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Endometriosis - Symptom, Treatment And Causes

What is Endometriosis?

Endometriosis is an extremely painful disorder where the tissues which lines the inside of the uterus (endometrium) starts growing on the outside of the uterus (womb). Endometriosis usually includes the tissues lining the pelvis, fallopian tubes and our ovaries. During Endometriosis, the endometrial tissues breaks down and bleeds as it normally would. This tissue doesn’t have any way to exit from the body so it gets trapped. Endometriosis causes chronic pain during your periods. Sometimes, fertility can also be affected and it might create issues during conceiving a baby.

What causes Endometriosis?

The exact cause of Endometriosis is not yet known but studies suggest that it can be caused due to some factors such as:

  • Retrograde menstruation- In this condition, menstrual blood that contains endometrial cells usually flow back into the pelvic cavity through the fallopian tubes instead of passing out from the body. These endometrial cells stick to the pelvic organs and pelvic walls where they thicken and start bleeding over the course of the menstrual cycle.
  • Changing of the peritoneal cells- This is also called induction theory. Endometriosis can be caused due to the transformation of peritoneal cells.
  • Embryonic transformation of cells- Hormones like estrogen can transform embryonic cells in the early stages.
  • Surgical scar implantation- After a surgery like C-section or hysterectomy, the endometrial cells can attach itself to a surgical incision.
  • Endometrial cells transport- The tissue fluid (lymphatic) or blood vessels can transport the endometrial cells to other body parts.
  • Immune system disorder- If there is a problem with the immune system, it may make the body impossible to destroy and recognize the endometrial tissue which grows outside the uterus.

Risk factors that make you more susceptible in developing Endometriosis is:

  • Not giving birth.
  • Starting your period very early in life.
  • Having your menopause at a very old age.
  • Menstrual cycle less than 27 days.
  • High levels of estrogen in your body or exposure to a high level of estrogen produced by your body.
  • Low body mass
  • Excessive Alcohol consumption
  • One or more family members having Endometriosis.
  • A medical condition which avoids the passage of menstrual blood out of the body.
  • Abnormalities in the uterus (womb).

The symptoms of Endometriosis can end permanently if you experience menopause and can end temporarily if you get pregnant. Taking estrogen supplements can also trigger Endometriosis in some women.

Treatable by medical professional Require medical diagnosis Lab test always required Chronic: can last for years or be lifelong
Pain in lower abdomen. Lower abdomenal cramps. Menstrual irregularities.

Popular Health Tips

Conceiving After PCOS Or Endometriosis - How Can IVF Help?

MBBS Bachelor of Medicine and Bachelor of Surgery
IVF Specialist, Agra
Conceiving After PCOS Or Endometriosis - How Can IVF Help?

Getting pregnant can become an immensely frustrating experience for women with endometriosis or cyst with IVF treatment. Many women with endometriosis worry about whether they will be able to conceive and bear a child. This is because, in such a case, there is a collection of endometrial tissues outside the uterus that results in a painful inflammation along with the formation of blood-filled cysts in the ovary and bands of scar tissues.

How does PCOS or endometriosis affect the process of reproduction?
When a woman has any of these fertility issues, there could be endometrial growths of the tissue hindering the normal functioning of the reproductive organs. When the endometrial tissue formation involves the ovaries, there is a restriction on the release of eggs. On the other hand, when the fallopian tubes are affected, it would prevent the sperm from reaching the egg or it may also stop the fertilized egg from travelling to the uterus. Though each of these instances may sound challenging, experts suggest that IVF treatment can be helpful in offering desired results. It is estimated that about one-third of women suffering from endometriosis can conceive naturally without any treatment whatsoever. But for the rest of the women that suffer from endometriosis, IVF can be the best bet.

How can IVF help in getting pregnant in this scenario?
In order to make pregnancy possible for women with multiple adhesions, endometriosis or PCOS, the doctor would definitely begin with a comprehensive evaluation of hormones along with the presence of other chemicals in the body. Diagnostic tests such as hysteroscopy, hysterosalpingography, and laparoscopy can also be of great value in offering an insight into the individual patient’s condition.

When the IVF process has been successful, the embryo will get implanted in the uterus and cause the much-desired pregnancy. If there is any embryo remaining, it may be stored for use in future or donated to other couples. IVF is deemed successful for overcoming most of the female factor caused infertility including cyst, PCOS, and even endometriosis. There are 5 fundamental steps in IVF and they are:

  1. Super-ovulation or the process of stimulating the reproductive organs of a woman for releasing numerous healthy eggs. This is the first point of contradiction between IVF and normal pregnancy where a single egg is released and ovulated.
  2. The second step constitutes retrieval of eggs and sperm collection
  3. Then there is insemination as well as fertilization of the eggs with the help of the sperm
  4. Development of embryos and subsequent genetic evaluation when needed
  5. Transfer of the embryo in the uterus of the woman

Since IVF allows a controlled interaction between the egg and the sperm, it offers a high rate of success even when the patient is affected by complex disorders such as endometriosis, PCOS or cyst. Hence, discuss with your doctor if it is a viable option for the given situation. In case you have a concern or query you can always consult an expert & get answers to your questions!

4876 people found this helpful

Endometriosis - Can Retrograde Mensuration Cause It?

Fellowship in Minimal Access Surgery, MS - Obstetrics and Gynaecology, MBBS
Gynaecologist, Bangalore
Endometriosis - Can Retrograde Mensuration Cause It?

Do you know about the ill effects and various serious consequences that are associated with endometriosis? 

In this disorder, there is a presence of endometrium (lining of uterus) outside uterus. It is likely to spread to ovaries and other nearby areas. It can involve any other part of the body also. Endometriosis, at times, causes great pain and may result in infertility

The exact cause of endometriosis is not known. 

  1. It may occur because of a process, known as retrograde menstruation. In this, menstrual blood flows back via fallopian tubes into the pelvic cavity, along with natural process of flowing out from the uterus. 
  2. The displaced endometrial cells stick to the pelvic wall and on the surface of pelvic organs such as ovaries, bladder, and rectum. They continue growing thicker and bleed during menstrual cycle. 
  3. The condition is also likely to occur when small regions in the pelvis convert into endometrial tissue. 

The intensity of symptoms of this condition vary. 

  1. In some women, mild symptoms are experienced, while the intensity may be severe in others. Pain in the lower abdomen is one of the common symptoms. 
  2. The severity of pain experienced does not indicate the degree or extent of endometriosis. 
  3. Other symptoms include painful periods, lower abdominal pain during and before menstruation, development of cramps, abnormal uteine bleeding, pain during sexual intercourse, discomfort during bowel movements, and lower back pain during menstrual periods. 
  4. It is also likely for you to experience no symptoms at all. 

Complications and Consequences 

  1. Problems with fertility are considered to be common with endometriosis. 
  2. Women who have mild endometriosis can conceive and give birth to a baby. 
  3. Medications do not help in improving fertility. 
  4. It is possible for some women to conceive after having the endometrial tissue removed via surgical procedures. 
  5. In case, these measures do not show effective results, you should opt for undergoing fertility treatments such as IVF i.e. in vitro fertilisation. These might improve your chances of giving birth. 

If you are affected by endometriosis and want to have a child, consult Gynaecologist. This is because your symptoms can worsen with time, which may make it difficult for you to conceive on your own. It is recommended for you to talk to doctor for suggestions and remedies.

In case you have a concern or query you can always consult an expert & get answers to your questions!

2684 people found this helpful

Endometriosis - Signs & Symptoms That Indicate It!

MBBS, MS - Obs and Gynae, MRCOG(London), DNB, Fellowship In Uro Gynaecology
Gynaecologist, Mumbai
Endometriosis - Signs & Symptoms That Indicate It!

What is endometriosis?

Endometriosis is a common condition where cells of the lining of the womb (the endometrium) are found elsewhere, usually in the pelvis and around the womb, ovaries and fallopian tubes. It mainly affects women during their reproductive years. Endometriosis is not an infection and it is not contagious.

What are the symptoms?

The main symptoms of endometriosis are pelvic pain, pain during or after sex and painful, sometimes heavy periods. It may cause problems with getting pregnant. It can affect many areas of a woman’s life including her general physical health, emotional wellbeing and daily routine. Many women may have no symptoms. It is a long-term condition. Some women with endometriosis become pregnant easily while others have difficulty getting pregnant.

What causes endometriosis?

Endometriosis occurs when the cells of the lining of the womb are found in other parts of the body, usually the pelvis. Each month this tissue outside the womb thickens and breaks down and bleeds in the same way as the lining of the womb. This internal bleeding into the pelvis, unlike a period, has no way of leaving the body. This causes inflammation, pain and damage to the reproductive organs. Less commonly, endometriosis may occur on the bowel and bladder, or deep within the muscle wall of the uterus (adenomyosis). It can also rarely be found in other parts of the body.

The symptoms of endometriosis are common and could be caused by a number of other conditions such as irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID).

  • There is no simple test for endometriosis.
  • Your gynaecologist may examine your pelvic area, this will include an internal examination.
  • You may be offered a scan. This can identify whether there is an endometriosis cyst in the ovaries. A normal scan does not rule out endometriosis.
  • For most women, having a laparoscopy is the only way to confirm endometriosis; because of this, it is often referred to as the ‘gold standard’ test. This allows the gynaecologist to see the pelvic organs clearly and look for any endometriosis.

Several factors may influence your decision about treatment. These include:

  • How you feel about your situation
  • Your age
  • Whether your main symptom is pain or problems getting pregnant

What treatment can I get?

The options for treatment may be:

Pain relief

Hormone treatments: There is a range of hormone treatments to stop or reduce ovulation (the release of an egg) to allow the endometriosis to shrink or disappear. The hormonal methods below are contraceptives and will prevent you from becoming pregnant:

  • The combined oral contraceptive (COC) pill or patch. These contain the hormones estrogen and progestogen and work by preventing ovulation and can make your periods lighter, shorter and less painful.
  • The intrauterine system (IUS): this is a small T-shaped device which releases the hormone progestogen. This helps to reduce the pain and makes periods lighter. Some women get no periods at all.
  • The hormonal methods below are non-contraceptive, so contraception will be needed if you do not want to become pregnant:
  • Use of hormonal progestogens or testosterone derivatives
  • GnRH agonists are drugs that prevent estrogen being produced by the ovaries and cause a temporary and reversible menopause.

Some women find that recreational exercise improves their wellbeing, which may help to improve some symptoms of endometriosis.

Surgery: Surgery can be used to remove areas of endometriosis. There are different types of surgery, depending on where the endometriosis is and how extensive it is. How successful the surgery is can vary and you may need further surgery.

  • Laparoscopic surgery: The gynaecologist removes patches of endometriosis by destroying them or cutting them out.
  • Laparotomy: If the endometriosis is severe and extensive, you may be offered a laparotomy. This is major surgery which involves a cut in the abdomen, usually in the bikini line.
  • Hysterectomy: Some women have surgery to remove their womb (a hysterectomy) with or without the ovaries. Depending upon your own situation, your doctor should discuss hormone replacement therapy (HRT) with you if you have your ovaries removed.

What if I am having difficulty getting pregnant?

Getting pregnant can be a problem for some women with endometriosis. Your doctor should provide you with full information about your options such as assisted conception. If you become pregnant, endometriosis is unlikely to put your pregnancy at risk. In case you have a concern or query you can always consult an expert & get answers to your questions!

4439 people found this helpful

Ovarian Cysts And Pregnancy - Understanding The Connection!

Gynaecologist, Chandigarh
Ovarian Cysts And Pregnancy - Understanding The Connection!

Are you aware of the connection between ovarian cysts and pregnancy? A woman’s ovaries produce eggs and sex hormones, namely estrogen and progesterone. Sometimes, a sac filled with fluid may develop on one of your ovaries. Ovarian cysts are common and are experienced by all women in their lifetime. Commonly, these cysts are painless, accompanied by no specific symptoms. As the cysts grow, symptoms such as swelling or bloating, painful bowel movements, painful sexual intercourse, and pelvic pain during menstrual periods are indicated. Other symptoms like breast tenderness, lower back and thigh pain, nausea and vomiting are also likely.

Link between ovarian cysts and pregnancy
Ovarian cysts are connected to pregnancy as they are associated with a woman’s fertility. Some ovarian cysts which can affect your fertility and hence pregnancy include the following:

• These are ovarian cysts, which are associated with complications in fertility and occur on account of endometriosis. This is a health condition in which the normal tissue lining around your uterus or the endometrium starts growing outside your uterus.

Ovarian cysts occurring because of polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is featured by the development of several small cysts on the surface of your ovaries.
• Irregular menstrual periods and the increase in levels of certain hormones are indicated.
• This condition is associated with fertility. It results in irregular ovulation that causes complications in fertility in many women.

Ovarian cysts which only affect fertility after becoming large
There are some types of ovarian cysts, which do not affect fertility unless they become very large. They are as follows:

Functional cysts

  • These cysts include corpus luteum cysts and follicular cysts. These are the most common forms of ovarian cysts.
  • Functional cysts from a usual menstrual cycle do not contribute to infertility in any way. Instead, they indicate the functions, which lead to fertility.


  • These are developments or growths in your ovaries. They usually occur from the surface of your ovaries.
  • These cysts require treatment, but do not affect fertility in any negative way.

Dermoid cysts

  • These are solid cysts containing tissues similar to skin, teeth and hair instead of fluid content.
  • These cysts too are not related to infertility problems during pregnancy.

If you are diagnosed with ovarian cysts and are concerned whether they will affect your pregnancy, it is important for you to consult your doctor. You will be able to discuss the various treatment measures, which revive your pregnancy chances. 

In case you have a concern or query you can always consult an expert & get answers to your questions!

4145 people found this helpful

Can Pelvic Pain Be A Sign Of Endometriosis?

MBBS, MS - Obstetrics and Gynaecology, Gynae-Laproscopy
Gynaecologist, Delhi
Can Pelvic Pain Be A Sign Of Endometriosis?

For most women, the week of her period is uncomfortable. However, for some women, periods are associated with debilitating pelvic pain. This is usually the result of a condition known as endometriosis. This is a condition where the tissue that lines the uterus or the endometrium is found outside the uterus as well. It usually involves the ovaries, fallopian tubes and tissues lining the pelvic region. In rare cases, it may be found in other parts of the body as well. Endometriosis can lead to cysts in the ovaries, adhesion of pelvic tissues and organs and also cause infertility.

The pain associated with endometriosis is caused due to the fact that the tissue that is outside the uterus behaves in the same manner as that inside the uterus but has no way of being removed from the body. Hence, it causes an inflammatory reaction that can be felt as a dull ache or muscle cramps. Cysts formed as a result of endometriosis may also put additional pressure on pelvic organs while urinating, passing stool or during intercourse and hence cause pain.

However, endometriosis is not the only cause for pelvic pain. Some of the other causes of pain in the abdomen include:

  • Ovulation
  • Dysmenorrhoea
  • Pelvic inflammatory disease
  • Rupture of an ovarian cyst
  • Fibroids in the uterus
  • Appendicitis
  • Cystitis
  • Irritable bowel syndrome
  • Hernias
  • Muscle and bone problems

Hence, it is necessary to understand and recognise the other symptoms of endometriosis as well. While some women may exhibit no other symptoms, others may experience:

  • Painful intercourse
  • Bleeding between periods
  • Pain while passing stool
  • Infertility
  • Blood in the urine or faeces

If the pain in the pelvic region is accompanied by any of the above symptoms for an extended period of time, you must consult a doctor immediately. Though endometriosis is not a cancerous condition, it can lead to further complications like blockages in the bowel if left untreated. To confirm a diagnosis of this condition, you will usually be advised to undergo laparoscopy.

This is a minor surgical procedure that involves making a small incision in the abdomen through which a telescope-like instrument is passed into the body. This allows the doctors to look inside and identify any patches of endometrium tissue. Once confirmed, your doctor may advise you leave it under observation, give you a course of painkillers or advise hormone replacement therapy or surgery to remove the extra endometrium tissue.

In case you have a concern or query you can always consult an expert & get answers to your questions!

3627 people found this helpful

Popular Questions & Answers

Hi doctors, Please help me. I had severe endometriosis. Had a laparoscopy on last November after that took lupron 11.25 mg injection on dec 11 .doctor told me that after 3 months I will get periods back. But I didn't get my periods yet. 4 months over. What I want to do. Do I want to consult a doc. Or I want to take any medicine to induce periods? Sometimes I am having period like cramps. But menses is not coming.

MBBS Bachelor of Medicine and Bachelor of Surgery, M.S Obsterics & Gynaecology, DNB (Obstetrics and Gynecology), Fellowship in Reproductive Medicine & Infertility
Gynaecologist, Delhi
After depot injections like this periods can be delayed. There is nothing much to worry. See a specialist if you don't get periods soon and earlier if you plan to conceive. Based on ultrasound you may be required to take medications to get your periods.
1 person found this helpful

Today is my 15th day of menses and a ultrasound showed 18x18 3 DF in right ovary, in left 18x18 1 DF. And today I got hcg injection. Is there more chances of conceiving.

MD - Obstetrtics & Gynaecology, FCPS, DGO, Diploma of the Faculty of Family Planning (DFFP)
Gynaecologist, Mumbai
Yes, there is chance. Remember Any couple desirous of pregnancy and not getting same naturally must meet Gynecologist or infertility specialist accepting facts that it needs many reports and different trials of treatment. Means couple must have patience and go to one in whom they have trust to stick for long time.
1 person found this helpful

I have polyps in fundic endometrium I am 26 years married women trying for baby since 6 years I am on homeopathic treatment I want to know what is polyps.

Mbbs,, MS OBGY
Gynaecologist, Pune
Please go for hysterscopic removal of polyp. Conception will not be possible without it. Meet a good fertility expert at your place.
1 person found this helpful

Hello I have undergone medical abortion on 11th January. Today my USG report says that'upper part of endometrium is thickened. Heterogeneous collection along with Cystic area is noted at lower uterine cavity. No embryonic pole is detected. My doc says I have to do d&c. Is it really necessary to undergo surgical process? Is not there any other option? Please let me know. Thanks in advance.

MD - Obstetrtics & Gynaecology, FCPS, DGO, Diploma of the Faculty of Family Planning (DFFP)
Gynaecologist, Mumbai
15 days After medical termination trial sonography is must as in 5 % cases process does not get completed. As in your case still some products are there something needs to be done. Either straight D & C or after trial of some other drugs and repeat sonography. Only examining doctor can decide.
1 person found this helpful

Table of Content

What is Endometriosis?

What causes Endometriosis?

Risk factors that make you more susceptible in developing Endometriosis is:

Play video
Know More About Endometriosis
Hello Everyone,

This is Dr. Sanket Pisat. I am a consultant Gynecological Laparoscopic surgeon working in Adheri in Mumbai.

And today we are going to talk about endometriosis. Endometriosis, as you may have heard from newspapers or report, is a disease that effects the reproductive track of the females quite commonly. The incidence of endometriosis in the past few years, mainly attributed to a late age of marriage, a late age of pregnancy or sometime because of having no children at all. So what is actually endometriosis? Endometriosis is the abnormal growth of the uterine lining which should normally be growing within the uterus at places where it should not be growing like the other organs within the abdominal cavity for example on the ovaries. What happens that is this endometrial lining causes pockets of blood filled tissues on the other organs like the ovaries or the intestines and result in tremendously painful periods to the patient, also sometimes resulting in infertility. The diagnosis of endometriosis is largely clinical, in a sense that sequelae or a set of symptoms commonly suggest that you may be suggesting from endometriosis. These include very heavy periods, tremendously painful periods or an onset of pain just before the periods but going away as the period start or sometimes just plainly infertility. Other times in some patient it may be a difficulty in sexual intercourse or pain during sexual intercourse and all of these require intensive investigation. Sometimes endometriosis can be diagnosed by an ultrasound examination in which the cyst in the ovary show the presence of endometriosis and these are the patients who require surgery. Endometriosis surgery can nowadays be done by laparoscopy or minimally invasive surgery in which there are hardly three or four cuts take in the abdomen which are less than a centimetre in size and the entire disease of endometriosis can be removed by surgery through these three or four ports. Of course, some pockets of endometriosis which are attached to vital organs within the body may not be removed but these then can be managed by medicines alone. In other patients, endometriosis is not as wide spread, the entire disease can be controlled by medicines alone and the patient can be given long term therapy for about three months or six months to make sure that the endometriosis stays quist and does not grow again. A word of conscience for these patients with endometriosis who are also suffering from infertility is that it is essential to plan pregnancy and child birth early because endometriosis is a disease of recurrence and a disease of progression and as age advances an endometriosis increases in intensity. It becomes more and more to conceive either naturally or by any form of assistive reproductive techniques.

If you have any further question in regards please feel free to contact me via Lybrate. Thank you.
Play video
Infertility Treatment
Namaskar, main Dr Pradnya Aptikar hoon. Thane mein main 16-17 years se practice kar rahi hoon as an ayurvedic gynaecologist. Ayurvedic gynaecology may be a new concept for you all. So ayurvedic gynaecology kis tarike se kaam karta hain? Jo classical Ayurved ki jaankari rakhte hain, aur modern science ki bhi jaankari hain, under one roof, I am working as an ayurvedic gynaecologist. Jis disease main Ayurved acchi tarike se kaam karta hain, usme ayurvedic medicines ki tarike se hum kaam karte hain. Aur jis diseases mein humein modern technology ki zarurat padhti hain diagnosis ke liye, jaise ki infertility ki baat hum lete hain, jisme hume X-ray, yap hire laparoscopy, hysteroscopy or surgery ki zarurat padti hai. In sab cheezon ko dhyan humein rakhte huye hume kaam karna padhta hain. Toh ayurvedic gynaecology hone ke bawajood, main baaki medicines or ayurvedic medicines ki bhi jaankari rakhti hoon. Jaise ki diabetes hai, thyroid disorders hai, endocrinological disorders hai, us me hum kaam karte hain. Aur yeh sab kaam ayurvedic medicines ke zariye kiya jaata hain. Ayurved jo hain, who alag tarike se kaam karta hain.

Aj hum infertility ke baare mein pehle baat karenge. Jaise ki by definition infertility ka matlab hain ki patient, ya couple agar ek saal se conceive nahi kar paa raha hain, phir toh hum unhein infertile bolte hain. Jaise ki the couple is trying for a baby for one year with unprotected sex, still they are not getting success, then the couple is defined as an infertile couple. Toh uske liye hum kaam karte hain. Toh agar apko dekha jay, toh isko hum anatomy apko mein batati hoon.

Isme yeh aap dekhte sakte hain ki yeh body of the uterus hain, yeh ovaries hain, and fallopian tubes hain. Toh isme agar PCOD jaise conditions hain, jaise ki ovaries mein agar anda taiyar nahin ho raha hain, har mahine mein period aate hain, to periods start hone k 14th or 16th day ek ek anda right ya left ovaries se nikalta hain. Lekin agar ye nahi nikalta hain, ya phir immature nikalta hain, ya phir ovarian cyst taiyar ho jata hain, wo anda puri tarike se bahar nahi nikalta. Toh, yeh anda poori tarike se nikalne ke baad, yeh naliye usme kaam karte hain. Naliya usko jaise kheech leti hain. Then agar sperms acchi quality ke hain, toh ye upar swim karke aate hain, and yeh. Accha sperm is helpful in fertilizing the ovum, and the embryo is formed in the fallopian tube, and that get implanted in the uterine cavity.

Aisi tarike se fertilization hoke, implantation hoke, pregnancy hoti hain. Lekin ye kisi bhi factor mein agar problem hai, toh infertility hoti hain. Jaise ki maine kaha ki ovarian cyst hain, PCOS hain, endometriosis hain, ya phir tubal blockage hain, toh phir humein success nahin milta hain, or humein infertility ka samna karna padhta hain. Toh is tarike mein, is mamle mein, ayurved kaise help karta hain?

Toh is mamle mein humein purification process rehti hain panchakarma se. Anda normal ya mature anda taiyyar hone mein hum kaam karte hain. Aur male partners mein agar sperm ki quality achchi nahi hain toh usme bhi hum panchakarma processes kar ke, hum sperm ki quality acChi tarike se badhate hain. Aur jis jis mein tubal blockages hain ya phir endometriosis hain, use bhi hum gynaceological panchakarma rehte hain. Jaise jise hum _____ bolte hain, aur uterus ki peeling process karke hum us mein kaam karte hain. Is me tubal blockages bhi nikal aatein hain, aur implantation ki chances badh jaate hain. Endometrium ki quality hum badhatein hain. IUI aur IVF jaise jo artificial reproductive techniques hain, isme bhi yeh karne se pehle agar hum panchakarma aur ye agar process karte hain, toh humein achchi tarike se results milte hain.

And further information ke liye, you can contact me via Thank you.
Having issues? Consult a doctor for medical advice