Efficacy and Safety of Eight-Week Therapy with Ashwagandha Root Extract in Improvement of Sexual Health in Healthy Men: Findings of a Prospective, Randomized, Double-Blind, Placebo-Controlled Study

doi:10.21203/rs.3.rs-5203033/v1

Ashwagandha, a traditional Indian Ayurvedic remedy, an adaptogen, may improve sexual dysfunction in men and women. This 8-week prospective, double-blind, randomized, placebo-controlled study evaluated the efficacy and safety of Ashwagandha Root Extract (ARE) on improving sexual health in healthy adult men based on Satisfying Sexual Events (SSEs), the Sexual Desire Inventory (SDI-2), the International Index of Erectile Function (IIEF) score, semen parameters and the Quality Of Life (QOL) using the SF-12 tool. A total of 100 healthy men aged 30 to 50 years were randomly assigned to receive ARE 300 mg twice daily (n=50), or identical placebo (n=50) in a 1:1 ratio for 8 weeks. Study assessments were done at baseline, week 2, week 4, and week 8. Three participants from ARE and four participants from the placebo group were excluded due to follow-up loss. The efficacy analyses were done on Per-Protocol (PP) dataset of 93, whereas safety analyses were done on all 100 participants. Significant improvements were observed with ARE for semen volume (p=0.005), sperm number (p=0.006), sperm concentration (p=0.007), and sperm morphology (p=0.007). The improvement in scores was better with ARE for SDI-2 (p<0.05), orgasm and sexual desire domains of IIEF (p<0.05), and SF-12 (p<0.0001). No adverse events were reported in the study.

Sexual & Reproductive Medicine

Ashwagandha

Male Sexual Dysfunction

Semen Parameters

SF-12

IIEF

Sexual desire, sexual activity, and sexual satisfaction are important aspects of human life, and these contribute to the quality of life for both men and women ¹. Male sexual dysfunction (MSD) or impaired sexual functioning includes a variety of conditions, including low libido, erectile dysfunction (ED), Peyronie’s disease (PD), and premature ejaculation (PE)².The prevalence of MSD increases with age and is relatively high (> 50%) in men aged 40–70 years ³ .Among the sexual dysfunctions, premature ejaculation and erectile dysfunction are the most prevalent types ^4–6. Low sexual desire includes a lack of interest in thinking about sex or in being sexual, either alone or with a partner ³. Lifestyle disorders like obesity and dyslipidemia, along with excess smoking and alcohol can contribute to MSD ^7–9. Sexual dysfunction in men can be caused by various systemic diseases and medication. Long-term use of drugs like antihypertensives, antidepressants, diuretics, antiandrogens, opioids, anti-parkinsonians and sympathetic blockers can cause MSD ¹⁰. Psychological factors have shown to play an important role in sexuality and sexual satisfaction.¹¹

Ashwagandha [Withania somnifera, (WS) fam. Solanaceae)], also called ‘Indian Winter Cherry’ or ‘Indian Ginseng’, is an adaptogenic herb used in Ayurveda, the traditional Indian medical system ¹². For centuries, it has been utilized as a ‘Rasayana’ and recognized for its various health benefits ^13,14. Different investigators have reported that Ashwagandha is beneficial in the treatment of male infertility ^15,16. Experimental studies have shown that treatment with Ashwagandha induced testicular development and spermatogenesis in immature Wistar rats by directly affecting the seminiferous tubules, improves the prosexual behavior of sexually sluggish mice, and increases testicular daily sperm production and serum testosterone level ¹⁷. It has been well documented that high levels of reactive oxygen species (ROS) in the semen induce oxidative damage to the sperm and are associated with abnormal sperm parameters leading to infertility ^18–21. Ashwagandha has been found to counteract the formation of ROS in infertile men.

Considering the probable benefit of ashwagandha extract supplementation on sexual wellness, this clinical study was conducted to evaluate the efficacy and safety of treatments with Ashwagandha Root Extract (ARE) in improvement of sexual health in men.

Study design and setting

This was an 8-week treatment period, prospective, randomized, double-blind, placebo-controlled study in healthy men. Participants who met the criteria for inclusion and exclusion were allocated to either of the two treatment groups.

The study and related documents were reviewed and approved by the Institutional Ethics Committee (DYP/IEC/14/2022; dt. 26-08-2022). Written informed consent was obtained in preferable languages (Hindi, Marathi, and English) from all participants prior to the enrolment. Each participant was explained in detail about the study objective and the expected outcome before taking the consent. The study adhered to the Good Clinical Practice (GCP) guidelines, New Drugs and Clinical Trials 2019 (India), and the Declaration of Helsinki (Taipei 2016). It also registered with the clinical trials registry of India [# CTRI/2022/09/045646; dt: 19/09/2022).

Study participants

The study sample consisted of 100 healthy men between 30 to 50 years of age visiting the study sites for seeking interventions for their sexual problems. The study only enrolled those who met the inclusion and exclusion criteria.

Men with poor sexual satisfaction on self-perception for a minimum of the previous three months were screened for study. Those with baseline total scores between 11–16 on IIEF-EF (International Index of Erectile Function – Erectile Function) scale and in a stable, monogamous, heterosexual relationship were enrolled. Men agreed to abstain from using other medications or treatments for ED or improving sexual performance during the study period. All participants and their partners were required to be physically present for at least 50% of each calendar month, willing to engage in regular sexual intercourse, and used medically approved form of contraception throughout the study. Men were required to have a compliant partner who was willing to observe study procedures. The study expected the participants to attempt sexual intercourse at least four or more times in two weeks. Men with any acute illness, those with a clinically significant medical history, or conditions that could jeopardize safety or study validity were not enrolled. Men participating in other clinical studies involving dietary supplements, or with a history of hypersensitivity reactions, known history of substance abuse or dependence were also excluded. Men with a primary hypoactive sexual desire, or with erectile dysfunction caused by other primary sexual disorder, or failure of surgery in the pelvic cavity were excluded. Those with spinal injury or had a radical prostatectomy, penis deformity, penile implants, history of malignancy, a refractory psychiatric disorder, or significant neurological abnormalities were also excluded. Men with alcohol addiction or persistent abuse of drugs of dependence were not included. The participants were not expected to plan a pregnancy for the next six months. Those with relationship with a pregnant partner were also excluded.

Randomization and blinding

Enrolled participants were randomly assigned to ARE or placebo in 1:1 randomization ratio. Randomization was performed using a computer-generated pre-determined randomization list. Both the study products were identical in size, shape, and colour. This ensured that the participants as well as the investigator and the staff can not differentiate between active/placebo treatments. The investigator received the randomization codes in separate pre-sealed envelopes for each study participant (study participant ID) and was instructed to open the envelope only after assigning the study number to the eligible participant. An independent investigator who was blinded to therapy collected the outcome measures at scheduled visits.

Interventions

The ARE group received capsule containing 300mg ARE (KSM-66 Ashwagandha, Ixoreal Biomed Inc., Los Angeles, California, USA) orally twice daily after breakfast and dinner (preferably 30 minutes before the anticipated sexual intercourse) with a glass of water or milk for a period of eight weeks. The placebo group received identical placebo capsule (300 mg starch) for similar period. All men were asked to continue their routine diet and physical activities during the study period.

Primary outcome

Primary study outcome was the mean change in scores for the Satisfying Sexual Events (SSEs) scale from baseline to week 8.

Secondary outcomes

The secondary efficacy outcomes were mean changes in scores for the Sexual Desire Inventory – version 2 (SDI-2), International Index of Erectile Dysfunction (IIEF), semen parameters, serum sex hormones (testosterone, dihydrotestosterone (DHT), follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and Quality of Life (QoL) using the SF-12 (Short Form 12) questionnaire.

Study assessments

A thorough physical examination and vital signs were assessed during site visits at baseline, week 2, week 4 and week 8.

Satisfying Sexual Events (SSE)

The SSE were self-reported by men for total number of intercourse events (sexual and non-sexual), number of orgasms, and number of satisfying sexual activities ²². The sexual activity was recorded for the 2-week period prior to the assessment date and were based on recall by participant at baseline assessment. For follow-up assessments, sexual activity diary was maintained. Sexual desire levels were recorded for 24 hours prior to visit on a four-point Likert scale (0 = No desire, 1 = Mild desire, 2 = Moderate desire and 3 = Strong desire).

Sexual Desire Inventory 2 (SDI-2)

SDI-2 is a brief 14-item scale which is based on the select items using theoretical models of desire, and diagnostic criteria used in the DSM-III-R for Hypoactive Sexual Desire Disorder (HSDD), and clinical experience in assessing and treating sexual desire disorders ²³. The Higher scores indicate stronger sexual satisfaction.

International Index of Erectile Dysfunction (IIEF)

IIEF is a 15-item validated, multi-dimensional, self-administered questionnaire commonly used in the clinical assessment of erectile dysfunction and treatment outcomes in clinical study ²⁴. The scoring of 0 to 5 is marked for 15 questions that assess the four domains which are Erectile Function (EF), Orgasmic Function (OF), Sexual Desire (SD), and Intercourse Satisfaction (IS). Sum of scores of the four domain yields the total IIEF score.

Short Form 12 (SF-12)

The SF-12 is a self-reported outcome measure assessing the impact of health on an individual's everyday life and is often used as a quality-of-life measure ²⁵. The SF-12 uses the same eight domains as the original SF-36 scale of 36 items.

Semen analysis and laboratory tests

Laboratory tests and semen analysis were done at baseline and week 8. Standard manual semen analysis was performed according to World Health Organization (WHO) guidelines ²⁶. The semen sample was collected after a minimum of 2 days of sexual abstinence. Semen parameters included semen volume (mL), sperm count (X 10⁶ per mL), total sperm count in ejaculate (X 10⁶), total sperm motility (%), pH, sperm vitality (% of vital sperms), and normal sperm morphology (%). Blood samples were collected and tested using the chemiluminescence method at screening to estimate the levels of serum testosterone, DHT, FSH, LH and prolactin. Other serum tests for safety were hemoglobin (Hb), creatinine, blood urea nitrogen (BUN), bilirubin (total and direct), proteins (albumin, globulin, A:G ratio), alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP).

Statistical analysis

Sample size calculations were performed based on the reported data for improvement in IIEF scores with a tribulus terrestris²⁷. A total sample size of 92 (46 in each arm) was deemed necessary to attain 80% statistical power and maintain a 2.5% (one-sided) significance level to detect a difference of 24.12 between herbal treatment and placebo for total SDI score. We enrolled 100 cases in the study to account for potential 10% dropouts.

We employed summary statistics to summarize continuous variables and other demographic characteristics, which included the number of observations, mean, and standard deviation with a 95% confidence interval (for normally distributed data). Data for continuous variables were analyzed for differences between the two groups at each time point using independent sample t-test. Between group comparisons with baseline and follow-up data were analyzed using repeat measures Analysis of Variance (ANOVA). For ordinal data of sexual desire scores, Mann-Whitney ‘U’ test is used for between group comparisons.

A total of 133 men were screened, of which 100 were enrolled in the study (CONSORT flow chart, Fig. 1). The per-protocol (PP) dataset was used for efficacy analysis, which included 93 patients (47 ARE and 46 placebo) who completed the study as per protocol. The safety dataset was the intent-to-treat (ITT) dataset which included all 100 men who were randomized and received study medication.

Baseline data

The two groups (ARE and placebo) were similar (p > 0.05) with respect to demography, Body Mass Index (BMI) and vital parameters in both ITT and PP datasets (Table 1). There were no differences (p > 0.05) between the two groups with respect to the baseline data for all parameters, including semen analysis, serum hormones, IIEF, SDI-2, sexual events, and SF-12 in both PP and ITT datasets (Table 2).

Table 1

Demography and vital parameters at baseline ITT (n = 100) and PP dataset (n = 93)
		ITT dataset (n = 100)					PP dataset (n = 93)
					2-sample t-test					2-sample t-test
	Treatment	N	Mean	SD	t	p	N	Mean	SD	t	p
Age (yrs.)	ARE	50	35.64	9.67	1.302	0.196	47	35.91	9.89	1.341	0.183
	Placebo	50	33.54	6.04			46	33.61	6.25
SBP (mm Hg)	ARE	50	117.80	4.67	-0.358	0.721	47	117.89	4.61	0.002	0.998
	Placebo	50	118.14	4.82			46	117.89	4.95
DBP (mm Hg)	ARE	50	80.20	5.57	-0.253	0.800	47	80.09	5.59	-0.191	0.849
	Placebo	50	80.48	5.47			46	80.30	5.50
Pulse rate (per min.)	ARE	50	78.79	7.40	0.223	0.824	47	78.94	7.56	0.127	0.900
	Placebo	50	78.52	4.03			46	78.78	4.07
Respiratory rate (per min.)	ARE	50	17.14	1.09	-1.195	0.235	47	17.09	1.10	-1.307	0.194
	Placebo	50	18.94	10.60			46	19.20	11.01
BMI (kg/sq.m)	ARE	50	25.58	4.75	-1.183	0.240	47	25.34	4.78	-1.325	0.188
	Placebo	50	26.60	3.79			46	26.54	3.92
ARE: Ashwagandha root extract; BMI: Body mass index; ITT: Intent to treat; PP: Per protocol; SD: Standard deviation

Table 2

Serum sex hormones, semen parameters and sexual activity parameters at baseline (n = 93)
		ITT dataset (n = 100)					PP dataset (n = 93)
					2-sample t-test					2-sample t-test
	Treatment	N	Mean	SD	t	p	N	Mean	SD	t	p
Serum hormone levels
Testosterone (ng/dL)	ARE	50	492.11	297.27	-0.025	0.980	47	489.97	301.18	-0.058	0.954
	Placebo	50	493.49	241.99			46	493.30	249.75
Dihydrotestosterone (pg/mL)	ARE	50	354.80	231.86	0.055	0.956	47	360.73	237.10	-0.019	0.985
	Placebo	50	351.40	370.73			46	361.99	384.49
FSH (IU/L)	ARE	50	7.53	6.14	0.459	0.647	47	7.35	5.80	0.117	0.907
	Placebo	50	7.00	5.46			46	7.21	5.64
LH (IU/L)	ARE	50	6.31	4.22	-0.602	0.548	47	6.35	4.27	-0.583	0.561
	Placebo	50	6.81	4.16			46	6.87	4.31
Prolactin (ng/mL)	ARE	50	15.43	8.10	-0.256	0.799	47	14.93	7.84	0.204	0.839
	Placebo	50	15.89	9.54			46	14.61	6.94
Semen parameters
Semen volume (mL)	ARE	50	1.76	1.52	-0.593	0.555	47	1.74	1.57	-0.501	0.618
	Placebo	50	1.91	0.95			46	1.88	0.97
Sperm count (X10⁶ per mL)	ARE	50	21.72	21.43	0.497	0.620	47	21.25	22.16	0.319	0.751
	Placebo	50	19.53	20.35			46	19.73	21.14
Sperm number (X10⁶ per ejaculate)	ARE	50	41.53	45.62	0.074	0.941	47	40.45	47.15	-0.046	0.964
	Placebo	50	40.85	42.67			46	40.91	44.18
Sperm motility (%)	ARE	50	24.37	16.68	-0.685	0.495	47	23.60	16.39	-0.273	0.786
	Placebo	50	27.03	19.85			46	24.67	18.95
Semen pH	ARE	50	7.71	1.27	-0.460	0.647	47	7.65	1.30	-0.501	0.618
	Placebo	50	7.83	1.22			46	7.79	1.26
Sperm vitality (%)	ARE	50	33.79	21.33	-0.010	0.992	47	31.98	21.01	0.022	0.983
	Placebo	50	33.84	22.75			46	31.87	22.79
Sperm morphology (% normal)	ARE	50	20.48	15.53	0.522	0.603	47	19.60	15.75	0.288	0.774
	Placebo	50	18.49	20.16			46	18.43	20.50
Sexual Desire Inventory − 2
SDI-2 total Score	ARE	50	58.20	14.90	0.253	0.801	47	57.77	15.24	0.157	0.875
	Placebo	50	57.52	11.77			46	57.33	11.41
Satisfying sexual events (SSE in past 2 weeks)
No. of intercourses	ARE	50	6.40	5.57	0.244	0.808	47	6.57	5.69	0.262	0.794
	Placebo	50	6.12	5.89			46	6.26	5.84
No. of non-sexual intercourses	ARE	50	6.84	8.04	-0.355	0.723	47	7.15	8.17	-0.034	0.973
	Placebo	50	7.30	4.37			46	7.2	4.43
No. of orgasms	ARE	50	1.44	2.66	0.889	0.376	47	1.4	2.71	0.685	0.495
	Placebo	50	1.00	2.28			46	1.04	2.36
No. of satisfying sexual activities	ARE	50	3.96	3.68	0.022	0.982	47	4.06	3.74	-0.115	0.908
	Placebo	50	3.94	5.19			46	4.17	5.34
Level of Sexual desire	ARE	50	1.62	0.90	2.109	0.038	47	1.09	0.72	-0.014	0.989
	Placebo	50	1.26	0.80			46	1.09	0.59
IIEF
Erectile function	ARE	50	15.82	5.50	0.127	0.899	47	15.43	5.39	-0.147	0.883
	Placebo	50	15.70	3.80			46	15.57	3.58
Orgasmic function	ARE	50	5.84	2.16	0.000	1.000	47	5.83	2.19	-0.103	0.918
	Placebo	50	5.84	1.54			46	5.87	1.45
Sexual desire	ARE	50	5.80	1.43	-0.590	0.557	47	5.74	1.45	-0.411	0.682
	Placebo	50	6.00	1.93			46	5.89	1.96
Intercourse satisfaction	ARE	50	5.86	2.63	0.295	0.769	47	5.79	2.69	0.224	0.823
	Placebo	50	5.72	2.08			46	5.67	2.14
Total IIEF score	ARE	50	41.92	12.84	0.427	0.671	47	41.40	12.97	0.302	0.763
	Placebo	50	40.96	9.39			46	40.70	9.32
QoL
SF-12 total score	ARE	50	28.40	3.37	0.890	0.376	47	28.34	3.43	0.132	0.896
	Placebo	50	27.70	4.42			46	28.24	3.97
ARE: Ashwagandha root extract; PP: Per protocol; SD: Standard deviation; FSH: Follicle-Stimulating Hormone; ITT: Intent to treat; LH: Luteinizing Hormone; IIEF: International index of erectile dysfunction; ITT: Intent to treat; PP: Per protocol; QoL: Quality of life; SD: Standard deviation; SF-12: Short Form (12) Health Survey; SDI: Sexual Desire inventory.

Primary outcome

Greater improvement in the number of sexual events (p = 0.042), satisfying sexual events, orgasms, and sexual desire scores were observed with ARE compared to placebo (Fig. 2, Table 3).

Table 3

Change from baseline in serum sex hormones, semen parameters and sexual activity parameters in PP dataset (n = 93)
			Change from baseline		Mean Difference	95% C.I. of the difference		2-sample t-test
	Treatment	N	Mean	SD		Lower	Upper	t	p
Serum hormones (Week 8)
Serum testosterone (ng/dL)	ARE	47	70.46	242.05	120.13	27.18	213.09	2.567	0.012
	Placebo	46	-49.68	207.50
Dihydrotestosterone (pg/mL)	ARE	47	37.64	129.71	57.19	-64.99	179.36	0.930	0.355
	Placebo	46	-19.55	400.80
FSH (IU/L)	ARE	47	-0.19	1.70	-0.70	-2.18	0.79	-0.932	0.354
	Placebo	46	0.51	4.82
LH (IU/L)	ARE	47	0.29	2.21	1.12	-0.28	2.52	1.585	0.116
	Placebo	46	-0.83	4.29
Prolactin (ng/mL)	ARE	47	0.70	4.64	1.60	-0.31	3.50	1.663	0.100
	Placebo	46	-0.90	4.62
Semen parameters (Week 8)
Semen volume (mL)	ARE	47	0.45	0.93	0.50	0.16	0.85	2.906	0.005
	Placebo	46	-0.06	0.73
Sperm count (X10⁶ per mL)	ARE	47	6.83	25.14	4.88	-2.58	12.33	1.300	0.197
	Placebo	46	1.96	3.96
Sperm count (X10⁶ per ejaculate)	ARE	47	19.82	47.02	21.20	6.09	36.30	2.787	0.006
	Placebo	46	-1.38	21.40
Sperm motility (%)	ARE	47	8.87	19.46	4.95	-2.14	12.04	1.386	0.169
	Placebo	46	3.92	14.58
Semen pH	ARE	47	0.50	2.01	0.45	-0.14	1.05	1.518	0.133
	Placebo	46	0.04	0.29
Sperm vitality (% vital)	ARE	47	6.32	21.30	7.09	-0.21	14.38	1.930	0.057
	Placebo	46	-0.77	13.05
Sperm morphology (% normal)	ARE	47	4.33	12.33	6.13	1.75	10.51	2.779	0.007
	Placebo	46	-1.80	8.55
SDI-2 Total score
Week 2	ARE	47	7.83	14.59	6.11	0.27	11.95	2.078	0.040
	Placebo	46	1.72	13.75
Week 4	ARE	47	12.96	15.57	9.20	3.00	15.39	2.949	0.004
	Placebo	46	3.76	14.47
Week 8	ARE	47	20.89	17.88	14.63	7.67	21.59	4.176	< 0.0001
	Placebo	46	6.26	15.82
SSE
No. of intercourses
Week 2	ARE	47	2.09	4.02	2.23	0.56	3.9	2.658	0.009
	Placebo	46	-0.14	3.76
Week 4	ARE	47	3.7	3.92	0.92	-1.4	3.23	0.789	0.432
	Placebo	46	2.79	6.6
Week 8	ARE	47	8.25	6.03	2.75	0.11	5.39	2.068	0.042
	Placebo	46	5.5	6.3
No. of non-sexual intercourses
Week 2	ARE	47	-0.73	8.76	-3.25	-8.18	1.68	-1.311	0.194
	Placebo	46	2.52	13.8
Week 4	ARE	47	-0.57	7.11	0.27	-2.59	3.12	0.185	0.854
	Placebo	46	-0.83	6.15
Week 8	ARE	47	0.25	8.12	0.63	-2.53	3.79	0.397	0.693
	Placebo	46	-0.38	6.49
No. of orgasms
Week 2	ARE	47	0.27	3.76	0.15	-1.16	1.47	0.233	0.817
	Placebo	46	0.12	2.1
Week 4	ARE	47	2	3.22	0.48	-1.33	2.29	0.523	0.602
	Placebo	46	1.52	5.06
Week 8	ARE	47	4.82	6.61	2.34	-0.15	4.83	1.869	0.065
	Placebo	46	2.48	4.83
No. of satisfying sexual activities
Week 2	ARE	47	-0.52	5.31	-1.31	-3.32	0.7	-1.294	0.199
	Placebo	46	0.79	3.93
Week 4	ARE	47	0.55	5.61	-1.5	-3.85	0.84	-1.273	0.206
	Placebo	46	2.05	5.32
Week 8	ARE	47	4.39	7.23	0.7	-2.19	3.59	0.479	0.633
	Placebo	46	3.69	6.17
Level of Sexual desire
Week 2	ARE	47	0.8	1.13	0.2	-0.27	0.67	0.845	0.400
	Placebo	46	0.6	1.06
Week 4	ARE	47	0.93	0.97	0	-0.44	0.45	0.015	0.988
	Placebo	46	0.93	1.09
Week 8	ARE	47	1.23	0.77	0.32	-0.04	0.69	1.749	0.084
	Placebo	46	0.9	0.93
IIEF
Erectile function
Week 2	ARE	47	2.70	4.67	1.14	-0.98	3.25	1.067	0.289
	Placebo	46	1.57	5.58
Week 4	ARE	47	3.77	6.09	2.51	-0.20	5.21	1.836	0.070
	Placebo	46	1.26	7.04
Week 8	ARE	47	1.87	9.83	1.22	-2.34	4.78	0.680	0.498
	Placebo	46	0.65	7.24
Orgasmic function
Week 2	ARE	47	0.49	2.39	1.08	0.22	1.93	2.510	0.014
	Placebo	46	-0.59	1.68
Week 4	ARE	47	0.43	2.61	0.27	-0.84	1.38	0.489	0.626
	Placebo	46	0.15	2.78
Week 8	ARE	47	1.11	3.67	1.78	0.38	3.18	2.522	0.013
	Placebo	46	-0.67	3.11
Sexual desire (IIEF)
Week 2	ARE	47	0.83	1.97	0.83	-0.01	1.67	1.972	0.052
	Placebo	46	0.00	2.09
Week 4	ARE	47	0.77	2.00	0.53	-0.55	1.60	0.971	0.334
	Placebo	46	0.24	3.12
Week 8	ARE	47	1.81	2.14	2.31	1.20	3.42	4.118	< 0.0001
	Placebo	46	-0.50	3.17
Intercourse satisfaction
Week 2	ARE	47	0.83	2.68	-0.71	-1.76	0.33	-1.358	0.178
	Placebo	46	1.54	2.37
Week 4	ARE	47	1.72	3.53	0.46	-0.81	1.73	0.724	0.471
	Placebo	46	1.26	2.53
Week 8	ARE	47	1.68	3.32	0.62	-0.66	1.89	0.958	0.340
	Placebo	46	1.07	2.86
Total IIEF score
Week 2	ARE	47	5.79	9.21	2.85	-1.39	7.09	1.336	0.185
	Placebo	46	2.93	11.30
Week 4	ARE	47	7.21	14.25	4.13	-1.96	10.21	1.347	0.181
	Placebo	46	3.09	15.27
Week 8	ARE	47	7.55	22.51	6.34	-2.14	14.81	1.486	0.141
	Placebo	46	1.22	18.36
SF-12 Total score
Week 2	ARE	47	2.23	4.75	1.26	-0.79	3.30	1.218	0.226
	Placebo	46	0.98	5.19
Week 4	ARE	47	2.70	4.07	1.98	-0.04	4.01	1.948	0.055
	Placebo	46	0.72	5.64
Week 8	ARE	47	4.40	4.13	5.40	3.30	7.51	5.100	< 0.0001
	Placebo	46	-1.00	5.95
Note: Negative mean value indicates reduction, and positive value indicates increase in scores from baseline
ARE: Ashwagandha root extract; PP: Per protocol; SD: Standard deviation; FSH: Follicle-Stimulating Hormone; ITT: Intent to treat; LH: Luteinizing Hormone; IIEF: International index of erectile dysfunction; ITT: Intent to treat; PP: Per protocol; SD: Standard deviation; SF-12: Short Form (12) Health Survey; SDI: Sexual Desire inventory, QoL: Quality of life

Secondary efficacy outcomes

Table 3 presents the descriptives for the change from baseline for all parameters in the PP dataset. ARE therapy caused a greater increase (p < 0.05) in SDI-2 scores from baseline after 2, 4, and 8 weeks. Men receiving ARE treatment had greater improvements in the orgasmic function (OF) domain of IIEF (p = 0.013), sexual desire (SD) domain of IIEF (p < 0.0001), and SF-12 QoL scores (p < 0.0001) (supplementary material). ARE also led to a greater increase in semen volume (p = 0.005), sperm count per ejaculate (p = 0.007), and normal sperm morphology (p = 0.007) compared to placebo.

Safety outcomes

During the study period, none of the participants reported any adverse events. Table 4 presents the descriptives for data for hematological, hepatic, and renal parameters (baseline and change after 8 weeks) in PP dataset (n = 93). No differences were observed in any of the laboratory parameters with ARE and placebo at the end of the 8-week therapy.

Table 4

Hematological, hepatic and renal parameters (baseline and change after 8 weeks) in PP dataset (n = 93)
					Mean Diff.	95% C.I.		2-sample t-test
	Treatment	N	Mean	SD		Lower	Upper	t	p
Hb (gm/dL)
Baseline	ARE	47	10.20	1.33	-0.06	-0.61	0.49	-0.212	0.833
	Placebo	46	10.25	1.34
Change at week 8	ARE	47	0.09	0.34	-0.03	-0.17	0.11	-0.431	0.667
	Placebo	46	0.12	0.34
Creatinine (gm/dL)
Baseline	ARE	47	0.68	0.21	-0.08	-0.17	0.00	-1.993	0.049
	Placebo	46	0.76	0.19
Change at week 8	ARE	47	-0.07	0.08	-0.03	-0.06	0.01	-1.423	0.158
	Placebo	46	-0.04	0.10
BUN (IU/L)
Baseline	ARE	47	19.20	1.33	-0.06	-0.61	0.49	-0.212	0.833
	Placebo	46	19.25	1.34
Change at week 8	ARE	47	0.37	1.14	-0.36	-0.89	0.17	-1.358	0.178
	Placebo	46	0.73	1.42
Bilirubin Total (mg/dL)
Baseline	ARE	47	0.65	0.19	-0.01	-0.09	0.06	-0.335	0.739
	Placebo	46	0.66	0.17
Change at week 8	ARE	47	-0.07	0.07	-0.02	-0.06	0.01	-1.337	0.185
	Placebo	46	-0.05	0.09
Bilirubin Direct (mg/dL)
Baseline	ARE	47	0.21	0.13	0.00	-0.05	0.06	0.072	0.943
	Placebo	46	0.21	0.14
Change at week 8	ARE	47	0.01	0.07	0.02	-0.01	0.05	1.591	0.115
	Placebo	46	-0.01	0.06
Protein (gm/dL)
Baseline	ARE	47	7.98	2.03	-0.56	-1.43	0.31	-1.282	0.203
	Placebo	46	8.54	2.19
Change at week 8	ARE	47	-0.23	0.17	-0.04	-0.14	0.07	-0.686	0.494
	Placebo	46	-0.19	0.30
Albumin (gm/dL)
Baseline	ARE	47	4.82	1.02	-0.27	-0.71	0.16	-1.244	0.217
	Placebo	46	5.09	1.10
Change at week 8	ARE	47	-0.14	0.14	0.01	-0.07	0.08	0.201	0.841
	Placebo	46	-0.15	0.21
Globulin (gm/dL)
Baseline	ARE	47	3.16	1.02	-0.29	-0.72	0.15	-1.316	0.191
	Placebo	46	3.45	1.10
Change at week 8	ARE	47	-0.08	0.06	-0.04	-0.08	-0.01	-2.280	0.025
	Placebo	46	-0.04	0.11
A-G Ratio
Baseline	ARE	47	1.56	0.14	0.05	0.00	0.11	2.034	0.045
	Placebo	46	1.51	0.12
Change at week 8	ARE	47	0.00	0.04	0.03	0.01	0.04	2.776	0.007
	Placebo	46	-0.03	0.04
ALT (IU/L)
Baseline	ARE	47	30.00	1.33	-0.06	-0.61	0.49	-0.212	0.833
	Placebo	46	30.05	1.34
Change at week 8	ARE	47	0.38	1.15	-0.36	-0.89	0.17	-1.337	0.185
	Placebo	46	0.73	1.42
AST (IU/L)
Baseline	ARE	47	30.20	1.33	-0.06	-0.61	0.49	-0.212	0.833
	Placebo	46	30.25	1.34
Change at week 8	ARE	47	0.38	1.15	-0.36	-0.89	0.17	-1.337	0.185
	Placebo	46	0.73	1.42
ALP (IU/L)
Baseline	ARE	47	89.99	4.00	-0.18	-1.83	1.47	-0.212	0.833
	Placebo	46	90.16	4.01
Change at week 8	ARE	47	0.38	1.15	-0.36	-0.89	0.17	-1.337	0.185
	Placebo	46	0.73	1.42
Note: Negative mean value for change indicates reduction, and positive value indicates increase from baseline
ALP: Alkaline Phosphatase; ALT: Alanine Aminotransferase; ARE: Ashwagandha root extract; AST: Aspartate Aminotransferase; BUN: Blood Urea Nitrogen; C.I: Confidential interval; Hb: Haemoglobin; PP: Per Protocol; SD: Standard deviation.

We evaluated the efficacy and safety of an 8-week treatment with ARE in men attending an infertility clinic. One of the first studies of ARE (90-day treatment) was reported by Ambiye VR et al. (2013) in a randomized, placebo-controlled study involving 46 men with oligospermia (sperm count < 20 million/mL) ²⁸. This pilot study involved men with oligospermia, and significant improvements (p < 0.05) in semen parameters were seen to the extent of 167% for sperm count, 53% for semen volume, and 57% for sperm motility. Our study involved men with sperm counts on the lower side of the reference range, and we also observed a similar trend in the semen parameters after 8 weeks. With ARE the increase in semen volume was 25.56% (p = 0.005), the sperm count was 47.72% (p = 0.006), and the sperm vitality improved by 18.70% (p = 0.007). Few of the patients in our study visited for infertility treatment and had a low sperm count, as well as a low sexual function. Although the sperm count levels were lower in these men, the serum testosterone levels were normal, and there was no hormonal disruption in any of the men included in the study.

Sexual function and sexual satisfaction are two of the most important outcomes of the male and female sexual dysfunction studies. Although benefits of ARE for female sexual function and satisfaction have been reported, no study has been reported for men ²⁹. We observed improvements in sexual satisfaction and sexual activity, including the SDI-2 and IIEF scores, with 8-week ARE treatment. The oral administration of ARE has been previously reported to promote an increase in male testosterone among human participants, although the mechanisms still need to be explored. The results of this study provide additional evidence that ARE may be administered for therapeutic purposes without inducing deleterious effects on the fertility and reproductive health of males ³⁰. We also observed improvements in serum testosterone (p = 0.012), DHT, prolactin, FSH, and LH levels. A systematic review of the effects of Withania somnifera on the reproductive system by Nasimi R. et al (2018) reports that Ashwagandha improves reproductive system function by enhancing semen quality, enhancing enzymatic activity in seminal plasma, and decreasing oxidative stress ³¹. Ashwagandha also improves the FSH and LH balance, leading to folliculogenesis and an increase in gonadal weight.

In contradiction to our findings, a randomized placebo-controlled trial did not observe any difference between ashwagandha root extract (n = 41) and placebo (n = 45) for change in IIEF scores in men with psychogenic erectile dysfunction ¹⁵. The differences in the results could be due to the method of extract preparation and the lack of standardization of the end product. The ARE used in our study was the KSM-66 Ashwagandha, which uses a unique proprietary aqueous extraction process, based on “green chemistry” principles without using alcohol or any other chemical solvent. This extraction process yields the optimum percentage of withanolides, retaining the other important bioactives of the plant, which are required for the efficacy and safety of the herb. Psychological factors have an important role in sexuality and sexual satisfaction ¹. KSM-66 ashwagandha has a high withanolide content (> 5%), which helps fight stress by improving brain function, memory, and reproductive balance. It also makes the body more resistant to stress and boosts cell-mediated immunity. Hence, by virtue of its effects on stress, it may be beneficial for improving psychogenic sexual dysfunction.

A systematic review and meta-analysis described the results of 42 placebo-controlled clinical trials involving alternative medicines and herbal remedies in the management of erectile dysfunction (ED) ⁶ The authors concluded that Panax ginseng, Pygnogenol, Prelox, and Tribulus terrestris have promising evidence as herbal products, alongside L-arginine as a nutritional supplement, for ED based on IIEF outcomes, but need further exploration. Another meta-analysis of 2 trials on the efficacy of aspirin on erectile function in men with vasculogenic ED reported a significant improvement in erectile function with aspirin (mean difference: 5.14, 95% CI [3.89, 6.40], and I² = 0%). However, aspirin caused adverse events, and the overall quality of the evidence was moderate. Although vasodilators like sildenafil and tadalafil are widely used, they are associated with their share of adverse effects and a long list of contraindications. Hence, there is a dire need for a safe remedy to improve sexual function in both men and women.

Lack of sleep can lead to multiple disease conditions in an individual, and stress, anxiety, and sleep have an unavoidable relationship. Salve J. et. al. (2019) reported a significant reduction in the PSS scores with Ashwagandha 250 mg/day (p < 0.05) and 600 mg/day (p < 0.001) ¹².^{Error! Bookmark not defined.} Compared to the placebo group participants, the participants receiving Ashwagandha had a significant improvement in sleep quality. Stress is one of the most common causes of subpar sexual performance and diminishing sex drive. Stress adversely affects sexual function. As an adaptogen, Ashwagandha significantly helps to manage stress by reducing the concentration of stress hormones in the blood. Thus, this stress-managing effect of Ashwagandha makes a direct contribution to sexual health. Additionally, ARE enhances overall energy, stamina, and endurance. Stress can interfere with sexual function and cause ED ³². Thus, the ashwagandha herb might initially aid in lowering stress levels. In our study, we also observed improvements in QOL with ARE treatment, suggesting that Ashwagandha could potentially have benefits for stress and infertility.

The safety of ARE is established through various published clinical studies in humans.^33–35 Animal studies have also reported the safety of ARE for reproductive organs and fetuses. In a recent study, the No Observed Adverse Effect Level (NOAEL) of ARE was 2000 mg/kg body weight/day in rats after repeated oral administration for 90 days (Kalaivani et al., 2023).³⁴ Langade D. et al. (2023)³⁵ reported that with 28-day repeated dose administration, ARE does not show any major abnormality in rats with doses up to 5 times the recommended human dose. These findings substantiate the safety of ashwagandha root extract.

The most consistent positive finding of the present study was an improvement in orgasm, sexual desire, and intercourse satisfaction. Beyond its myriad other benefits, ARE boasts a historical legacy of enhancing sexual health, spanning thousands of years. This herbal remedy holds significant potential for elevating overall health and well-being, serving as a general tonic for the same purpose. Furthermore, ashwagandha's capacity to enhance neuromuscular endurance, mental and physical resilience, and tissue viability makes it a recommended complementary treatment in various psychosomatic disorders. The strengths of this study include its double-blind design and use of validated outcome measures.

Limitations

The limitations of the study were the relatively small sample in a controlled environment with the inclusion of healthy men. However, the real-world scenario could be different. Many participants in the study had a lack of awareness and education about sexual activity and sex. Further real-world evidence-based research will confirm these findings in larger and more diverse populations.

The study observed noteworthy enhancements in the sexual activity scores and semen parameters with 8-week oral administration of Ashwagandha root extract in healthy men visiting the infertility center. Furthermore, a substantial improvement has been observed in the scores of both the SDI-2 and the IIEF, specifically for orgasmic function (OF) and sexual desire (SD) domains, and satisfaction with sexual activity. Ashwagandha root extract was well tolerated with no adverse events reported by the participants, and no changes in hepatic and renal parameters in blood.

URL for the datafile on figshare. https://doi.org/10.6084/m9.figshare.27200847.v2

Acknowledgements

The authors thank Ixoreal BioMed Inc., Los Angeles, California, USA, for supplying the KSM- 66 ashwagandha root extract used in the study. We would like to acknowledge all the study investigators for conducting the study. Writing and editorial support by Clinsearch Healthcare Solutions Pvt. Ltd Thane, Maharashtra.

Data availability

The data that support the results of this study or protocol are available from the corresponding author upon reasonable request.

Author contribution

Amit Shrenikraj Mutha

Study planning, clinical assessments, data collection, manuscript review

Amit Shashikant Beldar

Clinical assessments, data collection, manuscript preparation

Alok Mahendra Mulay

Clinical assessments, data collection

Anupama Hem Tanuja

Clinical assessments, data collection

Sonali Amit Mutha

Clinical assessments, data collection, manuscript preparation

Deepak Langade

Study planning, data analysis, manuscript review

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

The ethical approval was taken from Institutional Ethics Committee (DYP/IEC/14/2022; dt. 26-08-2022). The study was registered with the clinical trials registry of India [# CTRI/2022/09/045646; dt: 19/09/2022)

Competing Interests

There were no competing financial interests in relation to the work described.

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The authors declare no competing interests.

Efficacy and Safety of Eight-Week Therapy with Ashwagandha Root Extract in Improvement of Sexual Health in Healthy Men: Findings of a Prospective, Randomized, Double-Blind, Placebo-Controlled Study

Status:

Version 1

Abstract

Figures

Introduction

Materials and Methods

Study design and setting

Study participants

Randomization and blinding

Interventions

Primary outcome

Secondary outcomes

Study assessments

Satisfying Sexual Events (SSE)

Sexual Desire Inventory 2 (SDI-2)

International Index of Erectile Dysfunction (IIEF)

Short Form 12 (SF-12)

Semen analysis and laboratory tests

Statistical analysis

Results

Baseline data

Primary outcome

Secondary efficacy outcomes

Safety outcomes

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1