3. CLINICAL STUDIES

3.1. Materials and methods

The experimental data from Tribestan administration have been clinically confirmed so far by three groups of researchers: by the Higher Military Medical Institute under the guidance of Prof. I. Viktorov, Corresponding Member of the Bulgarian Academy of Sciences; by the Medical University of Sofia; State University Hospital of Endocrinology, Gerontology and Geriatry, under the guidance of Prof. E. Bozadzhieva, and by the National Institute of Obstetrics and Gynecology - under the guidance of Prof. M. Protich.

The studies were carried on 212 male individuals, aged between 14 and 60 years. The therapeutic properties of Tribestan were studied in patients with partial or complete impotence. Both the tolerance and the adverse effects of the product were studied. The studies were carried out by the method of simple blind experiment, using placebo. In nozological terms, the studies covered various types of male impotence: idiopathic oligoasthenozoospermia - 39 patients, resection of the left internal testicular vein in varicocele, with subsequent oligoasthenozoospermia - 50 patients; inflammatory process of the prostate with oligo- and azoospermia - 53 patients, primary and secondary male hypogonadism - 20 patients, impotentia coeundi - 50 patients. The product was individually administered to all patients who had not received hormonal agents for at least one month prior to the treatment.

The duration of the treatment depended on acuteness of the disease - 30 - 60 days on the average (Bozadzhieva et al., and Protich et al.) and 90 days (Victorov et al.). the mean daily dose was 3 - 6 filmtablets of 0.250g. Some of the patients were favorably affected by 3 tablets daily (Protich et al.), whereas the other research teams administered 6 tablets (3 x 2). The andrological state was used as the basis for the adequate evaluation of the reproductivity of the patients by all three teams. The basic parameters of sperm were observed, i.e. volume and pH of the ejaculate, concentration of spermatozoa (number/1ml), percentage of motile spermatozoa, mean rate of population motility and percentage of pathological forms of the spermatozoa. Detailed case history on the sexual behavior of the patients was recorded prior to and after the therapeutic Tribestan course. The effect of the product on hair growth was observed in some patients. One of the teams (Bozadzhieva et al.) also observed the changes in the serum levels of gonadotropins, progesterone, testosterone, estradiol and cholesterol. The other team (Victorov et al.) followed up the changes in testosterone serum levels in the Tribestan treated patients. The hormonal levels were radioimmunologically determined using kits and reagents provided by the French-Italian-Belgian Association CEA-IRE-SORIN. The results from these studies were statistically assessed by variation analysis.

3.2. Results

Significant changes in spermatozoon motility were found after Tribestan intake for 60 days (with a daily dose of 3 filmtablets) by males with idiopathic oligoasthenozoospermia. The number of spermatozoa with normal motility, as well as the mean motility rate, were increased.

The percentage of the motile spermatozoa was 29, on the average, prior to the treatment and reached up to 36.66 after the treatment (p < 0.005). The mean motility rate of spermatozoa prior to the treatment was 1.95 mm/sec, after the treatment - 3.63 respectively (p < 0.001). No changes were observed in the ejaculate volume. In both cases (before and after treatment) the ejaculate volume was within the limits of the norm, about 4 ml on the average. The number of spermatozoa in the treated patients was higher by 3 ml/ml ejaculate on the average. In some cases, normalization of the spermogram occurred during repeated treatment with a daily dose of 6 tablets. In these cases, the improvement of the spermogram (normalization of the increased viscosity, increased ejaculate volume, increased concentration and accelerated motility of the spermatozoa) was accompanied be elevation of the serum levels of the lutenizing hormone and testosterone, and reduction of the estradiol level.

The patients with idiopathic azoospermia after 90-day treatment with a daily dose of 1.5g are of particular interest. The results were significant in three of all 7 patients treated. No spermatozoa were detected prior to the treatment. After the treatment, 3.5-million/1ml ejaculate were recorded in one of the patients, 15 million/ml in the second and 28 million/ml in the third. The percentage of motile spermatozoa in the first patient was 10, and in the other two - between 25 and 30. The motility rate of the spermatozoa was about 5 mm/sec. In two of the patients, 30 - 40 spermatozoa per field were observed, and in the third - about 5 spermatozoa per field after the treatment, compared with the absence of any prior to the treatment. One of the patients failed to be affected by the product. The studies on the patients from that nozological group continued with the administration of maintenance dose.

The clinical comparison of the results from the treatment with provirone of patients with idiopathic azoospermia and after Tribestan administration revealed a favorable effect on three of the patients (out of 6), unsuccessfully treated with provirone for a long period of time. The results in the patients with varicocele and oligoasthenozoospermia as regards the motility of the spermatozoa were identical in the reports of all research teams, regardless of the differences in the doses and duration of the treatment. Protich et al. found an average of 26.88% motile spermatozoa prior to the treatment and after 60-day course with a dose of 1 tablet, three times daily - 39% (p < 0.02) with a mean motility rate of spermatozoa 2.06 mm/sec prior to the treatment and 4.44 mm/sec post treatment respectively. No change in the ejaculate volume was found. The other team (Victorov at al.) observed more pronounced changes in the ejaculate volume after 90-day treatment with a daily dose of 1.5 g (4.5 ml compared to 1 - 2 ml prior to the treatment, i.e. an average of 1.55 ml of ejaculate volume in all patients). The number of spermatozoa in 1 ml reached the values in 100% of the patients treated. The mean percentage of motile spermatozoa prior to the treatment was 2.06 and was increased to 33.09 (Tables 1,2,3).

Table 1. Results of Tribestan treatment (1 tablet 3 times daily for 60 days) of 38 males with idiopathic oligoasthenozoospermia (represented in mean values)

Table 2. Results of Tribestan treatment (1 tablet 3 times daily for 60 days) of 16 males after varicocele operation with existing oligoasthenozoospermia 

Table 3. Results of Tribestan treatment (2 tablets 3 times daily for 90 days) of 36 males after varicocele operation and existing oligoasthenozoospermia 

The results of Tribestan administration to patients with unilateral or bilateral hypothrophy of the testes and azoospermia deserve particular attention. The patients complained of a sense of heaviness and distention, as well as of a slight pain in the testes between 40th and 60th day after the start of the treatment with a daily dose of 6 tablets. Upon examination, a slight pain in the testes occurred upon palpation, as well as a slight swelling, with no other evidence of pathological changes. Improvement both as regards the ejaculate volume and the concentration and motility of the spermatozoa was observed towards the end of the treatment. The testosterone serum level was elevated from 1.75 mg/ml to 3.75 mg/ml. The pain in the testicular region upon palpation abated within 2 - 3 months after treatment. Tribestan administration to patients with chronic inflammatory process of the prostate and disorders in the spermogram led to insignificant changes in these cases when the inflammatory process had been treated previously.

No changes were found in patients with chronic inflammation of the prostate (not treated previously). Out of 14 patients with reduced libido and absence of pathology in the male genital organs, treated for 30-days (daily dose - 2 tablets, three times), 12 manifested obvious improvement of the libido, one patient - a slight improvement (after a 60-day treatment cycle) and no effect was observed in another one. Out of a total of 36 patients with chronic prostatitis and reduced libido, 15 were very favorably affected by the end of the treatment cycle (a total dose of 90 - 100 g), 12 - favorably, and in 9 of the cases with a duration of the inflammatory process over 5 years, no effect occurred. The patients with hypotrophy of the testes and idiopathic azoospermia had no complaints as regards the libido, but in the course of the treatment aimed at improving the spermogram an apparent libido enhancement was recorded. Out of 9 patients treated for one of the gravest forms of male hypogonadism (Klinefelter's syndrome, due to chromosomal anomalies), the libido was enhanced in three of the patients, erection was reported in two and sexual intercourse and masturbation were reported in another two patients. Elevated levels of lutenizing hormone after the treatment were found in these patients. The levels of the remaining sexual hormones and cholesterol were reduced. Two of the patients with secondary insufficiency of sexual glands (Noonan's syndrome) attained improvement of the libido and erections during the treatment. The self-confidence was improved in one of them, and in the second - hair grew in the male genital region.

The results of the treatment of three patients with cryptorchidism (one of them with uncorrected malformation) comprised improvement of the libido and often masturbation. The duration of the erection was prolonged in one patient from that group, aged 37. The spermogram of the same patient was significantly better compared to the initial status one month after treatment, i.e. on day 90 ftehr the beginning. One patient with secondary hypogonadism reported hair growing in the axillary and genital region, parallel with enhanced libido and frequent masturbation.

The serum testosterone levels were elevated in 20 patients from various nozological groups, the initial and final values being within the norm. In seven patients with testosterone serum level below the lower limit of the norm, the physiological levels were reached after the treatment, whereas in the rest of the patients with normal initial levels, the testosterone was not significantly changed after treatment.

3.3. Tolerance and side effects

All clinicians engaged in the studies reported a very good tolerance and no drug-related side effects. The clinical laboratory data on Tribestan treated males showed no deviations in the blood count, ESR, flocculation tests and urine.

3.4. Discussion of the results

The clinical studies of all three research teams on a total of 212 patients (males with disorders in the sexual function) confirmed the experimental data on a pronounced stimulating effect of the new Bulgarian phytochemical preparation on the sexual functions. It restored and improved the libido in all forms of impotentia coeundi after the administration of a mean daily dose of 1.5 g for 30 - 40 days. This suggests that not only the diminished libido was stimulated, but also that a therapeutic effect on both primary and secondary male hypogonadism was present. The assumption that the product was a favorable effect on spermatozoa motility after 60-day administration corresponds to the experimental data, according to which it stimulates both the mitosis and maturation of the germinal cells.

It is well known that at least 80 days elapse from the time of the division of the spermatogonia till the formation of a mature spermatozoon in males, hence the concentrations of the spermatozoa in the semen are different within that period. The team that used a therapeutic course of 90 days observed very good results in terms of both the motility and the concentration of the spermatozoa in the ejaculate. The studies of ejaculate from patients receiving the product for 60 days proved its apparent effect on the motility of the spermatozoa and an insignificant effect on their concentration on the basis of identical initial spermatozoal levels, as well as the presence of identity in the nozological groups prior to the treatment. This confirms the fact that the minimum therapeutic cycle should last at least as long as one complete germinal cycle (i.e. 80 - 90 days in males). Both idiopathic oligo- and azoospermia are diseases with so far undistinguished etiology. The serum levels of sex steroids are not changed in the majority of the patients with such deviations and good therapeutic levels of the product are observed. No data are available from testes biopsy that can throw light as to which of the phases of this complicated process of spermatogenesis has been affected pathologically and hence favorably affected by the product. Kumanov at al. advanced the hypothesis of diminished central effect of the product, associated with its mechanism of action, based on the elevated level of the lutenizing hormone. On the other hand, they admitted the existence of a peripheral effect, which could be responsible for the effect of the product on hair growth.

The reduced level of serum cholesterol under the effect of the product provided grounds for the same authors to assume that it also had an effect of cholesterol metabolism. The mechanism of action of Tribestan has not been elucidated so far. It can be concluded, on the basis of the clinical studies carried out so far, that it has a very good stimulating and therapeutic effect in all forms of impotentia coeundi, as well as a very good therapeutic effect in patients with oligoasthenospermia. The product has a very good tolerance and no undesired side effects. Based on the date presented so far, we recommend Tribestan for the treatment of impotentia coeundi and generaldi, due to oligospermia and diminished motility of spermatozoa.