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Withania somnifera improves semen quality by
regulating reproductive hormone levels and oxidative
stress in seminal plasma of infertile males
Mohammad Kaleem Ahmad, M.Sc.,
a
Abbas Ali Mahdi, M.A., M.S., Ph.D.,
a
Kamla Kant Shukla, M.Sc.,
a
Najmul Islam, Ph.D.,
c
Singh Rajender, Ph.D.,
d
Dama Madhukar, M.V.Sc.,
d
Satya Narain Shankhwar,
M.Ch.,
b
and Sohail Ahmad, M.D.
e
a
Departments of Biochemistry;
b
Urology, Chhatrapati Shahuji Maharaj Medical University, Lucknow;
c
Department of
Biochemistry, J. N. Medical College, Aligarh Muslim University, Aligarh;
d
Endocrinology Division, Central Drug Research
Institute, Lucknow; and
e
Department of Pharmacology, State Government T. T. College and Hospital, Lucknow, India
Objective: To investigate the impact of Withania somnifera roots on semen profile, oxidative biomarkers, and
reproductive hormone levels of infertile men.
Design: Prospective study.
Setting: Departments of Biochemistry and Urology, Chhatrapati Shahuji Maharaj Medical University, Lucknow,
India.
Patient(s): Seventy-five normal healthy fertile men (control subjects) and 75 men undergoing infertility screening.
Intervention(s): High-performance liquid chromatography assay procedure for quantization of vitamin A and E in
seminal plasma. Biochemical parameters in seminal plasma were estimated by standard spectrophotometric pro-
cedures. Estimation of T, LH, FSH, and PRL in blood serum by RIA methods.
Main Outcome Measures(s): Before and after the treatment, seminal plasma biochemical parameters, antioxidant
vitamins, and serum T, LH, FSH, and PRL levels were measured.
Result(s): Withania somnifera inhibited lipid peroxidation and protein carbonyl content and improved sperm
count and motility. Treatment of infertile men recovered the seminal plasma levels of antioxidant enzymes and
vitamins A, C, and E and corrected fructose. Moreover, treatment also significantly increased serum T and LH
and reduced the levels of FSH and PRL.
Conclusion(s): The treatment with W. somnifera effectively reduced oxidative stress, as assessed by decreased
levels of various oxidants and improved level of diverse antioxidants. Moreover, the levels of T, LH, FSH
and PRL, good indicators of semen quality, were also reversed in infertile subjects after treatment with the herbal
preparation. (Fertil Steril
2009;-:-–-.2009 by American Society for Reproductive Medicine.)
Key Words: Withania somnifera, male infertility, alternative therapy, reproductive hormone, oxidative stress,
antioxidant
Infertility may be defined as failure to conceive by a couple
after 12 months of unprotected sexual intercourse (1). Infer-
tility affects 15% of all couples, and approximately 50% of
these have an abnormality detectable in the male partner as
the cause of infertility. Specific and directed treatment for
male infertility is not available owing to the unexplained
and heterogeneous nature of the disorders (2). Under such cir-
cumstances, only assisted reproductive technologies are of
some help. However, these treatments are expensive and
inaccessible to all. The lack of available specific therapies
for men with infertility demands the exploration of alterna-
tive therapies. Given the lack of knowledge about etiologic
factors, a nondirected but general therapy may yield good
results in a subcategory of patients. The rationale for the
use of these therapies is based on the speculation that some
forms of male infertility are caused by oxidative insult and
hormonal imbalance, and the use of alternative therapies
may improve male fertility potential and semen quality (3).
The latter is also supported by our previous studies (4–6).
Aerobic metabolism of human sperm produces different
reactive oxygen species (ROS), which are essential for sperm
capacitation, acrosome reaction, and oocyte fusion (7).To
counteract the toxic effects of ROS, seminal plasma and sper-
matozoa are well endowed with an array of antioxidant mech-
anisms. The antioxidant enzymes catalase, superoxide
dismutase (SOD), glutathione peroxidase, and glutathione
reductase have all been detected in seminal plasma (8).In
addition, semen contains high concentration of thiol groups,
ascorbic acid and uric acid, as well as less substantial
Received December 8, 2008; revised April 3, 2009; accepted April 13,
2009.
M.K.A. has nothing to disclose. A.A.M. has nothing to disclose. K.K.S. has
nothing to disclose. N.I. has nothing to disclose. S.R. has nothing to
disclose. D.M. has nothing to disclose. S.N.S. has nothing to disclose.
S.A. has nothing to disclose.
Supported by the Central Council for Research in Unani Medicine, New
Delhi, India (3-94/2005-CCRUM/Tech).
Reprint requests: Prof. Dr. A. A. Mahdi, Medical Elementology and Free
Radical Biology Lab, Department of Biochemistry, CSM Medical Uni-
versity (formerly King George’s Medical University), Lucknow-226003
(U.P.), India (FAX: þ91-522-2257539; E-mail: mahdiaa@rediffmail.
com).
0015-0282/09/$36.00 Fertility and Sterility
Vol. -, No. -,-2009 1
doi:10.1016/j.fertnstert.2009.04.046 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
ARTICLE IN PRESS
amounts of glutathione and a-tocopherol (9). Spermatozoa
themselves also possess high concentration of thiol groups,
as well as smaller amounts of ascorbic acid, a-tocopherol,
uric acid, and glutathione (10). However, uncontrolled and
excessive production of ROS may result in seminal oxidative
stress (11). The imbalance between ROS production and ROS
degradation has been hypothesized as a cause of oxidative
stress in semen, with peroxidative injury to the sperm mem-
brane and a consequent impairment of the related functional
properties, such as sperm motility and morphology. (12).
Growing evidence suggests that such seminal oxidative stress
is involved in many cases of idiopathic male factor infertility
(11).
In the Ayurveda and Unani systems of medicine practiced
in India, several plants and plant products have been docu-
mented to fight against stress, impotence, infertility, and the
aging process (13).Withania somnifera, also known as Indian
ginseng, has been described in folk medicine as an aphrodi-
siac and geriatric tonic. Different investigators have reported
that W. somnifera possesses antiserotogenic, anticancer, and
anabolic activity and is beneficial in the treatment of arthritis,
geriatric problems, stress, and male sexual dysfunction. It
also possesses adaptogenic, cardiotropic, cardioprotective,
and anticoagulant properties (14).W. somnifera has been
shown to inhibit lipid peroxidation in stress-induced animals
(15). Earlier studies have shown that aqueous extract of this
plant elicits changes in pituitary gonadotropins coupled
with an enhancement in epididymal sperm pattern in adult
male rats and folliculogenesis in immature female rats (16).
W. somnifera induced testicular development and spermato-
genesis in immature Wistar rats by directly affecting the sem-
iniferous tubules (17). In view of the above considerations,
the present study was undertaken to investigate the impact
of W.somnifera on semen profile, oxidative biomarkers,
and reproductive hormone levels of infertile men.
MATERIALS AND METHODS
Plant Materials
The roots of W.somnifera were procured from the Central
Council for Research in Unani Medicine, New Delhi. The
roots were dried under shade and made to fine powder using
a laboratory grinder.
Study Design
The Institutional Review Board and Ethics Committee of
Chhatrapati Shahuji Maharaj (CSM) Medical University,
Lucknow, approved this study. The study was conducted
between February 2007 and August 2008, and the study pop-
ulation included normal healthy and fertile men (n ¼75) and
infertile patients (n ¼75), aged 25–40 years, recruited from
the Outpatient Department of Urology, CSM Medical Uni-
versity. The control group comprised age-matched healthy
men who had previously initiated at least one pregnancy
and exhibited normal semen profile (sperm count >20
10
6
/mL, motility >40%, and >40% normal morphology).
Normozoospermic infertile men (n ¼25) had normal semen
profile (defined as in the control group) and infertility of
unknown etiology. Oligozoospermic infertile men (n ¼25)
had a sperm count of <20 10
6
/mL, motility >40%, and
>40% normal morphology. Asthenozoospermic infertile
men (n ¼25) had a sperm count of >20 10
6
/mL, motility
<40%, and >40% normal morphology. Before enrollment in
the study, each subject’s informed written consent was
obtained in response to a fully written and verbal explanation
of the nature of the study. The potential participants, each
with infertility persisting longer than 1 year, were carefully
examined. As an inclusion criterion, the infection of acces-
sory glands was ruled out in all subjects. Moreover, subjects
having diabetes, hypertension, arthritis, tuberculosis, or
human immunodeficiency, those on drugs, and those having
other conditions known to influence oxidative stress were
excluded. Complete physical, biochemical, and semen exam-
inations were performed as the screening tests. Additionally,
medical histories of patients and their female partners were
recorded. Infertile cases where a problem could be diagnosed
in the female partner were excluded from the study. All sub-
jects were instructed to continue normal diets without switch-
ing to dietary supplements during the course of treatment. To
further ensure this, the details of the diet were taken from the
patients at monthly intervals.
Treatment
Infertile men were prescribed W.somnifera root powder
(5 g/day) orally for 3 months with milk. This dosing schedule
was as reported earlier by Singh (18).
Sample Collection and Preparation
Semen samples were collected into sterile plastic containers
by masturbation after 3–4 days of abstinence and allowed to
liquefy for 30 minutes. Semen volume was recorded after liq-
uefaction; an aliquot was taken to assess sperm motility and
count. Semen profile was constructed with the procedures de-
scribed by the World Health Organization (19). Liquefied
semen samples were centrifuged at 1,200gfor 20 minutes
for separation of seminal plasma. The supernatant (seminal
plasma) was centrifuged at 10,000gfor 30 minutes to elimi-
nate all possible contaminating cells. Seminal plasma was
quickly frozen and stored at 20C until the assessment of
different biochemical parameters. Venous blood samples
were drawn between 8 a.m. and 10 a.m. and centrifuged at
3,000gat 4C for 10 minutes and serum was aspirated out
for hormone assays.
Hormonal Assays
Serum T, LH, FSH, and PRL were measured by a double-
antibody RIA method using Gamma Counter (Stratec Bio-
medical System, Birkenfeld, Germany) (20). Intra- and inter-
assay coefficients of variation in T, LH, FSH, and PRL were
10.0%, 14.0%, 8.5%, and 12.5%, respectively. Receiver’s
Q1 2Ahmad et al. Effect of Withania somnifera on infertile males Vol. -, No. -,-2009
ARTICLE IN PRESS
operating characteristic (ROC) curves were created for the
hormone values to understand their diagnostic value.
Biochemical Assay
Seminal plasma lipid peroxides were estimated according to
the method of Ohkawa et al. (21), with modifications as
described by Sanocka et al. (22), and protein carbonyl group
by the method of Levine et al. (23). Ascorbic acid and fruc-
tose levels were estimated as described by Butler (24) and
Gavella (25). Corrected seminal fructose values were
deduced by multiplying the logarithm of sperm concentration
and seminal plasma fructose concentration (26). Seminal
plasma SOD and catalase activities were measured according
to McCord and Fridovich (27) and Aebi (28), respectively,
and reduced glutathione level was estimated as described
by Hissin and Hilf (29).
Vitamins A and E were measured by high-performance liq-
uid chromatography (HPLC) per the modified method of Omu
et al. (30). Briefly a-tocopherol acetate and retinol acetate
were pipetted into an Eppendorf tube. To this, seminal plasma
was added and vortex mixed. Hexane extract of vitamins A
and E was aspirated out in a glass tube, dried under nitrogen
stream, and dissolved into methanol. Finally, this preparation
was injected into HPLC fitted with a reverse-phase C-18 stain-
less steel column. The vitamins were eluted with methanol at
a flow rate of 1.5 mL/min for 15 minutes. The peak heights and
the curve areas of vitamins A, E and their acetates were mea-
sured to calculate the amount of these vitamins in seminal
plasma in an ultraviolet detector with 292-nm filters.
Statistical Analysis
The four independent groups—control, pretreated normo-
zoospermic, pretreated oligozoospermic, and pretreated
asthenozoospermic—were compared by one-way analysis
of variance followed by Dunnett test. A paired ttest was
used to analyze the significance of mean difference between
pre- and posttreatment infertile groups. All hypothesis testing
was two tailed. The results were expressed as mean SD,
and P<.05 was considered to be statistically significant.
The statistical analyses were carried out with commercial
software (Instat 3.0; GraphPad Software, San Diego, CA).
The ROC curves were constructed using SPSS (Version 12;
SPSS, Chicago, IL), and cutoff values for each of the four
hormones were determined that could be used as indicators
of infertility. Low values of LH and T and high values of
FSH and PRL were assumed to be better indicators of infer-
tility for construction of ROC curves.
RESULTS
Semen Profile
The semen profiles of the fertile (control) group and the
pre– and post–W. somnifera–treated infertile groups are
shown in Table 1. Sperm concentration increased signifi-
cantly in normozoospermic, oligozoospermic, and astheno-
zoospermic men compared with the pretreatment
parameters. Motility was also significantly improved in all
groups of infertile individuals (Table 1) after treatment, but
the increase was less than optimal in asthenozoospermic in-
fertile men. The semen volume was significantly increased
(P<.01) in normozoospermic and oligozoospermic, whereas
in asthenozoospermic the change was not significant. Sperm
count per ejaculate was found to be significantly improved
(P<.01) upon treatment.
Oxidative Biomarkers
The level of lipid peroxides (LPO) and protein carbonyl groups
in the seminal plasma of fertile men were 1.74 0.19 nmol
Malondialdehyde (MDA)/mL and 2.07 0.37 nmol/mg pro-
tein, respectively. These parameters were significantly ele-
vated in the seminal plasma of all the infertile groups (Tabl e
2). Upon treatment, significant reversal in the level of LPO
and protein carbonyl groups were observed in normozoosper-
mic, oligozoospermic, and asthenozoospermic men (P<.01).
The SOD activity in seminal plasma of the control group
was 8.17 0.71 U/mg protein. However, this enzyme was
found to be significantly suppressed in the groups of infertile
men. Treatment significantly enhanced the activity of SOD
in normozoospermic, oligozoospermic, and asthenozoosper-
mic men compared with pretreatment parameters. Similarly,
treatment significantly recovered the seminal plasma activity
of catalase in all the infertile groups (P<.01). Reduced gluta-
thione also improved significantly upon treatment (P<.01).
Antioxidant Vitamins and Corrected Fructose
The levels of vitamins A, E, and C and corrected seminal
fructose in the seminal plasma of fertile men were 28.61
4.43 mg/dL, 0.143 0.012 mg/dL, 5.64 0.71 mg/dL, and
3.63 0.34 mg/mL, respectively (Table 3). These parameters
were suboptimal in all groups of infertile men. Treatment
recovered the levels of vitamins A, E, and C in normozoo-
spermic (P<.01), oligozoospermic (P<.01), and asthenozoo-
spermic men (P<.01) compared with pretreatment levels.
After treatment, the levels of corrected seminal fructose
was also restored in all groups (P<.05).
Hormonal Profile
Mean basal hormone levels of infertile subjects and controls
are listed in Table 4.
Testosterone and luteinizing hormone Serum T levels were
suboptimal in all groups of infertile men. Treatment recov-
ered the levels of T in normozoospermic, oligozoospermic,
and asthenozoospermic men significantly (P<.01). The se-
rum LH concentration in the control group was 7.94 0.63
mIU/mL. This parameter was significantly lower in all of
the infertile men. Treatment significantly increased the level
of LH in all of the groups of infertile men.
Follicle-stimulating hormone and prolactin The FSH and
PRL levels in the serum of fertile control men were
Fertility and Sterility
3
ARTICLE IN PRESS
5.67 0.91 mIU/mL and 7.10 0.67 ng/mL, respectively.
These parameters were significantly elevated in oligozoosper-
mic and asthenozoospermic men. After treatment with W.
somnifera, FSH and PRL levels were reduced significantly.
The ROC curves suggested that low levels of LH and T were
very good indicators of infertility (Figure 1), explaining up to
93.4% and 96.2%, respectively, of cases of infertility (Table 5).
Testosterone values <5.81 ng/mL (average for control sub-
jects: 7.09 ng/mL) may indicate infertility with good sensitiv-
ity (82.67%) and high specificity (100%). Similarly, LH
values <6.43 mIU/mL (average for control subjects: 7.94
mIU/mL) may indicate infertility with good sensitivity
(78.67%) and specificity approximating 100%. However,
high values of FSH and PRL were relatively less good indica-
tors of infertility, explaining up to 77.6% and 75.7%, respec-
tively, of infertility cases (Tab l e 5 ). FSH values >7.19 mIU/
mL (average for controlsubjects: 5.67 mIU/mL) may indicated
infertility with low sensitivity (37.33%) and good specificity
(99%). Similarly, PRL values >8.0 ng/mL may indicate infer-
tility with low sensitivity (49.33%) but high specificity (99%).
DISCUSSION
The results of this study demonstrate that oxidative stress is
associated with reduced antioxidant capacity along with
TABLE 1
Effect of Withania somnifera on semen profile of infertile men.
Group Treatment
Semen
volume
(mL)
Sperm
concentration
(10
6
/mL)
Sperm count
(310
6
per ejaculate) Motility (%)
Control (n ¼75) None 2.84 0.45 79.00 15.37 223.00 52.25 72.67 7.63
Normozoospermic
(n ¼25)
Pretreatment
a
2.21 0.43 54.04 8.80 119.37 29.65 54.17 10.18
Posttreatment
b
2.65 0.39 71.88 10.70 191.38 42.12 63.54 10.05
Oligozoospermic
(n ¼25)
Pretreatment
a
1.86 0.37 9.78 1.89 18.06 4.74 52.5 8.47
Posttreatment
b
2.42 0.30 27.32 5.67 65.63 13.52 62.71 9.32
Asthenozoospermic
(n ¼25)
Pretreatment
a
2.44 0.45 43.49 8.84 103.37 17.65 16.44 2.91
Posttreatment 2.54 0.54
NS
57.6 11.79
b
141.91 21.95
b
24.44 4.48
b
a
P<.01 compared with control (Dunnett test).
b
P<.01 compared with pretreatment (paired ttest).
NS
Not significant.
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
TABLE 2
Effect of Withania somnifera on oxidative biomarkers in seminal plasma of infertile men.
Group Treatment
Lipid
peroxides
(nmol
MDA/mL)
Protein
carbonyl
groups
(nmol/mg
protein)
SOD
(U/mg
protein)
Catalase
(U/mg
protein)
Glutathione
(mg/dL)
Control (n ¼75) 1.74 0.19 2.07 0.37 8.17 0.71 9.18 0.93 1.68 0.15
Normozoospermic
(n ¼25)
Pretreatment 3.48 0.44
a
3.14 0.56
a
6.71 0.88
a
8.14 1.26*1.34 0.13
a
Posttreatment
b
2.33 0.29 2.25 0.53 7.36 0.77 10.17 1.77 1.62 0.13
Oligozoospermic
(n ¼25)
Pretreatment 2.68 0.27
a
3.74 0.83
a
5.61 0.90
a
8.33 1.14*1.27 0.15
a
Posttreatment
b
2.06 0.27 2.85 0.49 6.93 1.09 9.98 1.01 1.67 0.15
Asthenozoospermic
(n ¼25)
Pretreatment 3.01 0.55
a
2.80 0.61
a
5.29 0.69
a
6.64 1.00
a
1.31 0.15
a
Posttreatment
b
2.14 0.22 2.21 0.39 6.49 0.93 8.27 1.99 1.61 0.12
Note: SOD ¼superoxide dismutase.
*P<.05 compared with control (Dunnett test).
a
P<.01 compared with control (Dunnett test).
b
P<.01 compared with pretreatment (paired ttest).
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
4Ahmad et al. Effect of Withania somnifera on infertile males Vol. -, No. -,-2009
ARTICLE IN PRESS
derangement in hormone levels, and that these are negatively
correlated with sperm concentration and motility in infertile
men (31). Certain individual reports previously showed
a direct correlation between seminal oxidative stress and
the presence of immature and abnormal spermatozoa due to
lipids and protein peroxidations (32). We could trace the rea-
son for oxidative stress to be reduced activity of antioxidant
enzymes, namely SOD and catalase, and low glutathione
level. We observed that treatment with W. somnifera signifi-
cantly improved the activity of SOD and catalase and the
level of glutathione, eventually reducing the levels of LPO
and protein carbonyl groups in infertile men. Complementing
our findings, earlier studies have reported that W. somnifera
inhibits lipid peroxidation in stress-induced animals (15).
Reduced stress, in effect, might have contributed to the
significant improvement in sperm concentration and motility.
Although we observed an increase in fructose level with an
increase in sperm motility, it remains to be explored if the
two could have the cause-and-effect relationship. We
have previously reported similar activity in Mucuna pruriens
(4, 5), but the present results show that W. somnifera has bet-
ter antioxidant properties.
We also observed significantly reduced levels of vitamins
A, C, and E in infertile men. Vitamin A is a biologic antiox-
idant which functions as a detoxifying agent, immunopoten-
tiator, and immunoactivator (33). Similarly, vitamin E
(a-tocopherol) contributes to the body’s defense system
TABLE 3
Effect of Withania somnifera on seminal plasma levels of antioxidant vitamins and corrected fructose
in infertile men.
Group Treatment
Vitamin A
(mg/dL)
Vitamin E
(mg/dL)
Vitamin C
(mg/dL)
Corrected
fructose
(mg/mL)
Control (n ¼75) 28.61 4.43 0.143 0.012 5.64 0.71 3.63 0.34
Normozoospermic
(n ¼25)
Pretreatment
a
17.86 3.02 0.109 0.013 4.18 0.42 2.49 0.30
Posttreatment 21.73 4.05
b
0.129 0.019
b
5.12 0.49
b
2.77 0.52*
Oligozoospermic
(n ¼25)
Pretreatment
a
16.86 3.66 0.089 0.016 4.95 0.77 2.18 0.29
Posttreatment 19.50 3.41
b
0.123 0.026
b
6.03 0.91
b
2.51 0.29*
Asthenozoospermic
(n ¼25)
Pretreatment
a
15.23 2.39 0.078 0.020 5.05 0.88 2.32 0.40
Posttreatment 17.91 3.06
b
0.108 0.031
b
6.13 0.90
b
2.55 0.41*
a
P<.01 compared with control (Dunnett test).
b
P<.01 compared with pretreatment (paired ttest).
*P<.05 compared with pretreatment (paired ttest).
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
TABLE 4
Effect of Withania somnifera on hormonal profile in serum of infertile men.
Group Treatment LH (mIU/mL) T (ng/mL) FSH (mIU/mL) PRL (ng/mL)
Control (n ¼75) 7.94 1.00 7.09 0.63 5.67 0.91 7.10 0.67
Normozoospermic (n ¼25) Pretreatment 6.87 0.60
a
5.80 0.88
a
6.07 0.69
NS
7.21 0.72
NS
Posttreatment 7.85 0.53
b
6.65 0.78
b
5.75 0.60** 6.93 0.67
NS
Oligozoospermic (n ¼25) Pretreatment 4.02 0.57
a
3.51 0.56
a
7.78 0.77
a
10.57 1.42
a
Posttreatment 5.98 0.80
b
4.94 0.54
b
6.27 0.76
b
8.75 1.28
b
Asthenozoospermic (n ¼25) Pretreatment 3.82 0.59
a
4.32 0.89
a
6.49 0.85
a
7.78 0.82*
Posttreatment 5.37 0.61
b
5.23 0.80
b
5.95 0.96** 7.19 0.82
b
a
P<.01 compared with control.
b
P<.01 compared with pretreatment.
*P<.05 compared with control.
** P<.05 compared with pretreatment.
NS
Not significant.
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
Fertility and Sterility
5
ARTICLE IN PRESS
against lipoprotein oxidation and may help in improving
sperm motility (34). Healthy fertile men with normal sperm
parameters contain adequate amounts of vitamins A and E
(35). The impaired antioxidant activity in men with sperm
dysfunction may be a reflection of low seminal levels of vita-
mins A and E (36). Ascorbic acid is a water soluble vitamin
and possesses potent ROS-scavenging activity. Seminal
plasma is very rich in ascorbic acid content, with a concentra-
tion reported to be tenfold higher than in serum (37), high-
lighting its importance for fertility. Earlier studies also have
reported reduced levels of vitamin C in infertile men (38).
Treatment with W. somnifera improved levels of vitamins
A, C, and E, indicating the strength of this herb to protect
against infertility due to vitamin loss.
Circulating levels of various sex hormones have been cor-
related with semen quality parameters (39). Testosterone
plays an essential role in spermatogenesis (40). Elevated
levels of FSH have been correlated with damage to the
seminiferous tubules. FSH has been suggested as a marker
of Sertoli cell function and spermatogenesis (41). Our results
confirm that LH, T, FSH, and PRL hormone levels could be
used as markers of semen quality. We observed decreased
levels of LH and T and increased levels of FSH and PRL in
TABLE 5
Area under the receiver’s operating characteristic curve for different hormones.
Asymptotic 95% confidence interval
Test result
variable Area SE
a
Asymptotic
Significance
b
Lower bound Upper bound
FSH 0.776 0.037 0.000 0.703 0.849
PRL 0.757 0.039 0.000 0.680 0.835
LH 0.934 0.018 0.000 0.899 0.969
T 0.962 0.014 0.000 0.935 0.989
Note: Area under the curve was calculated assuming low values of LH and T and high values of FSH and PRL to indicate
positive test for infertility.
a
Under the nonparametric assumption.
b
Null hypothesis: true area ¼0.5.
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
FIGURE 1
Receiver’s operating characteristic (ROC) curves showing the diagnostic value of different hormones: the ROC
curves were constructed assuming low values of LH and T (left) and high values of FSH and PRL (right)to
indicate positive test for infertility.
Ahmad. Effect of Withania somnifera on infertile males. Fertil Steril 2009.
6Ahmad et al. Effect of Withania somnifera on infertile males Vol. -, No. -,-2009
ARTICLE IN PRESS
men with poor semen quality. The ROC curve analyses indi-
cated that low values of T and LH were better markers for
infertility than high values of FSH and PRL. The sensitivity
of both T and LH levels as infertility markers was much
higher compared with both FSH and PRL levels. However,
the values of all four hormones taken together may help in
better decision making regarding the fertility status of an
individual. Treatment with W. somnifera restored the level
of all four hormones. This directly correlates these hormones
with semen quality and highlights the capability of W. somni-
fera to restore the level of these hormones. Although direct
hormonal supplements have been tried in male infertility
treatment, the outcome was very poor (42) and with the
cost of certain side effects. Therefore, W. somnifera offers
a better and safe method of restoring sex hormones in male
infertility treatment.
The biologic basis and exact mechanism of action of W.
somnifera on infertility is not well known, but earlier exper-
imental studies showed that treatment with aqueous extracts
of W. somnifera induces testicular development and sper-
matogenesis in immature Wistar rats (17). Moreover, W. som-
nifera has been reported to have several pharmacologic
effects, including anthelmintic, narcotic, radiosensitizer,
antistressor, adaptogenic, and cardioprotective effects (43).
The roots of W. somnifera contain several alkaloids, withano-
lides, and a few flavanoids and reducing sugars (44). More
than 20 active constituents have been reported to date in
the root of W. somnifera, including withaferin A, sitoindo-
sides VII–X, withanosides I–VII, choline, and beta-sitosterol
(45). The presence of these compounds may be the reason for
diverse effects of W. somnifera on semen properties. How-
ever, the spermogenic and/or steroidogenic activity of any
of these compounds, if any, has not been explored. Therefore,
further in-depth studies are needed to explore the individual
properties of these active constituents.
Acknowledgments: The authors thank Dr. Ramesh Chander (Department of
Biochemistry, Era’s Lucknow Medical College, Lucknow), and Mr. M. P.
S. Negi (Biometry and Statistics Division, Central Drug Research Institute,
Lucknow), for assistance in statistical analysis of the data.
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