INTERNATIONAL AYURVEDIC MEDICAL JOURNAL International Ayurvedic Medical Journal, (ISSN: 2320 5091) (March, 2017) 5 (3) DEVELOPMENTAL ABNORMALITIES OF MULLERIAN DUCT- A REVIEW Kowsalya.R.G1, Padmasaritha.K2, Ramesh M3 1PG Scholar, 2Assistant professor, 3Professor; Dept of PTSR, Sri Kalabyreshwara Swamy Ayurvedic College and Hospital And Research Centre, Vijayanagar, Bangalore, Karnataka, India Email: [email protected] ABSTRACT The beeja (sukra and artava rupa) has chromosomes with genes representing the future organs to be developed. Any abnormality in the beeja, beejabhaga, beejabhagaavayava leads to various conge- nital abnormalities in foetus. Mullerian duct anomalies are one of the congenital abnormalities of the female reproductive tract resulting from failure in the development of the Mullerian ducts and their as- sociated structures. Their cause has yet to be fully clarified, and it is currently believed to be multi fac- torial. Symptoms appear during adolescence or early adulthood, and affect the reproductive capacity of these women. When clinically suspected, investigations leading to diagnosis include imaging methods such as hysterosalpingography, ultrasonography and MRI. Mullerian duct anomalies consist of a wide range of defects that may vary from patient to patient. The aim is to understand the congential malfor- mation of mullerian duct through Ayurveda. Keywords: Beeja, Beejabhaga, Mullerian duct anomalies. INTRODUCTION The beeja and its component are the subtle form bhagas lead to defective formation of the garb- of the future organs and parts of the body and hasaya and artava in fetus. Different degrees of the particular parts consequently develop into mullerian duct anomalies can be considered as the specific organs and parts. Acharyas states defective formation of garbhasaya and artava. that if specific part of beejabhaga avayava is Mullerian ducts are Paired ducts derived vitiated, it leads to the vitiation of that specific from intermediate mesoderm in females known organs being generated from the part. Vata do- as paramesonephric duct. Named after Johannes sha also vitiated and hampers the development peter mullero -described them in 1830. of reproductive organs. Some of the particular The mullerian ducts are paired embryologic beejabhaga is responsible for formation of structures that undergo fusion and resorption in garbhasaya and artava, vitiation of these beeja utero to give rise to the uterus, fallopian tubes, Kowsalya.R.G Et Al: Developmental Abnormalities Of Mullerian Duct- A Review cervix and upper 3/5 of the vagina. Interruption via dorsal mesentry populate the posterior body of the normal development of the mullerian wall. Induce the coelomic epithelium to form ducts can result in formation of mullerian duct primitive sex cords. Sex cords proliferate and anomalies (MDA). MDA are a broad and com- produce genital ridges. The sex cords surround plex spectrum of abnormalities that are often the germ cells and will become ovarian follicle associated with many gynaecological and obste- in female sertoli cells in males. At the end of 6 tric complications. The prevalence of these weeks of fetal life, primitive ducts will be anomalies ranges from 0.001 to 10% in the gen- formed which includes both mesonephric duct eral population and from 8-10% in women with and paramesonephric ducts. After this point an adverse reproductive history1. The embryo- male and female phenotype diverges. The para- logical development of the female reproductive mesonephric ducts are situated lateral to meso- system is closely related to the development of nephric duct. In the absence of hormonal (Tes- the urinary system, and anomalies in both sys- tosterone and MIF) input these ducts will get tems may occur in up to 25% of these patients. close to each other. The two ducts are initially Other associated malformations may affect the separated by a septum but later fuse to form the gastrointestinal tract (12%) or musculoskeletal uterine canal. The united lower vertical parts system (10-12%) 2,3. form the uterovaginal canal. The unfused cranial EMBRYOLOGY part of each paramesonephric duct forms uterine At 5th week of intra uterine life tubes. The distal open end forms the abdominal primordial germs cells migrate from yolk sac ostium4. Picture 1: Embryology of Female Reproductive Organs UNDESTANDING OF MULLERIAN DUCT To understand the origins of uterine and vaginal ANOMALIES anomalies the process is typically related to IAMJ: MARCH, 2017 948 Kowsalya.R.G Et Al: Developmental Abnormalities Of Mullerian Duct- A Review Failure of mullerian duct to fuse at a particu- Complete formation and differentiation of mul- lar point lerian duct into female reproductive system de- Failure of the tubes to fully descend to the pends on completion of 3 phases of develop- urogenital sinus ment. Picture 2: Differentiation of Mullerian Duct Into Female Reproductive System A. Formation septal resorption fails to occur it will lead to B. Fusion Septate uterus. C. Septal resorption Asymmetric obstructed disorders of ute- Any defects in these three processes can lead to rus and vagina, as these tend to be associated MDA. with ipsilateral renal agenesis. Though there is FORMATION no direct reference for mullerian duct anomalies One or both mullerian duct may not develop in ayurveda, it can be considered under the fully – uterine agenesis or hypoplasia, un- broad heading of beeja dusti and beeja bhaga icornuate uterus. dusti mainly. FUSION- Lateral fusion – process during which lower BEEJA DUSTI segment of paired mullerian duct fuse. Im- Aggravated vata in mother affects arta- proper fusion can lead to uterine didelphys, va rupa beeja during garbhadana. Due to ab- Bicornuate uterus, Arcuate uterus. normalities of beeja, atma, karma, asaya, kala Vertical fusion – fusion of ascending sino- and ahara vihara, the vitiated doshas produce vaginal bulb with descending mullerian duct abnormalities of fetus, affecting its appearance, – Improper fusion can lead to Transverse varna and indriyas5.Abnormalities in beeja vaginal septum. leads to yonivyapad like sandi yonivyapad, su- SEPTAL RESORPTION- chimuki yonivyapad. After fusion central septum persist later resorps to form single uterocervical cavity – if IAMJ: MARCH, 2017 949 Kowsalya.R.G Et Al: Developmental Abnormalities Of Mullerian Duct- A Review SANDI YONIVYAPAD Whatever part of the beeja is defective; the body Acharya charaka says, due to abnormali- part developing from that portion of beeja will ties of beeja (artava) the uterus of the female is be abnormal. Beeja-bhaga is responsible for affected with vata. A woman with female phe- formation of various organs. Vitiation of beeja- notype having beeja doshas (chromosomal ab- bhaga responsible for the formation of repro- normalities) and suffering with deficient sec- ductive organ (uterus, fallopian tube, cervix and ondary sexual characters and un established re- vagina) leads to defective formation that par- productive functions like lack of menarche and ticular organ which exhibits congenital deformi- menstruation should be considered under sandi ties of female genital organs leading to repro- yonivayapad.6,7 ductive failure9. Sandi yonivyapad can be considered as Turner’s syndrome (XO monosomy) VANDHYA The beeja-bhaga responsible for SUCHIMUKI YONIVYAPAD formation of garbhashaya is totally vitiated it Acharya charaka says, that when a pregnant leads to vandhya. Vandhya can be consider as woman consumes vata aggravating ahara viha- different degrees of mullerian agenesis i.e. ab- ra, this aggravated vayu due to its dryness vi- sence or incomplete development of mullerian tiates yoni of female fetus, thus the orifice of ducts leading to complete absence of uterus, yoni becomes very narrow. It can be considered septate uterus, uterus didelphys, bicornuate ute- as different grades of mullerian agenesis and rus, unicornuate uterus, arcuate uterus10,11. dysgenesis.8 MULLERIAN DUCT ANOMALIES BEEJA BHAGA DUSHTI UTERINE ABNORMALITIES Acharya Charaka has explained garbhanga vi- CLASSIFICATION OF MULLERIAN ANO- kruti depends upon the condition of beeja. MALIES- According to AFS12 CLASS I – Agenesis/hypoplasia CLASS III – Didelphys Vaginal CLASS IV – Bicornuate Cervical Complete Fundal Partial Tubal CLASS V – Septate CLASS II – Unicornuate Complete Communicating Partial Non communicating CLASS VI – Arcuate No cavity CLASS VII – DES related anomalies No horn INCIDENCE OF MDA13 Unicornuate - 10% Total mullerian duct anomalies – 3-4% Uterine didelphys - 8% Agenesis - 4% Bicornuate uterus - 26% IAMJ: MARCH, 2017 950 Kowsalya.R.G Et Al: Developmental Abnormalities Of Mullerian Duct- A Review Septate uterus - 35% dus, the endometrial cavity, which demonstrates Arcuate uterus - 18% a small fundal cleft or impression (>1.5 cm). Mild thickening of the midline fundal myome- Class I (HYPOPLASIA/AGENESIS) includes trium resulting in fundal cavity indentation but entities such as uterine/cervical agenesis or hy- normal outer fundal contour. poplasia. The most common form is the Mayer- Class VII (DIETHYLSTILBESTROL- Rokitansky-Kuster-Hauser syndrome, which is RELATED ANOMALY) has occurred in sever- combined agenesis of the uterus, cervix, and al million women who were treated with die- upper portion of the vagina. thylstilbestrol (DES), an estrogen analogue pre- Class II (UNI-CORNUATE UTERUS) is the scribed to prevent miscarriage from 1945-1971. result of complete, or almost complete, arrest of Affected female fetuses have a variety of ab- development