E-ISSN:2456-3110

Case Report

Klaibya

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 4 April
Publisherwww.maharshicharaka.in

Ayurvedic management of Klaibya - Case Study

Barman J.1*, Rout S.2, Kumar Moharana P.3
DOI: http://dx.doi.org/10.21760/jaims.8.4.39

1* Jaykrishan Barman, Post Graduate Scholar, Department of Kayachikitsa, Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarethpet, Chennai, Tamil Nadu, India.

2 Suvendu Rout, Professor and HOD, Department of Kayachikitsa, Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarethpet, Chennai, Tamil Nadu, India.

3 Pradeep Kumar Moharana, Professor, Department of Kayachikitsa, Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarethpet, Chennai, Tamil Nadu, India.

Impotency means a man who is unable to perform sexual intercourse, being powerless and unable to carry out sexual activities. The male sexual dysfunctions have been elaborately described as Klaibya in Ayurvedic classics. In clinical practices Klaibya is the most common psychosexual disorders. It refers to a problem during any phase of the sexual cycle that restricted the man from experiencing satisfaction from the activity. Now days the incidence of sexual dysfunction is increases due of age, sedentary life style, unhealthy foods etc. About 5% of 35 years old men and between 15% and 25% of 50 years old men experience sexual dysfunctions. Vajikarana, branch of Ashtanga Ayurveda is deals with fertility, potency and healthy progeny. In this branch diagnosis and management of infertility and Sexual dysfunction are dealt in detail.

Keywords: Chandraprabha Vati, Klaibya, Kapikacchu Churna, Mustadi Yapan Basti, Oligoasthenozoospermia

Corresponding Author How to Cite this Article To Browse
Jaykrishan Barman, Post Graduate Scholar, Department of Kayachikitsa, Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarethpet, Chennai, Tamil Nadu, India.
Email: 		Jaykrishan Barman, Suvendu Rout, Pradeep Kumar Moharana, Ayurvedic management of Klaibya - Case Study. J Ayu Int Med Sci. 2023;8(4):230-238.
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https://jaims.in/jaims/article/view/2300

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-02-22 2023-02-24 2023-03-03 2023-03-10 2023-03-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2023by Jaykrishan Barman, Suvendu Rout, Pradeep Kumar Moharanaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Barman J et al: Ayurvedic management of Klaibya Case Study

Introduction

Vajikarana is branch of Ashtanga Ayurveda deals with fertility, potency and healthy progeny.[1] In this branch diagnosis and management of infertility and Sexual dysfunction are deals in detail.[2] The male sexual dysfunctions have been elaborately described as Klaibya[3] in Ayurvedic classics. The word Klaibya in Vajikarana refers to impotence i.e., a man who is unable to perform sexual intercourse, being powerless, helpless or the inability to carry out sexual activities.[4]

It basically includes sexual desire disorders, sexual arousal disorders or erectile disorders, orgasm disorders and sexual pain disorders. Sukradhatu is the final tissue element produced from the progressive metabolic transformation of Annarasa.[5 It is responsible for Bala (strength), Varna (color) and Upacaya in both male and female and by this it can be presumed that probably the whole endocrine system with special reference to hypothalamic hypophyseal gonadal hormones can be included under the term Sukra. Sukra is that substance which is responsible for systemic body activities especially regeneration, reproduction, metabolism and tends to impart vigor and energy, and part of it comes out of the body at the time of sexual act and performs the specific function of reproduction.[6] Therefore Shukra is responsible for conception and any defect in Shukra leads to Klaibya. The process of erection and ejaculation is a complex phenomenon which covers both the psycho behavioral and physical aspects of sexual physiology or expression. Sankalpa (determination) is the mental preparation for the sexual act without this the further stage of sexual responses are not possible. Further sexual acts, Pidana i.e., Specific stimulation of the genital parts are also determined by Manas, and then only the acts are proceeded. So, any defective determination or making by Manovikaras will not keep the sexual thoughts and feelings intact. This is the first phase arousal defect of copulation or ejaculation because the ejaculation is strictly depending upon this phase.

After Sankalpa, Cesta and Pidana the Sarva Sarirasrita Sukra and Manas are stimulated simultaneously.[7] Therefore any of the defective coordination due to functional deficit of Manas also causes sexual dysfunctions in the form of erectile dysfunction and premature

ejaculation. Krodha, Soka, Bhaya, Ajnana, Moha etc. are the Manovikaras and Alpa Sattva are the causes of the genesis of Klaibya. The external injuries, ageing, chronic debilitating disease, alcohol, endocrine abnormalities will directly show their effect on Manas. These are a few examples to show the Manas as a cause for Klaibya and it will in turn affect the Manas simultaneously. The classification of Klaibya according to Acharya Charaka has classified Klaibya into 4 types[8] viz Dhwajabhangaja, Bijopaghataja, Sukra Kshayaja and Jaraja while Acharya Sushruta has classified the same into 6 types[9] viz Manasa, Saumya Dhatukshaya/Pittaja, Sukra Kshayaja, Medrarogaja, Sahaja and Sthira Sukranimittaja, and Bhavaprakasha, Klaibya has been classified into 7 types[10] viz Manasa, Pittaja, Shukrakshayaja, Medhrorogaja, Upaghataja, Shukrastambhaja and Sahaja.

General Symptoms of Klaibya

A person’s persistent inability to perform sexual act even with the beloved, willing and submissive partner affecting the desire and capacity to perform sexual act due to difficulty in erection, non-erection or flaccidity of penis associated with tachypnea, perspiration, exhaustion, difficulty and or cessation of ejaculation where the efforts remain to fail is called the general symptoms of Klaibya.[11]

Different types of Klaibya quoted by Acharyas

  • Dhvajabhangaja and Medhrarogaja Klaibya are due to inflammatory disease of the Penis.
  • Bijophagataja Klaibya is due to abnormality in the sperms.
  • Jaraja Klaibya is due to decreased levels of serum testosterone in old age i.e. Andropause or Male menopause.
  • Sukrakshayaja Klaibya is due diminution of semen as a result of various Aharaja, Viharaja and Manasika
  • Sukrasthambaja Klaibya is due to prolonged sexual abstinence.
  • Sahaja Klaibya (congenital impotence) i.e., defects due to various chromosomal abnormalities.
  • Manasika Klaibya is the (psychogenic impotence) is due to various Manasika Vikaras and

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  • Marmachedaja Klaibya (impotence due to damage to the vital parts) is a result of pelvic fracture, Pelvic surgery etc.

Case

Presenting Concern: A 35-year male diagnosed with Oligoasthenozoo-spermia presented in outpatient department of Kayachikitsa in Sri Jayendra Saraswathi Ayurveda College and Hospital, Nazarethpet, Chennai-600123, with a desire of child. Patient has a married life of 7 years. Since 5-year couple tried to conceive but failed. Complaints of weakness, erectile dysfunction and early ejaculation also presented (Table 1).

Table 1: Timeline of the case

SN Complaints Duration
1. Unable to conceive 5 years
2. Weakness 1.5 years
3. Problem in erection 3 years
4. Early ejaculation 3.5 years

Past H/o: He had no history of diabetes, bronchial asthma, T.B and hypertension.

Family H/o: No family history of diabetes, hypertension, Bronchial asthma and T.B.

Addiction H/o: He had no addiction history of smoking, tobacco and alcohol.

Semen analysis report

Table 2: Previous semen analysis report

SN Test Result
1. Color White
2. Reaction Alkaline
3. Volume 0.5 ml
4. Count 13 million
5. Pus cells Nil

Diagnostic criteria: Diagnosis will be made on the basis of symptoms given in ancient text and modern literature. Laboratory investigation and clinical finding shall be considered for making diagnosis for Shukra Kshaya. As defined by the World Health Organization (WHO) in 2021, low sperm count indicated if less than 39 million sperm/ml and low motility indicated if less than 42%.

Shukra Kshaya Lakshana [12]

1. Durbalata (General debility)

2. Pandutavam (Pallor)

3. Sadan (Bodyache)

4. Sharm (Tiredness)

5. Mukha Sosha (Dryness of mouth)

6. Medha Vrishana Vedna (Pain in penis and Scrotum)

7. Dhumayativa (Burning in penis and Urethra)

8. Chirat Praseka or Alpa-Rakta-Yukta Shukra Pravritti or Shukra Avisarga (Delayed or blood mixed or no ejaculation)

9. Maithune Ashakti (Problematic or not satisfactory coitus)

10. Klaivya (Impotence)

Clinical finding

General Examination and Personal history: General Condition of the patient was good. No deviation in vital signs. He is Hindu of Indian ethnicity. He had a moderate appetite, Normal bladder, bowel habit and regular sleep pattern. He had a sedentary life style, well-built and well nourished. He had BMI 26.6 and waist circumference 102 cm. His Prakruti was Kaphaja Vataja Dominant and Sarata was Mansa-Meda Sarata. He had Madhyam Satva.

Clinical Investigation: Investigation was carried out before intervention like routine haematological test complete blood count (CBC), liver function test (LFT), Kidney function test (KFT), lipid profile, blood sugar FBS and PPBS, urine routine and microscopic all investigation was under normal range.

Table 3: Therapeutic intervention

Internal

SN Medicine Dose Anupana Time of administer
1. Gandharvasthadi Kashayam 15 ml/twice Warm water Before food
2. Chandraprabha Vati 1 tab/twice With Kashaya Before food
3. Stresscom 1 cap/once Water Bed time
4. Kapikacchu Churna 3 gms/thrice Milk After food

External

SN Treatment Medicine Duration
1. Abhyangam Mahanarayan oil 3 days
2. Nadi Sweda - 3 days
3. Virechana Trivrit Lehyam (40gm) + Triphala Kashaya (50ml) + Draksha Kashaya (50ml) 1 day
4. Sastika Shali Pinda Sweda (SPSS) - 8 days
5. Mustadi Yapan Basti (Kashaya Basti) Honey - 200gm, Saindhava lavana - 15gm, Sneha (Ksheeribala oil - 100ml + Sukumara Ghritam - 100ml), Kalka Dravya (Yastimadhu - 15gm + Satapuspa - 15gm), Kashaya (Musta - 25gm), 3 days
6. Matra Basti Ksheeribala oil - 50ml + Sukumara Ghritam - 50ml) 5 days

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Date Treatment Treatment procedure Observation
18/10/22 Abhyangam Nadi Sweda Abhyangam with Mahanarayan oil followed by Nadi Sweda Not specific was found
19/10/22 Abhyangam Nadi Sweda Abhyangam with Mahanarayan oil followed by Nadi Sweda He was feel lightness of body.  
20/10/22 Abhyangam Nadi Sweda Abhyangam with Mahanarayan oil followed by Nadi Sweda He was feel lightness of body.
21/10/22 Virechana Trivrit Lehyam + Triphala Kashaya + Draksha Kashaya Patient Virechana medicine taken at 7:30 am Total Vegas came- 10
22/10/22 Abhyangam Nadi Sweda Abhyangam with Mahanarayan oil followed by Nadi Sweda Advice Samsarjan Karma
23/10//22 SPSS Matra Basti Shastika Shali Pinda Sweda Ksheeribala oil + Sukumara Ghritam Matra Basti was given at 2:00 pm. Total Vegas came- 2
24/10/22 SPSS Kashaya Basti Shastika Shali Pinda Sweda Mustadi Yapan Basti Mustadi Yapan Basti was given at 11:00 am. Total Vegas came- 3
25/10/22 SPSS Matra Basti Shastika Shali Pinda Sweda Ksheeribala oil + Sukumara Ghritam Matra Basti was given at 2:00 pm. Total Vegas came- 1
26/10//22 SPSS Kashaya Basti Shastika Shali Pinda Sweda Mustadi Yapan Basti Mustadi Yapan Basti was given at 11:00 am. Total Vegas came- 4
27/10/22 SPSS Matra Basti Shastika Shali Pinda Sweda Ksheeribala oil + Sukumara Ghritam Matra Basti was given at 2:00 pm. Total Vegas came- 2
28/10/22 SPSS Kashaya Basti Shastika Shali Pinda Sweda Mustadi Yapan Basti Mustadi Yapan Basti was given at 11:00 am. Total Vegas came- 2
29/10/22 SPSS Matra Basti Shastika Shali Pinda Sweda Ksheeribala oil + Sukumara Ghritam Matra Basti was given at 2:00 pm. Total Vegas came- 1
30/10/22 SPSS Matra Basti Shastika Shali Pinda Sweda Ksheeribala oil + Sukumara Ghritam Matra Basti was given at 2:00 pm. Total Vegas came- 2

Assessment Criteria: Assessment shall be made by the improvement on the subjective and objective parameters before and after treatment on Shukra Dhatu.

Subjective Parameters: The main symptoms of Shukra Kshaya (Chaturvedi Gorakhnath et.al, 2009; Shashtri Ambikadutta.2008; Kaviraj Atridev Gupt, 2011) shall be given grading which will be assessed.

Objective Parameters

1. Semen Analysis Report

2. Biomarker Analysis (Serum FSH, Serum LH, Serum Testosterone, Serum Inhibin-B).

Results

There was marked improvement in sperm count (Table 5) as well as sperm motility after the treatment. Patient showed marked improvement in signs and symptoms of Shukra Kshaya and Klaivya as per the classics (Table 4) and modern parameters. There was marked improvement in serum testosterone & serum Inhibin-B level after the treatment in this case. Level of serum LH decreased after treatment (Table 6).

Table 4: Patient showed marked improvement in signs and symptoms of Shukra Kshaya and klaivya as per the classics.

SN Lakshana Before treatment After Treatment
1. Durbalata (General debility) 4 1
2. Pandutavam (Pallor) 3 1
3. Sadan (Bodyache) 2 2
4. Sharm (Tiredness) 4 2
5. Mukha Sosha (Dryness of mouth) 4 2
6. Maithune Ashakti (Problematic or not satisfactory coitus) 4 1
7. Klaivya (Impotence) 10 24

Table 5: Effect of therapy on objective parameters (semen analysis).

SN Test Before treatment After treatment
1. Semen volume 0.5 ml 2 ml
2. Semen colour Whitish Whitish
3. Reaction Alkaline Alkaline
4. Total sperm count 13 million 65 million
5. Motile sperm 35% 47%
6. Sluggish sperm 40% 50%
7. Immotile sperm 35% 20%

Table 6: Effect of therapy on objective parameters (Serum biomarkers of spermatogenesis).

SN Test Before treatment After treatment
1. Serum FSH 9.09 mIU/ml 8.17 mIU/ml
2. Serum LH 12.50 mIU/ml 6.03 mIU/ml
3. Serum Testosterone 25.20 ng/dl 380.89 ng/dl
4. Serum Inhibin- B 102.29 pg/mL 178.99 pg/mL

Discussion

1. Gandharvahastadi Kashayam[13] - It normalizes Vata-Kapha Doshas and its Anulomana property helps in relieving constipation. It contains Gandharvahasta, Chirabilva,


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Chitraka, Vishwa, Pathya, Punarnava, Yavasa and Bhumiamla. Majority of contents possess Anti -inflammatory action mainly Punarnava and Gandharvahastha. Chirivilva, Viswa and Chitraka reduce Aamavastha via their Deepana (carminative) and Pachana Pathya has Rasayana properties which help to normalize all Dhathus. Sahasra Yoga Kashaya Prakarana 394, Vatahara Kwatha.

2. Chandraprabha Vati[14] - Chandraprabha Vati is one of the important formulations used in the classics. It is considered as Sarva Roga Pranaashini which cures all types of diseases. In Sharangadhara Samhita 37 ingredients have been mentioned, they are Chandraprabha (Karpura), Vacha, Musta, Bhunimba, Amrita (Guduchi), Suradaru, Haridra, Ativisha, Darvi, Pippalimula, Chitraka, Dhyanaka, Triphala, Chavya, Vidanga, Gajapippali, Trikatu, Makshika, Sarja Kshara, Yava Kshara, Saindhava Lavana, Souvarchala Lavana, Vida Lavana, Trivrit, Danti, Patraka, Tvak, Ela, Vamslochana, Loha, Sheeta, Shilajatu, Guggulu It acts on Tridoshaja more commonly Vatakapha Shamaka, in acts on Rasa, Rakta, Mamsa, Medas, Asthi, Majja, Shukra Dhatus, in acts on Bahya and Madhyama Rogamarga and acts on all Srotas. In Klaibya the drugs like Trivrit, Pippalimoola, Guggulu, Yavakshara relieve anxiety, contains Loha Bhasma and Shilajatu it helps in increasing the Bala, reduce fatigue and general debility.

3. Stresscom[15] - It contains dry extract of Ashwagangha, is the manufacturing by Dabur India Ltd. Ashwagandha, Withania somnifera is very renowned herb of the Ayurvedic system of medicine as a Rasayana (tonic). Rasayana is described as an herbal, mineral and herbomineral preparation, it promotes a youthful state of physical and mental health and expands happiness. These can be given to small children as Brimhana, and are also taken by the middle aged and elderly to increase longevity. Among the Ayurvedic Rasayana herbs, Ashwagandha have the most prominent place. It is known as “Sattvic Kapha Rasayana”. Rasayana herbs are mainly adaptogen/anti-stress action. It promotes the function of the brain and nervous system and improves the memory. It improves the reproductive system, followed by promoting a healthy sexual and reproductive balance and being a powerful adaptogen, it enhances the body's resiliency to stress. Ashwagandha improves the body's defense mechanism to disease by improving the cell-mediated immunity.

It also having antioxidant properties, it help to protect against cellular damage which caused by free radicals.

4. Kapikacchu Choorna[16] - Kapikacchu (Mucuna pruriens Linn.) is the most popular drug in Ayurvedic system of medicine. It is famous for its powerful aphrodisiac as it is well known to increase the sperm count[17] and to increase testosterone levels in the body as well. Kapikacchu is an agent that helps the body in building up the mass as well as endurance and also helps the body to increase the muscular strength. It is very commonly known as athletes friends as many sports person uses these supplements to enhance their body performance. This herb helps in reducing the fats in the body and side by side helps in increasing the muscle mass in the body. This herb is also promoting the mood for sexual indulgence thereby increases the libido power and is also beneficial for people who are undergoing depression. This drug mentioned in the Ayurvedic classic of different book. It’s having Guru, Snigdha Guna; Ushna Virya; Madhura Vipaka; Vatahara and Pittahara Karma. Pharmacological actions are Antivenom activity, Hypoglycemic Activity, Aphrodisiac Activity, Antioxidant Activity, Antimicrobial Activity, Antiparkinson’s Activity etc. Kapikacchu Churna effectively raised the sperm count. The results on sperm count found highly significant. It also showed good improvement in other seminal parameter like Volume of semen, Ph of semen, motility of sperms etc. It showed mild significant result in Non progressive sperm (NP) and Not significant in Slow linear progress of sperm (SLP). It also significantly increased the sexual desire, penile rigidity, erection and duration of ejaculation with orgasm.[18]

5. Mahanarayan Oil[19] - Matra Basti through rectum reaches instantly into systemic circulation thus has faster absorption and gives quick results. According to the modern science, there is no digestive action of fat or oil in stomach. The fat digestion and absorption takes place in large intestine and no food substances other than water and salt are absorbed from the large intestine not because it is not possible but the Chyme contains no absorbable substances by the time it reaches the large intestine. Mahanarayana Taila is a renowned Vata balancing herbal oil formula in Ayurvedic The drugs of Mahanarayana Taila have Prajasthapana, Rasayana, Balya properties. The drugs of Mahanarayana Taila possess antioxidant,


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adaptogenic, immunomodulatory effects. It is a rich combination of Ayurvedic herbs, produce no irritation on skin and arrest further progress of chronic arthritic changes of joints, pain, stiffness, restricted movement, distortion and restores normal joint function. In the case, Matra Basti with Mahanarayana Taila improved the condition of the patient, perhaps it enhances the blood flow over low back area and helps the patient nourished.

6. Sukumara Ghritam[20] - Sukumara Ghrita was used for Matra Basti (consumption of fat through intestine) purpose. It is one of the examples for Yamaka (combination of two) type of Sneha (unctuousness) which contain Ghrita (ghee) and Eranda Taila (castor oil) as ingredients. It consists of Dashamoola (Ten roots) as Kashaya Dravya best Vata Samaka Dravya (Vata-normalizing drug). Eranda Taila having Madhura (sweet), Katu (pungent), Kashaya (astringent) taste, Ushna Virya (hot potency), Srotovisodhaka (clear obstruction), Vata-Kapha Hara, Yoni-Sukra Visodhaka (purify gametes) and facilitates Vatanulomana (normal movement of Vata Dosha).

7. Sastika Shali Pinda Sweda[21] - Shastika Shali Pinda Sweda it is one kind of Snigdha Sankar Sweda. Nutrients of Shastika Shali get absorbed it gives strength to the muscles and heat applied over the area it decreases stiffness as well as sweat pores open and flow out various metabolic wastes from body. Increased blood flow promotes relaxation process and increasing range of movement. If oleation and sudation could soften dried timber, then definitely it helpful to get body nutrition in a patient. The word ‘Pinda’ means bolus, it refers to the sudation achieved with the using of bolus which is made by drug. Shashtika Pinda Sweda is carried out with the bolus of boiled Shashtika Shali with Balamula Kwatha and Ksheer. It carries Tnigdha, Guru, Sthira, Sheeta and Tridoshaghna Though a Sweda Karma, it has Brimhana Guna. The properties of drugs used in Shastika Shali Pinda Sweda, such as Brimhana, Snigdha, and Vata Shamaka, are antagonistic to vitiated Vata. The location of Vata is thought to be the skin (i.e., Sparshanendriya), when these therapies are immediately applied to the skin, they rectify Vata's disturbed functions, which in turn corrects the functions of Vata. In this procedure moist heat used, it is more effective than dry heat because it deeply penetrates the skin, so increases the effect on muscles, joints, and soft tissue.

Swedana makes the skin more permeable by opening the skin appendage through sweating, dilating blood vessel, all these things help in absorption of medicine. Most of the things are not permeable through the skin but amphipathic nature of the milk helps in absorption of other medicine. This procedure regulates Vata functions and provides nutrition to muscular tissue and enhance strength. So, Shastika Shali Pinda Sweda is one of the most preferred methods of Swedana which is beneficial for this condition.

8. Mustadi Yapan Basti[22] - According to Acharya Charaka’s Basti Chikitsa is the Ardha Chikitsa and it is important for the treatment of Vata Dosha. Vata Dosha is main reason for Shukra Kshaya. Moreover, the Yapana Basti are having Rasayana effect and can be administered for longer duration without any adverse effects to support life and promote longevity.[23] MYB performs as a Shodhana as well as Rasayana simultaneously. Rasayana becomes more effective when preceded by a suitable Panchakarma therapy.

The ingredients of Mustadi Yapana Basti have predominant Vatahara, Rasayana & Vajikaran properties. Drugs used in Mustadi Yapanaa Basti, it especially attributed with property of “Shukra-Mansa-Balajanan”. Due to drugs like milk, cow ghee, Sida cordifolia, Pluchea lanceolata, Tribulus terrestilis, Glycyrrhiza glabra which have properties of Balya, Snigdha, Jivaniya, Guru, Madhura Rasa, Madhura Vipak and Sheet Virya. Tikta Rasa may have positive impact on cell implantation and also reduce the degeneration of Asthi and Majja Dhatus.[24] Therefore, MYB has a good effect on neurological disorders and wasted muscles. Susrhuta explains when Basti is administered properly, it remains in large intestine through the anal root, pelvis area and below the umbilicus for some time, and the potency of the Basti materials spreads in the whole body through the channels and gives its effect with is a short periods.[25]

So, the immense number of nerves which are located in Enteric Nervous System can be nourished easily and quickly due to Sadyaobalajanana and Rasayana effect of MYB. If MYB is given daily, it will reduce Dourbalya, can be improve muscle strengthening and others symptoms due to vitiated Vata will be reduced.



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Conclusion

Combination of Sodhana and Shaman treatment provided significant relief in the symptoms of Oligoasthenozoospermia. Basti along with medication may have acted on the systemic symptoms of Shukra Kshaya as well as give significant improvement on the seminal parameters like sperm count, sperm motility and gave significant improvement on the serum biomarkers specially on serum testosterone.

Patient Perspective: Patient told marked improvement in confidence during sexual intercourse. Patient told improvement in erection and performance during sexual intercourse. Patient felt better and felt marked improvement in weakness and increase level of sexual desire now. Overall patient had satisfactory and better sexual life after intervention.

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