Usefulness of homoeopathic medicine in treatment of primary infertility due to anti-müllerian hormone deficiency – A case report

INTRODUCTION

The incidence of infertility in women is rising rapidly amongst the Indian population, mirroring trends seen globally.^[1] Over time, Anti-Müllerian Hormone (AMH) has emerged as a crucial marker for evaluating ovarian reserve. In addition, there is increased interest in exploring the factors that may affect AMH levels, including obesity, physical activity, smoking, alcohol consumption, as well as race, ethnicity and socioeconomic status. AMH is a dimeric glycoprotein that plays a crucial role in reproductive biology. It belongs to the transforming growth factor b (TGF-b) superfamily, which includes a wide range of proteins involved in various cellular processes. Notably, AMH features a single domain that shows homology to other members of the TGF-b superfamily. This homologous region is located in the 3' portion of the fifth exon and encodes the bioactive component of the AMH molecule. This segment is characterised by a glycine-cysteine-rich sequence, which is essential for the hormone’s biological activity and functional interactions.^[2] AMH was identified in the 1940s by Alfred Jost, who outlined the hormone’s role in embryonic sexual differentiation.^[3] It has been established that AMH has a substantial effect on ovarian function, particularly in regulating follicle growth.^[4,5] This discovery has broadened the potential applications of AMH in gynaecology, extending its use from in vitro fertilisation (IVF) to the diagnosis of various ovarian diseases and cancers, as well as its prospective future applications.^[6] Many researchers advocate for the use of AMH as the most reliable biomarker for assessing ovarian reserve in patients. However, it is important to note that various genetic and environmental factors can influence both AMH gene expression and serum levels.^[7-10] Environmental factors known to affect AMH expression include vitamin D deficiency, obesity and smoking. In addition, genetic factors such as mutations in the BRCA1, FMR1 and MTHFR C677T genes may also play a role.^[11] The European Society of Human Reproduction and Embryology consensus criteria identify AMH concentrations of <0.5–1.1 ng/mL or 3.57–7.85 pmol/L as indicators of poor ovarian reserve. However, some sources propose a higher cut-off value of 12 pmol/L for determining poor ovarian response.^[12] In women with primary ovarian insufficiency (POI), AMH concentrations are typically undetectable. Consequently, AMH levels are regarded as a key predictor of POI in women.^[13] Infertility in women due to decreased ovarian reserve has been coded as E28.8 under the International Classification of Diseases-10. Research has shown that in assisted reproductive technology (ART), serum AMH levels serve as a more reliable endocrine indicator of follicular response to ovarian stimulation than other commonly assessed markers, including follicle-stimulating hormone (FSH), oestradiol, inhibin B and patient age.^[14] Treating low AMH levels typically focuses on underlying issues affecting ovarian function. Options may include lifestyle modifications, such as improving diet and increasing exercise, as well as medical treatments like hormonal therapies to stimulate ovarian function. In some cases, ART IVF may be recommended to enhance the chances of conception. Individuals need to consult with a fertility specialist to determine the most appropriate approach based on their specific circumstances.^[6] Homoeopathy operates on the principle of using highly diluted substances to stimulate the body’s self-healing abilities based on symptom similarity.^[15] In cases of primary infertility, homoeopathic medicine has proven to be effective in various studies.^[16,17] However, there are few documented clinical studies specifically evaluating homoeopathic treatments for primary infertility related to low AMH levels. The safety and efficacy of relying solely on Homoeopathy for managing this condition have not been established. This case report discusses the current scenario for the growing trend of female infertility in the Indian population context and explores how Homoeopathy may help to reduce both the economic burden and the side effects associated with conventional treatments of AMH-deficient primary infertility.

CASE REPORT

Past treatment and medical history

After consulting a doctor in February 2022, they were advised to pursue IVF in August 2022, but they sought support through homoeopathic treatment, which they started in September 2022, in hopes of improving their chances of conception. The patient presented with a blood test report indicating an AMH level of 0.667 ng/mL, which is considered significantly low [Figure 1].

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Figure 1:

AMH test report.

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Analysis of the case and repertorisation

Her complaints were carefully documented following a detailed case assessment, adhering to homoeopathic principles. Subsequently, after thorough analysis and evaluation [Table 1], the totality of symptoms was compiled, and the case was repertorised using Kent’s repertory with the assistance of Hompath Classic M.D version 8 software.^[18] After repertorisation, Natrum muriaticum was found to cover most symptoms and received the highest totality marks, followed by Sepia, Pulsatilla, and Sulphur [Figure 2].

Table 1: Analysis and evaluation of symptoms, conversion of symptoms to rubrics.

Evaluation order	Symptoms	Characterised by	Evaluation reason	Rubric (Dr. J. T. Kent’s repertory)
1	Sentimental and sensitive	- Expressing emotions easily - Contradictions - Headache - Weeping mania, having bouts of uncontrolled crying - Complaints<consolation	Singular mental disposition	- Mind, Weeping, involuntary - Mind, Contradiction, is intolerance of - Mind, Consolation agg.
2	Intolerance to milk		Singular disposition	Generalities, Food, Milk agg.
3	Headache	Ailments from contradiction	Peculiar disposition	Head, Pain, contradiction after
4	Menses scanty	Despite a regular menstrual cycle	Uncommon symptom	Genitalia, Female, Menses, scanty
5	Tendency to catch colds frequently	Fluent coryza throughout the year	Peculiar disposition	- Generalities, Cold tendency to take - Nose, Coryza, discharge with (fluent)
6	Empty and weak feeling in her stomach	If hungry	Peculiar symptom	Generalities, Hunger from

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Figure 2:

Repertorial sheet.

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Follow-up and outcomes

On the 3^rd visit, the patient was prescribed Natrum muriaticum 10 M single dose followed by placebo [Table 2]. On the 5^th visit, the patient was advised to undergo a urine human chorionic gonadotropin (HCG) test, which was positive [Figure 3]. An ultrasound sonography (USG) of the lower abdomen on 13 February 2024 revealed a single live intrauterine embryo with an average gestational age of 6 weeks and 3 days [Figure 4].

Table 2: Follow-up

Visits	Last menstrual period	Prescription with justification
Visit 1 22 September, 2022	28 September, 2022 Flow=3 days	Natrum muriaticum1 M/2 doses OD for 2 days. • Weeping mood with consolation aggravation • Headache contradiction after • Fluent nasal discharge • Weak feeling on an empty stomach • Scanty menses • Easily catches a cold • Milk intolerance.
Visit 2 27 October, 2022	30 October, 2022 Flow=3 days	• Patient did not experience any headache, fluent nasal discharge in the past 1 month • She was in a better phase to deal with her weeping mood frequently • She was not complaining of any weak sensation in her stomach • Overall, the patient experienced a sense of well-being. Hence, a placebo was prescribed for 30 days, to be taken once daily.
Visit 3 28 November, 2022	25 November, 2022 Flow=3 days	• The patient experienced a headache twice after a few conflicts in conversation • She cried alone as an outburst of her emotion • She started feeling emptiness in her stomach, while she used to feel hungry. Considering the persistence of these symptoms, Natrum muriaticum 10M, single dose, was prescribed, and the patient was asked to take the medicine early in the morning on an empty stomach.
Visit 4 03 January, 2023	29 December, 2023 Flow=3 days	• The patient did not complain of any headache, nasal discharge, or weak feeling in the stomach. Hence, placebo 200 was prescribed for 30 days, to be taken once daily.
Visit 5 09 February, 2023	29 December, 2023	Advice for urine HCG test

OD: Once a day; HCG: Human chorionic gonadotropin

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Figure 3:

Urine HCG test report.

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Figure 4:

USG of lower abdomen.

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DISCUSSION

The rising incidence of infertility in women amongst the Indian population reflects a global trend that has garnered significant attention in recent years. A key indicator in this context is AMH, which serves as an essential marker for assessing ovarian reserve.^[2] As researchers delve into the factors influencing AMH levels, a range of elements has come to light, including obesity, physical activity, smoking, alcohol consumption and demographic factors such as race, ethnicity and socioeconomic status.^[11]

Managing low AMH levels usually involves addressing the underlying factors affecting ovarian function. This may include lifestyle modifications, such as enhancing diet and increasing physical activity, along with medical interventions like hormonal therapies to stimulate ovarian activity. In certain situations, ART such as IVF may be suggested to improve the likelihood of conception.^[6] It is also hypothesised that vitamin D has a direct effect on AMH production, suggesting that patients with higher levels of vitamin D may be able to preserve their ovarian reserve for a longer period.^[21] Studies suggest that vitamin D acts as a positive regulator of AMH production.^[22] Other reports indicate that vitamin D levels are unrelated to ovarian reserve or ovarian response following ovarian stimulation.^[23,24] Homoeopathy aims to activate the body’s natural healing abilities and strengthen the immune system through the use of low doses of homoeopathic remedies. It emphasises treating the individual as a whole and addressing the root causes of illness rather than merely alleviating symptoms. Homoeopathy can be effective for infertility related to psychological issues, ovulation disorders, sperm abnormalities and cases of unknown origin.^[25,26] Meanwhile, Homoeopathy has been shown to effectively enhance patients’ overall health, improve sperm quality and regulate hormone levels.^[27] Parveen and Bhaumik^[28] employed individualised Homoeopathy to help an infertile patient with endometriosis, fallopian tube abnormalities and insufficient ovarian reserve successfully deliver a healthy newborn, indicating that Homoeopathy can have a positive impact on infertility. None of these trials addresses the role of AMH levels in infertility and the application of Homoeopathy in this context. In this case report, a patient with a low AMH level became pregnant with a viable foetus at 6 weeks and 3 days after only 6 months. In this case, the total outcome score according to the modified Naranjo criteria^[29] was +8, approaching the maximum score of 13 [Table 3]. This clearly indicates the strong causal link attributed to the homeopathic treatment for primary infertility and the outcome. This shows a positive effect of homoeopathic medicinal treatment upon low levels of AMH-associated with primary infertility. Therefore, there is a need for well-designed research studies to establish the efficacy of Homoeopathy in primary infertility associated with low serum AMH levels. The probable limitations of the study were the non-availability of luteinising hormone (LH), FSH and oestradiol evaluation reports on the 3^rd day of menses, as the patient was unwilling to undergo this test repeatedly. Due to the positive HCG report and USG of the lower abdomen, post-treatment AMH advice was neglected by the patient.

CONCLUSION

This case report suggests homoeopathic treatment as a promising complementary and alternative medicinal therapy and emphasises the individualisation and the need for repertorisation in Homoeopathic prescription. This case shows a positive role of Homoeopathy in the treatment of low AMH level induced primary infertility. Randomised control trials are suggested with proper methodological rigour to establish the efficacy of Homoeopathy.