Infertility is a complicated problem with physiologic, psychologic, and economic aspects. Infertility is defined as the inability to conceive after one year of unprotected sexual intercourse [
The causes of male infertility are classified as pretesticular, testicular, posttesticular, and unknown. Sperm abnormality causes 30%–40% of all infertility [
Different etiologies of female infertility include ovarian diseases, tubal disorders, endometriosis, uterine pathologies, cervical problems, congenital anomalies, and dysfunction of the hypothalamus-pituitary-ovarian axis and systemic diseases [
WS has been recommended for management of polyarthritis, lumbago, painful swellings, premature ejaculation, oligospermia, plague, asthma, vitiligo, general debility, impotency, ulcers, uterine infection, leucorrhoea, hemorrhoid, and orchitis in traditional Persian medicine [
In this systematic review which was performed in 2016, required data were gathered using databases such as Google Scholar, PubMed, Scopus, Web of Science, and Cochrane Library. The keywords used in present study were “
To search for unpublished articles (grey literature), European Association for Grey Literature Exploitation (EAGLE) and Health Care Management Information Consortium (HMIC) were searched.
The selected papers extracted from the databases were assessed by two investigators using Consort 2010 checklist. Discrepancies between the two raters were referred to the third investigator. First, the titles of all articles were reviewed to screen for eligibility and those found to be irrelevant with the objectives of the study were excluded from the study. In the later stages, the abstracts and full-text articles were, respectively, examined to identify and exclude those that did not match the inclusion.
One reviewer extracted the data from the included studies while a second author checked the results. Any disagreements were resolved by a discussion of reviewers. Data for the primary objective of the review was collected from the full text of each publication and included the trial name, year of publication, type of study, sample size, results, and other characteristics.
Statistical analysis was performed by SPSS software package version 16.0 for windows (SPSS Inc., Chicago, USA) [
The flowchart of the study is shown in Figure
Characteristics and results of human studies investigating effects of
Number | Author/year | Design | Participant | Intervention protocol | Duration | Results | Place | Part/ |
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(1) | Mahdi et al., 2011 [ | Controlled, prospective, | Normozoospermic infertile men ( | 5 g/d/PO/single dose with milk | 3 months | No marked change in semen volume, | India | Root powder |
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(2) | Ambiye et al., 2013 [ | Double-blind, randomized, placebo-controlled clinical trial (a pilot study) | Oligospermic infertile male ( | 675 mg: 1 capsule of 225 mg/thrice a day/PO | 90 days | ↑ 53% semen volume, ↑ 167% sperm count, ↑ 57% sperm motility ( | India | Full spectrum |
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(3) | Dongre et al., 2015 [ | Double-blind, randomized, placebo-controlled clinical trial (a pilot study) | Healthy married women ( | Capsules of 300 mg/ | 8 weeks | ↑ total score (FSFI) ( | India | High-concentration root water extract |
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(4) | Mamidi et al., 2014 [ | Randomized, single-blind, placebo-controlled, parallel-group study | Men with ED ( | Four tablets 500 mg thrice a day (6 g)/PO after food | 60 days | ↑ 10.52% on EDSI, ↑ 4.18% on IMHQOL, ↑ 39.22 on QEQ in WS group, ↑ 11.20% on EDSI, ↑ 5.95% on IMHQOL, ↑ 45.74% on QEQ ( | India | Root powder |
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(5) | Shukla et al., 2011 [ | Controlled, prospective, | Infertile men ( | 5 g/day/single dose with milk | 3 months | | India | Root powder |
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(6) | Gupta et al., 2013 [ | Controlled, prospective, before and after clinical trial | Infertile men ( | 5 g/day/PO/ | 3 months | ↑ sperm concentration, ↑ sperm motility, ↓ LPO, ↑ LH, ↑ T ( | India | Root |
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(7) | Ahmad et al., 2010 [ | Controlled, prospective, before and after clinical trial | Infertile men ( | 5 g/day/PO with milk | 3 months | ↑ sperm concentration, ↑ sperm count ( | India | Root |
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(8) | Mamidi and Thakar, 2011 [ | Randomized, single-blind, placebo-controlled, parallel-group study | Men with ED ( | Four tablets 500 mg/PO/thrice a day after food | 60 days | ↑ 12.6% IIEF in WS-treated and ↑ 19.11% in placebo group ( | India | Root powder |
ND, not determined; WS,
Characteristics and results of animal studies investigating effects of
Number | Author/year | Plant extract | Participant | Intervention protocol | Duration | Results | Place |
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(1) | AL-Qarawi et al., 2000 [ | Lyophilized aqueous extract | Immature female Wistar rats ( | 47 mg/100 g body | 6 days | In 25-day-old rats; ↑ FSH levels ( | Kingdom of Saudi Arabia |
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(2) | Mali et al., 2008 [ | 50% ethanolic extract | Fertility proven, adult healthy male albino rats | 50 mg/kg/PO/day | 60 days | ↓ sperm motility, ↓ density of testicular and cauda | India |
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(3) | Belal et al., 2012 [ | Root power | Adult male albino rats ( | Mixed with basal diet at ratio of 6.25%/po | 4 weeks | No significant alteration estrogen and cholesterol in treated with WS both diabetic and nondiabetic rats compared to controls groups ( | Egypt |
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(4) | Ilayperuma et al., 2002 [ | Methanolic extract of roots | Proven fertility, adult male Wistar rats ( | 3000 mg/kg/PO/day | 7 days | Considerable weakness in libido, sexual performance, sexual vigour, and penile erectile dysfunction, no marked change in SGOT, SGPT, urea nitrogen, pH of the seminal vesicular fluid, wet weight of the organs and no deaths in treated period | Sri Lanka |
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(5) | Abdel-Magied et al., 2001 [ | Lyophilized aqueous extracts of leaves | Immature male Wistar rats ( | 47 mg/100 g body weight/d/stomach tube | 6 days | ↑ LH, | Saudi Arabia |
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(6) | Dhas et al., 2015 [ | Ethanolic | Female and male fish ( | 120-200-300 mg/kg WS | ND | ↑ Gonadosomatic Index (GSI), ↑ fecundity, ↑ striping response, ↑ percentage of fertilization, ↑ percentage of hatching, | India |
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(7) | Shaikh et al., 2015 [ | Glycowithanolides extract of fresh leaves | Adult Swiss albino male mice ( | 20 mg/kg/injected subcutaneously | 20 days | ↑ epididymal sperm count ( | India |
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(8) | Kumar et al., 2015 [ | Ethanolic root extract | Males Charles Foster rats ( | 100 mg/Kg/PO/day | 30 days | ↑ sperm count, ↑sperm motility, ↑ T, | India |
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(9) | Walvekar et al., 2013 [ | Glycowithanolides extract of fresh leaves | Adult Swiss albino male mice ( | 20 mg/kg injected subcutaneously | 20 days | | India |
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(10) | Kumar et al., 2015 [ | Alcoholic root extract (5)% | Female Swiss albino mice; chlorpyrifos induced toxicity ovaries; 4 groups: control, chlorpyrifos, WS, | 50 mg/kg/day | 8 weeks | ↓ estrogen, ↓ cholesterol and restoration in germinal epithelium, graafian follicles and corpus luteum of ovary in WS-treated group compared to chlorpyrifos group | India |
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(11) | Patil et al., 2012 [ | Ethanolic extract of fresh leaves | Healthy male albino mice ( | 2% extract | 15 days | ↓ total and mitochondrial LPO, | India |
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(12) | Rajashree et al., 2011 [ | Alcoholic root extract | Male albino rats ( | 500 mg/kg/PO/day | 30 days | | India |
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(13) | Kiasalari et al. 2009 [ | Root | Wistar male rats ( | Plant-mixed pelleted food at ratio of 6.25%/po/day | 4 weeks | ↓ FSH ( | Iran |
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(14) | Rahmati et al., 2016 [ | Root powder | Male rats ( | Plant-mixed pelleted food at ratio of 6.25% | 21 days | | Iran |
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(15) | Prabu et al., 2014 [ | Hydroalcoholic root extract | Male Wistar rats ( | 1000 mg/kg/PO (gavage) | 70 days | ↓ WBC, ↓ LYM values ( | India |
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(16) | Bhargavan et al., 2015 [ | Ethanolic root extract | Healthy adult male Wistar rats ( | 200 mg/PO/day | 28 days | | India |
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(17) | Nirupama and Yajurvedi, 2015 [ | Chloroform and ethanolic extracts of roots | Adult male rats ( | 10 mg/kg/day/orally (intubation) | 1 month | | India |
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(18) | Kumar et al., 2013 [ | Alcoholic extract of root | Female Swiss albino mice ( | 50 mg/kg/day | 8 weeks | ↓ estrogen and cholesterol ( | India |
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(19) | Kumar et al., 2012 [ | Aqueous extract of roots | Male mice ( | 1000 mg/kg/day | 8 weeks | ↓ MDA, | India |
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(20) | Kaspate et al., 2015 [ | Hydroalcoholic extract of roots | Healthy female Wistar rats with tubal ligated ( | 100, 200 and | 21 days | | India |
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(21) | De and Chakraborty, 2016 [ | Root powder | Mixed-sex juveniles of | 0.0, 2.0, 3.0, 3.5, 5.0, 6.5, 7.0, 8.0, 9.5 g/kg mixed food | 30 days | Concentrations up to 7.0 g/kg have no side effect ( | India |
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(22) | Jasuja et al., 2013 [ | Methanolic extract of leaves and roots | Male albino rats ( | 100 mg/kg/PO/day | 15–30 days | ↓ testicular LPO, | India |
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(23) | Saritha et al., 2011 [ | Leaf powder-mixed pelleted food | Female rats ( | 500 mg/kg/PO/day | 45 days | ↓ length of the diestrus phase ( | India |
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(24) | Garg and Parasar, 1965 [ | Root power | Albino mice of either sex ( | 25 mg/PO/day | 10 days | ↓ fertility rate by 25%, ↓ mating behavior, ↓ number of pups per litter from 5.25 to 3.0 in WS treatment group compared to control group | India |
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(25) | Sahin et al., 2016 [ | Hydroalcoholic extract of roots | Male rats ( | 300 mg/kg/PO/day | 8 weeks | No significant changes in body weight and reproductive organ weights, abnormal sperms, serum biochemical and hematology parameters ( | Turkey |
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(26) | Shaikh et al., 2014 [ | Glycowithanolides extract of fresh leaves | Adult Swiss albino male mice ( | 20 mg/kg/injected subcutaneously | 20 days | | India |
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(27) | Saiyed et al., 2016 [ | Hydroalcoholic extract of roots | Female Wistar rats ( | 198 mg/kg | 28 days | | India |
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(28) | Mali, 2013 [ | Hydroalcoholic extract | Healthy, male albino rats ( | 200 mg/kg/day/po | 60 days | ↓ primary and secondary spermatocytes, mature sperms, ↓ weight of testis and other accessory reproductive organs, | India |
ND, not determined; WS,
Characteristics and results of animal-plant and cellular studies investigating effects of
Number | Author/year | Type of study | Participant | Intervention protocol | Plant/extract | Duration of studies | Results | Place |
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(1) | Bhattarai et al., 2010 [ | In vitro | GnRH neurons of male and female juvenile mice brain ( | Bath application of the 400 ng/ | Methanolic extract of root powder | ND | Production of potent membrane depolarization of the GnRH neurons, ↑ spontaneous action potentials, ↑ | Republic of Korea |
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(2) | Kataria et al., 2015 [ | In vitro & in vivo | Rat hypothalamic GnV-3 cells & Wistar adult male rats ( | In vitro: 0.05–1.5% ASH-WEX | Aqueous extract of leaves | 24 h & 21 days | In vitro: significant changes in morphology and physiological in GnV-3 as cell body size and neurite process, ↓ LDH levels at higher concentrations of WS, ↑ release of GnRH extra cellularly in the GnV-3 cells after treatment with WS, no elevated cytotoxicity, viable of 61.2% of cell after WS | India |
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(3) | Singh et al., 2013 [ | In vitro & in vivo (animal) | Rat semen & proven fertility, male albino rat ( | 2, 4, 6, 8, 10, 25 & 50 mg/kg/day/orally | Ethanolic extract of stems | 20 s & 60 days | In vitro: minimum effective concentration of WS to kill 1 million sperm in 20 s was around 10 ± 0.066 | India |
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(4) | Ganu et al., 2010 [ | In vitro & | Healthy male rats ( | 1 mg/ml & 100, 200, 400 mg/kg/PO | Aqueous extract of roots | 28 d | ↑ sperm count in all groups ( | India |
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(5) | Prithiviraj et al., 2013 [ | In vitro & in vivo (animal) | Male Wistar albino rats ( | 300 mg/kg dissolved in 2% gum acacia /gavage | Root power | 30 days | ↑ SOD ( | India |
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(6) | Kyathanahalli et al., 2014 [ | In vitro & in vivo (animal) | Prepubertal male rats ( | 500 | Aqueous root extract | 15 days | In vitro: considerable inhibition of deoxyribose and stable free radical DPPH | India |
ND, not determined; WS,
Flowchart of the systematic review process searching for studies investigating
Many phytochemicals have been extracted from WS, which includes alkaloids, flavonoids, steroidal lactones, saponins, neurotransmitters, essential and nonessential fatty acids, ergostane, and gamma amino butyric acid; of all these components, alkaloids, and withanolids such as withaferin A, withanosides, sitoindosides, beta-sitosterol, and various amino acids like alanine have more prominent effect on fertility status [
In animal studies, WS is known to have gonadotropic function which increases gonadal weight by growthing follicles size in female and also increasing seminiferous tubular cell layers in male animals [
In a study by Shukla et al. about effects of WS on men, WS root powder was used for 3 months and it was shown that sperm parameters such as count and motility in sperm analysis had improved due to decrease apoptosis and reactive oxidative stress among men with normospermia and oligospermia; also copper, zinc, iron, and gold ions of seminal plasma had increased after the treatment and subsequently semen quality increased. This increase in semen quality is proposed to be due to the increase in essential neurotransmitters, metallothionein which has antioxidative function, and metal ions as cofactors for essential enzymes [
In two clinical trials, the effects of 5 grams of WS root for 3 months on semen parameters of infertile men were investigated. Improvement in semen quality, increased vitamins E, C, and A, and increased fertility were reported which is proposed to be due to the high amount of alkaloids, ergostane steroids, and essential amino acids in WS which improved detoxification, decreased oxidative stress, and restorated testosterone secretion [
In another human study, treatment by WS aqueous extract in married healthy women increased their sexual function index and diminished sexual distress index statistically significant [
In a study by Bhattarai et al. about effects of WS root extract, it was found that GABA mimetic features of this extract led to an increased activity of gonadotropin releasing hormone secreting neurons [
Prabu et al. in a study on male rats found that hydroalcoholic WS root extract was found to decrease white blood cell and lymphocyte counts in blood, but no considerable effect on reproductive indices [
WS leaves and roots have been found to improve oxidative stress indices such as an increase in superoxide dismutase, catalase, glutathione, lactate dehydrogenase, alanine, glutamine, phenylalanine, and decrease in cortisol and fructose [
In a study investigating effects of 6.5 mg of WS root extract on
Traditional and complementary medicine have been more popular nowadays to cure health related conditions [
Based on the present study, it was shown that extracts of WS fruits, leaves, stems, and especially roots enhance sperm quality indices such as motility and count in men [
The mechanism of WS effect on the reproductive system is not known entirely yet, but this mechanism is proposed to be linked to the antioxidative features and ability to improve the hormonal balance of LH, FSH, and testosterone and improve detoxification process. Also, the GABA mimetic feature of WS extract is thought to play the main role in inducing gonadotropin releasing hormone secretion and improving hormonal balance [
Based on the results, it deems that
The authors declare that they have no conflicts of interest.
This research was supported by Tabriz University of Medical Sciences and presented as a Ph.D. thesis (Ramin Nasimi Doost Azgomi, no. 3) at School of Traditional Medicine, Tabriz University of Medical Sciences.