Male infertility due to congenital adrenal hyperplasia: testicular biopsy findings, hormonal evaluation, and therapeutic results in three patients

Physiopathology of spermatogenic arrest

OBJECTIVE

To review the world literature on the etiology, physiopathology, and treatment of spermatogenesis arrest.

STUDY SELECTION

All the pertinent literature on spermatogenic arrest has been selected. Most studies related to this topic have been identified through Medline and through published literature.

PATIENTS

Spermatogenic arrest has been diagnosed by testicular biopsy in men of reproductive age who had either severe oligospermia (partial arrest) or azoospermia (complete arrest), normal testicular volume, and depending on the etiology normal, high, or low levels of gonadotropins.

INTERVENTIONS

The effects of heat, radiotherapy, and chemotherapy have been reported. Depending on the etiology of spermatogenic arrest, different hormonal treatments have been tested.

MAIN OUTCOME MEASURE

Level of interruption of germ cell differentiation in testicular biopsy have been determined. Improvement of the sperm count or appearance of mature sperm after an hormonal treatment have been observed.

RESULTS

Spermatogenic arrest can occur at spermatogonial level in case of gonadotropin insufficiency or after germ cell damage due to chemotherapy or radiotherapy. The arrest is most frequently observed at primary spermatocyte level. Reversible arrest at that level can be due to heat, infections, hormonal and nutritional factors. Irreversible arrest at primary spermatocyte or spermatid level have a genetic origin due to chromosomes anomalies either in somatic cells or in germ cells.

CONCLUSIONS

Spermatogenic arrest is usually due to genetic factors resulting in irreversible azoospermia. However some cases may be consecutive to hormonal, thermic, or toxic factors and may be reversible either spontaneously or after a specific treatment.

Congenital adrenal hyperplasia with testicular tumors, aggression, and gonadal failure

Bilateral testicular tumors (adrenal rests) may occur in untreated or poorly controlled congenital adrenal hyperplasia. This case report describes two unique associated phenomena: (1) psychologic disturbances similar to those seen with exogenous androgen abuse, which resolved with appropriate glucocorticoid suppression of androgen over-production by this abnormal adrenal/adrenal rest tissue; and (2) testicular failure which showed a partial, delayed recovery with corticosteroid therapy. The need for a careful history and biochemical screening for all patients with bilateral testicular tumors is reinforced.

Reversible male infertility in late onset congenital adrenal hyperplasia

We have studied a male patient who presented with secondary infertility. His eldest daughter suffers from late onset congenital adrenal hyperplasia. Based on his hormonal profile, adrenal and gonadal stimulation tests, semen analyses and testicular biopsy he was diagnosed as suffering from the same disease as his daughter. Steroid treatment yielded improvement in all the parameters mentioned above. Four months later his wife became pregnant and he fathered a child. Suppression of gonadotropin secretion due to overproduction of adrenal androgens would appear to be the reason for the failure of testicular maturation and spermatogenesis in this patient. We conclude: 1) glucocorticoid treatment is indicated in infertile males suffering from nonclassical 21-hydroxylase deficiency; 2) Late onset congenital adrenal hyperplasia should be suspected in any male infertility of unknown origin.