6cH for three months. In the fifth month the researcher increased the remedy prescription to the 30th potency.
236 The participant showed significant and complete amelioration of her dysmenorrhoea and significant improvement in her sexual desires. Amelioration was noted in her premenstrual symptoms, and mentally, marked improvement was achieved. By the end of the trial the participant was no longer experiencing insomnia or constipation. Slight improvement was noted in her blood pressure.
The researcher was pleased with the remedy choices. Although good results were achieved the researcher questioned the possible results if the remedies had been prescribed in higher potency.
6.1.9 Case Nine
Participant nine was prescribed Lachesis muta 6cH. She responded well to the remedy and showed significant improvement in her dysmenorrhoea, premenstrual symptoms and sexual desire. She also expressed improvement in previous symptoms of constipation and noted improvement in her skin complaints. No change was noted in her high blood pressure but her energy levels improved greatly. She had also experienced reduction in her perspiration levels.
The participant had been experiencing marital problems which precipitated her mental symptoms. Retrospectively the researcher felt that had a high potency been prescribed she may have dealt with these mental symptoms better. Her husband filed for divorce in the fourth month of the trial. Owing to this the participant chose to leave the trial.
The researcher was, however, pleased with the results and progression of the participant over the three months she was in the trial. As mentioned above, the researcher felt that a higher potency may have helped her mental symptoms.
6.1.10 Case Ten
Participant ten was prescribed Medorrhinum 200cH for the first month of the treatment. The purpose of this treatment was to clear a possible miasmatic taint and help the participant to respond to the chosen similimum remedy. The participant responded well to the Medorrhinum which was followed by Sepia officinalis 6cH for two months. The researcher was pleased with the remedy choices.
237 The participant showed marked improvement in her dysmenorrhoea and amelioration in her premenstrual symptoms. Mentally she experienced much improvement. No change was noted in her insomnia.
Four months into the treatment period, the participant requested to leave the trial as she was feeling very stressed and anxious and explained that she felt that she could no longer cope with the stress of fertility treatment.
6.1.11 Case Eleven
Participant eleven was prescribed Natrum muriaticum 6cH twice a day for months one to four. In month five the remedy was prescribed in the 30th potency. During this time the participant experienced significant improvement in her dysmenorrhoea which would usually debilitate her and keep her from her daily duties. She also experienced significant improvement in her sexual function, and mild amelioration with her premenstrual symptoms. She expressed much improvement on a mental level as well as in her energy levels. Other symptoms that were noted to have improved were her general well-being, perspiration and skin symptoms. The participant did not experience improvement in her insomnia. She had not experienced any sporadic nose bleeds as she had before commencement of the trial.
It was felt that because of the profound action of the Natrum muriaticum on the participant, stopping the remedy would have interfered with the action of the remedy and halted progress. But it was noted by the researcher that a higher potency and less frequent administration may have resulted in an even better response to the remedy.
6.1.12 Final Conclusions
In conclusion, it was found by the researcher that the use of the homoeopathic similimum was a useful form of treatment in individuals pre-diagnosed with unexplained infertility. Despite no recorded pregnancies, improvements were noted regarding related fertility parameters, general parameters, related function in premenstrual symptoms, dysmenorrhoea and concomitant symptoms.
All the participants were keen to participate in and complete the study. Much gratitude was expressed regarding their improvements. Subsequent to completion of the trial five participants
238 requested to continue treatment regarding their unexplained infertility owing to the good results they were experiencing. This demonstrates the clinical significance of the trial.
Compared to other therapies such as artificial insemination, in vitro fertilisation and other assisted conception technologies, it was observed that homoeopathic treatment was significantly less expensive over the six month treatment period.
Based on the results of this study, it would be beneficial to do homoeopathic studies on larger scales and for longer periods of time. Doing so would determine the long-term and side effects of homoeopathic treatment on unexplained infertility.
6.2 PROBLEMS EXPERIENCED
Problems which were experienced during the research process occurred with the repertorisation process. Symptoms appearing in the Materia Medica did not correlate with those in the Repertory and vice versa. Also, remedies which did not score highly on repertorisation were still well indicated to the case and thus made remedy selection difficult.
Problems were also experienced with potency selection. The researcher found that despite theory stating that high potencies are indicated when there are marked mental symptoms, low potencies can have a marked effect on resolving mental symptoms. This was noted in case one, case two, case seven, case eight, case ten and case eleven.
6.3 RECOMMENDATIONS
6.3.1 Continued Studies
The following should be considered in future studies:
Increasing the duration of the study will enable the researchers to study the long-term significance of the homoeopathic treatment of unexplained infertility. Using a larger sample group would add weight to the results and would reduce sampling error. Male partners should be included for treatment in the similimum study on unexplained infertility.
239 Performing a double-blind placebo controlled study. Here two sample groups of participants with unexplained infertility are studied to compare the results of those participants receiving placebo and those receiving similimum treatment. Conducting the studies on the efficacy of homoeopathic complex remedies in the treatment of unexplained infertility. A study comparing the results of participants receiving a complex homoeopathic product versus those receiving single homoeopathic remedies. Focusing on a younger age group. Owing to literature which explains that fertility in females decreases with age, it may therefore be useful to examine the effect of a treatment on a specific age group. Thus, by using a younger sample group, the age related factor of decreased fertility will be eliminated. Using questionnaires as measurement tools of each individual’s dysmenorrhoea, premenstrual symptoms and main complaints. By doing this the progress of each complaint may be monitored and objectively studied before, during and after treatment. A study should be done comparing a group receiving dietary and lifestyle changes only and a group receiving similimum treatment. The supervisor or an experienced homoeopath with special interest in infertility should be present at consultations and during case taking so as to aid correct case taking techniques as well as remedy selection.
6.3.2 Benefits of the Study
Conventional and allopathic treatment of unexplained infertility is not only costly but also invasive and toxic for those seeking it. Homoeopathy offers a cost effective means of treatment which is non-invasive and non-toxic for those with a diagnosis of unexplained infertility.
6.3.3 Limitations of the Study
In retrospect, the researcher noticed certain imperfections and limitations in the study, namely:
The sample size of the study was small, and although acceptable for a qualitative research for minor dissertation, the research results would have benefited from a larger sample of participants. No control group was used.
240 Because conception requires both male and female partners it was felt that the male partner should also have been treated with the homoeopathic similimum. The efficacy of the General Well-Being questionnaires and Basal Body Temperature and midcycle mucus change charts were dependent on the truthfulness of each participant. This was dependent on participant compliance and diligence to record daily temperatures and midcycle mucus changes on a daily basis. No measures were in place to measure changes in dysmenorrhoea, premenstrual symptoms as well as changes in main complaints consistently. The study duration was the main limitation as the researcher felt most cases would have benefited from a longer treatment period.
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252 APPENDIX A: Invitation and Information and Consent form
My name is Bianca De Canha and I am a Masters student in Homoeopathy at the University of Johannesburg. I am doing a study on the use of homoeopathic similimum treatment on females diagnosed with unexplained infertility.
Unexplained infertility is the diagnosis assigned to a couple once they have undergone a diagnostic evaluation which has failed to reveal a definite cause for their infertility. If you are a female between the ages of 18-40 and have been previously diagnosed with unexplained infertility, you are invited to take part in this study.
If however, any of the following applies to you, you may not take part in the study: • Use of fertility drugs in the past twelve months • Recent use of long-acting contraceptives • A body mass index that is of abnormal range • Current use of recreational drugs • Social habits such as smoking and/or excessive alcohol intake • Eating disorders • Excessive exercising • Pathology of the reproductive system
This research study aims to determine whether homoeopathy can help in conception and thus pregnancy in individuals who have been previously diagnosed as infertile due to unknown cause or pathology. The method of treatment to be used in the study will follow the homoeopathic principles of similimum prescribing and potency selection. This method has been used by qualified homoeopaths over many years; however no formal research has yet been done on its effectiveness in unexplained infertility. This study will be take place over a period of six months hence seven consultations will be scheduled in order to complete the study.
You will be informed, at the first meeting of what will happen during the research study. You will be asked to sign a consent form and complete a questionnaire about your past medical history, life style habits and previous diagnosis of infertility. If you meet the criteria you will be invited to take part in the study. If you accept the invitation we will continue with pre-consultation counselling and the first consultation. During this consultation I will take your full case history perform a focused
253 physical examination and you will be required to complete a general-wellbeing questionnaire. At the end of this consultation I will give you: • A thermometer for you to record your daily basal body temperature • Instructions on how to use the thermometer • Recording charts for midcycle mucus changes and daily basal body temperature for the month • A general-wellbeing questionnaire
You will be contacted within a week to collect your medication in the form of powders, and instructions on how the remedy is to be taken. At the second consultation a full case history and focused physical examination will be taken. At the end of the consultation you will be given recording charts for cervical mucus changes and daily basal body temperature for the month. You will then be contacted within the week to collect your medication, in the form of powders, and instructions on how the remedy is to be taken. This process will be repeated for all 7 consultations. Should we, at anytime suspect the possibility of pregnancy, a urine test will be performed and depending on results you will be referred appropriately.
The consultations and medication provided throughout the duration of the study are free of charge. The use of any other homoeopathic treatment other than that issued to the participant by myself must not be used, unless the participant should become ill at any time during the duration of the study. The use of herbal supplements must be avoided and conventional medication must only be used if it is essential and must be documented in the questionnaire and in the case taking consultation.
The benefits of this study lie in the possible improvement in fertility and thus ability to conceive. Participants will be afforded privacy, confidentiality and anonymity. Risks of the study are stress and possible disappointment from failure to conceive. No other risks are expected and there are no side effects or anticipated risks in taking the medication. Participants will have the right to freedom of choice and expression and are free to ask questions at any time. Should the participant so choose, they may withdraw consent and participation from the study at anytime.
I,______accept and understand the aim and purpose of the research study for which I have been invited to take part. I take part of my own free will and I understand that at any point during this study I may refuse further participation or withdraw from the study completely.
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I have been fully informed of the study, the expected risks and benefits, as well as the procedure for which the study is to be carried out. In signing this consent form, I agree with the method of treatment and understand that the researcher will answer any queries that I may have at any time.
Signature: ______Date: ______
______
I, the researcher, have fully explained the techniques and purpose of the treatment used in this research. Any questions that arise from the participants will be answered to the very best of my ability.
Signature: ______Date: ______
Bianca De Canha 082 464 3446
Signature: ______Date: ______
Dr K.S. Peck (011) 559-6273
255 APPENDIX B: Participant Selection Questionnaire
Thank you for taking the time to complete this questionnaire. On completion, it will be analyzed by the researcher conducting the study and will be entered into a selection process. If your criteria fit the research study you will be invited to attend a full case taking session and physical examination. Thereafter a follow up consultation will be made. Please note that ALL information disclosed in this questionnaire is confidential.
Please answer the following questions:
Participant Number: ______Name:______Age:______Date of Birth:______Gender:______Occupation:______Marital Status:______Address:______(Contact numbers) Home:______Work:______Cell:______Email:______Height:______Weight:______BMI:______
1. How long have you and your partner been trying to conceive? Less than a year 1-2 Years 2-3 Years 3-4 Years 4-5 Years 5+ Years
2. Who have you consulted about your problem? Mark all applicable options. General Practitioner Gynaecologist Homoeopath Infertility Specialist Endocrinologist
Other. Please specify ______
3. What was his/her diagnosis? ______
4. Does your partner have any children? 0 1 2 3 Other
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5. Is your menstrual cycle active? Yes No
6. Do you or your partner have any difficulties with sexual relations? None Erectile dysfunction Stress at timed intercourse Painful intercourse Ejaculatory dysfunction
Other. Please specify ______
7. Which of the following lubricants have you and your partner used in the last 6 months? None K.Y. Jelly Other. Specify
8. Do you have a history of sexually transmitted diseases? (That is: have you ever acquired a sexually transmitted disease in your past or present medical history?) None Gonorrhoea Chlamydia Syphilis Genital Herpes Simplex
Other. Please specify ______
9. Do you smoke? No Yes, 1-5 per day Yes, 6-10 per day Yes, 11-20 per day Yes, more than 20 per day.
10. Have you smoked in the past? No Yes. Specify how long ago you stopped
11. Do you drink alcoholic beverages? No Yes, 1-2 units per day Yes, 3-4 units per day Yes, 5-6 units per day Yes, more than 7 units per day
12. Do you use recreational drugs? No Yes. Please specify.
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13. Have you had any toxic exposures? Radiation Chemotherapy Heavy metal exposure (E.g. Lead in Mercury poisoning Other. Please specify tap water)
14. What illnesses did you have as a child? Mumps Chicken Pox Measles Whooping Cough Shingles Rubella Other. Specify
15. Which immunizations have you had?
BCG DPT Hepatitis Malaria Yellow fever MMR Polio Other. Specify.
16. When was the last time you went to the doctor?______
17. When last did you have surgery?______
18. When was the last time you sought help from a psychologist/psychiatrist (depression/anxiety etc.)?______
19. Please state the age and health or age and cause of death of your grandparents, parents, siblings, children and spouse?
Mother Father M.Grandmother M.Grandfather F.Grandmother F.Grandfather Siblings Spouse Children
20. Please indicate the presence/absence of the following diseases in your family?
258 Heart TB Cancer Mental Arthritis Hypertension Endocrine Infertility Genetic Disease Illness problems disorders
21. Do you exercise?
No Yes, at least once a day Yes, at least once a week Yes, at least once a month Other
22. Describe your usual/normal daily diet? Breakfast Midmorning Lunch Midafternoon Supper
23. Current medication/ Daily supplements? Specify. ______
24. What does your occupation entail? ______
24. Please indicate your participation, date of procedure and results in the following basic infertility evaluation:
o Confirmation of Ovulation Date: Result:
o Assessment of Ovarian Reserve Date: Result:
259 o Tubal Patency : Hysterosalpingogram Laparoscopy Salpingoscopy Date Result
25. Please indicate your partner’s participation and results in the following infertility evaluation: o Semen Analysis Date Normal Abnormal Details:
o Tests of sperm function Date Normal Abnormal Details:
26. Have you participated in any of the following tests (If yes, please indicate results): o Postcoital tests Date Normal Abnormal Details:
o Endometrial Biopsy Date Normal Abnormal Details:
o Hysteroscopy Date Normal Abnormal Details:
27. Have you undergone any assisted conception procedures such as (if yes, please indicate date of procedure and results): o Intrauterine insemination Date Successful Unsuccessful Details:
260 o In vitro fertilization Date Successful Unsuccessful Details:
o Embryo Freezing Date Successful Unsuccessful Details:
o Gamete Intrafallopian tube transfer Date Successful Unsuccessful Details:
o Zygote intrafallopian tube transfer Date Successful Unsuccessful Details:
o Intracytoplasmic sperm injection Date Successful Unsuccessful Details:
o Egg donation/ Sperm Donation Date Successful Unsuccessful Details:
o Host surrogacy Date Successful Unsuccessful Details:
o Pre-implantation genetic diagnosis Date Successful Unsuccessful Details:
261 28. Do you have a history of pelvic inflammatory disease? Yes No
29. Do you have or have you ever experienced gynaecological problems such as? Endometriosis Fibroids Ovarian Cysts Other. Please specify
30. Have you ever experienced an eating disorder? No Yes. Please specify.
31. Please specify if you have been tested for, or been previously diagnosed with: Hirsutism Galactorrhoea
Thank you for taking the time to fill out this questionnaire. Your information will be analysed and carefully assessed. If you match the requirements for this study you will be invited to attend your first consultation and physical examination.
Participant accepted______Participant not accepted______
262 APPENDIX C: Pre-consultation Counselling
The initial consultation will consist of a review of the basic steps required for pregnancy to be achieved. This includes: • The deposition of sperm in the vagina and cervical mucus • Tubal transport of sperm • The function of the ovary including cyclic hormone production • Ovulation • The role of the uterus in implantation and foetal growth. This understanding of normal fertility is critical for the individuals understanding of the infertility evaluation.
Thereafter, preconception counselling will be conducted. This counselling will be directed at the education of women who may smoke, drink excessive alcohol or use illicit and potentially dangerous drugs. They will be informed of the significant risks of these behaviours to their ability to fall pregnant and to their developing child in the event of pregnancy. They will also be provided with appropriate support services should they participate in one or more of these behaviours.
Male partners will be advised to avoid smoking, excessive alcohol consumption and the use of potentially dangerous drugs. Owing to the negative impact on sperm production, male partners will also be required to avoid the use of tight underwear, motorbike racing, cycling and hot baths.
Patients will then be required to monitor their basal body temperature and will be instructed on how to complete the appropriate chart. Monitoring basal body temperature can help identify the change in temperature that occurs just before and after ovulation. Basal body temperature will be taken orally every morning, using an ovulation thermometer. Basal body temperature will only rise between 0.4 and 1 degree when ovulation occurs. As ovulation gets closer, a slight drop in temperature may be noticed followed by a sharp increase, indicating that ovulation has just occurred. The temperature spike occurs within 12 hours of ovulation and it will remain elevated until the next menstrual period begins. The most fertile days are just before the temperature spike, and for the three days following. For this reason, intercourse will be encouraged approximately four days before ovulation, on the day of presumed ovulation, and two days thereafter.
263 The consistency of cervical mucus changes during the menstrual cycle may also aid in identifying days of ovulation. In an average cycle, there are three to four dry days after a five-day menstrual flow. After the dry days, the mucus wetness increases daily, lasting approximately nine days until it becomes abundant, slippery, clear, and very stretchy, similar to egg whites. Ovulation occurs within two days of when mucus becomes clearest, slippery, and most stretchy.
To monitor cervical mucus, collect it from the vaginal opening every day with clean fingers by wiping from front to back, or examine the mucus that collects on underwear. Record the consistency, colour and feel daily to increase awareness of the fertile period.
264 APPENDIX D: Case Taking Form (First Consultation)
Participant Number: ______
Presenting complaint:
General Symptoms: Vital Tone: ______
Vital Temperature: ______
Environment/ Weather: ______
Appetite:
265 ______
Thirst: ______
Perspiration: ______
Sleep: ______
Side/ Position: ______
Urination ______
Stool: ______
Menses: ______ Age of Menarch:______ Duration of period:______
266 What type of sanitary wear do you use:______ Do you experience PMS: ______ Pregnancy:
Miscarriages: ______Births: ______Abortions: ______Children: ______Difficult Pregnancy: ______
Types and dates of use of previous contraception ___ Contraceptive pill Date of use (since):______Condom Date of use (since):______Diaphragm Date of use (since):______Other, Specify______ Reason for use:______ Adverse effects of contraceptive:______ Sexual Function: ______ Pain/other problems during intercourse:______ Frequency and timing of intercourse:______ Do you use Lubricants:______ Vulvovaginal Symptoms: ______
Mental/ Emotional: ______
267 ______When did you and your partner decide to fall pregnant:______How long have you been trying to fall pregnant:______When were you diagnosed as Infertile:______Participant’s thoughts and feelings about her infertility? ______ How has your infertility affected your life: ______ How has your partners life been affected:______
Personality: Fears/ Anxiety: Tearful/ Tearless: Grief/ Shock:
REVIEW OF SYSTEMS:
23. Skin/Hair/Nails:
24. Head:
25. Eyes:
26. Ears:
27. Nose and Sinuses:
28. Mouth, Throat and Neck:
30. Chest:
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31. GIT:
39. PVS and Cardiovascular:
40. Musculoskeletal:
41. Nervous System:
42. Haematological System:
43. Endocrine System:
APPENDIX E: Case Taking Form (Follow-up Consultation)
269
Participant Number: ______
Presenting complaint:
General Symptoms: Vital Tone: ______
Vital Temperature: ______
Environment/ Weather: ______
Appetite:
270 ______
Thirst: ______
Perspiration: ______
Sleep: ______
Side/ Position: ______
Urination ______
Stool: ______
Menses: ______
Mental/ Emotional:
271 ______
REVIEW OF SYSTEMS:
23. Skin/Hair/Nails: 24. Head: 25. Eyes: 26. Ears: 27. Nose and Sinuses: 28. Mouth, Throat and Neck: 30. Chest: 31. GIT: 39. PVS and Cardiovascular: 40. Musculoskeletal:
272 APPENDIX F: Daily Basal Temperature and Mucus Chart
Instructions: • Each morning before rising take your temperature • Do not eat or drink anything (hot or cold) or smoke before taking your temperature as this may alter the reading • Insert the thermometer under your tongue and close both lips • Keep the thermometer in your mouth for 3 to 5 minutes • Remove the thermometer and read it • Reinsert it for a minute and read it again • If the temperature is still rising, repeat this procedure until the reading is stable
Mucus Change Ratings:
Colour: 1 – Clear 2 – White 3 – Yellow
Consistency: 1 – Thick 2 – Sticky 3 – Stretchy (Egg white like)
Feel: 1 – Dry 2 – Wet 3 – Sticky 4 – Slippery
273 Day of Time Temperature Mucus Changes cycle: Taken: reading: Colour Consistency: Feel: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
274 APPENDIX G: General Well-Being Questionnaire (Hachler, 2008) Date: ______Patient Case Number: ______
The following questionnaire contains questions about how you feel and how you perceive your life situations over the last month. Please mark the answer that is most applicable to you with an X.
5 4 3 2 1 0 How are Excellent Very Good Good Alternating Bad Terrible you feeling good and in general? bad Have you None of Rarely Less than Half the Almost Every day been ill or the time half of the time every day unwell in time the past month? Have you None of Now and Several Almost Every day Every day felt the time then times every day with depressed suicidal during the thoughts past month? Have you Not at all A little Sometimes, Relatively Very Extremely felt enough to anxious or notice nervous during the past month? How are Very Reasonably Energy Generally Very low I feel your energetic energetic levels vary low energy energy drained energy quite a bit levels?
275 Have you Definitely Mostly Limited No, I could No, I No, I felt healthy only look needed needed help enough to after myself someone with do the to help everything things you with some want/had things to? Have you Not at all A little Some of the Quite a bit Very Extremely felt time much so worried or upset during the past month? How often All the Most of the Often Some of the A little of None of the have you time time time the time time felt happy during the past month?
276 APPENDIX H: Advertising Poster
Have you been diagnosed with unexplained infertility?
If you are between the ages of 18 and 40 years old and are wanting to fall pregnant, you may qualify to participate in a Research Study being conducted through the Department of Homoeopathy on
The effects of Homoeopathic treatment on Unexplained Infertility.
Ethical Clearance Number: 04/08
This study is being conducted at the University of Johannesburg’s Homoeopathic Health Clinic.
Participation is voluntary and strictly confidential! Consultations and treatment are FREE OF CHARGE!
For more information please contact Bianca De Canha 082 464 3446
277 APPENDIX I: Participant Two: S-Quantitative ßhCG Results
278 APPENDIX J: Participant Two: S-Quantitative ßhCG Results and Screen-S Test Results
279
280 APPENDIX K: Participant Two: Abdominal and Pelvic Ultrasound Report
281