Relationship between spermatogenesis and serum gonadotropin levels in azoospermia and oligospermia

Staging profile of hypofertile male subjects

Thirty-four hypofertile male subjects with either oligospermia or azoospermia underwent infertility evaluation with assay of serum follicle-stimulating hormone, luteinizing hormone, testosterone and testicular biopsy. Cytogenetic analysis of testicular tissue and peripheral leukocytes was competed on 11 patients. Fifteen male subjects underwnet bilateral contrast vasography. These studies permitted segregation of the hypofertile male population from those with post-germinal hypofertility, primary germinal hypofertility or pre-germinal hypofertility. Retrospective analysis indicates that segregation of the hypofertile male population permits optimum selection for treatment intervention.

Evaluation of testicular function in prepubertal boys by means of the luteinizing hormone-releasing hormone test

Luteinizing hormone (LH)-releasing hormone (LH-RH) tests (50 microgram/sq m intravenously) were performed in 112 prepubertal boys ages 13/12 to 11 years (mean +/- standard deviation, 75/12 +/- 16/12 years) suspected of having a testicular disorder because of improperly located testes (77 boys) or hypogonadism (35 boys). Four of the patients were retested within a period ranging from 6 to 16 months. Of the 112 boys tested, 17% were found to have high basal levels of follicle-stimulating hormone (FSH) and 23% were found to have an abnormally high release of FSH after LH-RH administration. Only three patients had abnormally high basal levels of LH and/or elevated LH responses to LH-RH. The basal plasma testosterone levels were found to be normal in all 112 bosy. The fact that plasma FSH levels were elevated more often than LH levels suggests that the tubular elements are damaged more frequently than are the Leydig cells. The surprisingly high incidence of an abnormal response of plasma FSH to LH-RH in boys with mobile testes calls for an increased awareness of the importance of regular examination of these patients until full puberty has been achieved. It is concluded that determination of basal plasma FSH levels and the response to LH-RH stimulation is a useful diagnostic tool for evaluating testicular function in prepubertal boys with suspected pathology of the testes.

Testicular damage due to cytotoxic drugs and recovery after cessation of therapy

Testicular function was assessed in 32 patients who received standard chemotherapy regimens for disseminated lymphomas. Thirty-one had evidence of germ cell damage, as assessed by the finding of azoospermia and/or high plasma levels of follicle-stimulating hormone (FSH). In addition, five patients had persistently low plasma testosterone levels associated in three with elevated plasma luteinising hormone (LH) levels. Reproductive function did not recover in any patient while chemotherapy continued. Cessation of therapy was possible in 16 patients with prolonged remissions of disease. Among these, recovery of germinal epithelium differed greatly between the cyclophosphamide / vincristine / prednisone treated group and the mustine/procarbazine/vincristine/prednisone treated group. Seventy per cent of the former patients had evidence of recovery after 34 months of follow-up while only one (17%) of the latter had begun to recover at 52 months post-therapy. Serial measurement of plasma FSH levels proved useful in predicting likely recovery of spermatogenesis.

Isolated FSH deficiency in a male. A case report

This report describes the case of a 26-year-old man investigated because of infertility. The patient appeared healthy with normal sexual activity, physical appearance and karyotype. Repeated semen analyses showed a marked oligozoospermia. A testicular biopsy specimen revealed arrested spermatogenesis and normal Leydig cells. Hormone analyses were normal except for a markedly reduced serum FSH level. Only a few such cases have been previously reported.

Relationships between spermatogenesis and serum hormone levels in subfertile men

The measurements of serum follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone were related to the sperm concentration and testicular biopsy in 137 subfertile men. The biopsies were classified into four histological groups: normal, focal tubular atrophy, maturation arrest and Sertoli-cell-only syndrome. A positive correlation was found between sperm concentration and the histological grade of spermatogenesis. FSH was directly related to the spermatogenesis and the values were significantly raised in maturation arrest and Sertoli-cell-only syndrome. This relationship was present, but to a much lesser extent, for LH. Serum testosterone levels remained unchanged and no relationship between testosterone and either sperm concentration or testicular biopsy was observed. These data indicate the value of FSH in the investigation of the subfertile male, but suggest that the routine measurement of testosterone is unnecessary.

Supranormal FSH response to gonadotrophin-releasing hormone in oligospermic men with a normal basal serum FSH concentration

Twenty-six men with severe oligospermia (sperm density less than 10 X 10(6)/ml, but greater than O), but normal serum concentration of FSH, as well as normal serum concentrations of LH and testosterone, were given a 250 microgram i.v. bolus dose of synthetic gonadotrophin releasing hormone (LHRH). The serum FSH and LH responses were compared to those of a group of normal men and a group of men with oligospermia or azoospermia and elevated basal serum FSH concentration. The mean FSH response to LHRH of the men with oligospermia but normal basal serum FSH concentration was 911 miu min/ml, nearly three times that of the normal men, 322 miu min/ml (P less than 0.001), though not so great as that of the men with oligo/azoospermia and elevated basal FSH concentration (2890 miu min/ml). Ten of the twenty-six men with oligospermia and normal basal serum FSH had a supranormal FSH response to LHRH. The mean LH response to LHRH of the men with oligospermia and normal basal serum FSH levels was not significantly different from that of the normal men. We conclude that LHRH stimulation can often elicit a deficiency of feedback inhibition of FSH secretion not readily recognizable by measurement of the basal serum FSH concentration.

Some interrelationships between plasma levels of LH, FSH, oestradiol 17beta, androgens and semen analysis data in male infertility patients

Serum LH, FSH and immunoreactive testosterone-like substances (TLS) have been measured by radioimmunoassay in 130 male infertility patients and oestradiol 17beta in 26 cases. A weak but significant negative correlation was found between FSH and sperm count (rs = -0.19, p less than 0.05) but not LH and sperm count. However, LH and FSH were strongly correlated in the azoospermic (rs = 0.71, p less than 0.01) and oligozoospermic (rs = 0.53, p less than 0.01) groups and levels of both gonadotrophins were significantly elevated in the azoospermic and oligozoospermic as compared to the normozoospermic group. The elevated LH levels in the oligozoo- and azoospermic groups could not be explained by reduced negative feedback of testosterone or oestradiol 17beta since firstly, TLS and oestradiol 17beta levels were similar in all three groups and, secondly, within-group correlations between LH and TLS were either non-significant or positive (azoospermic group r = 0.37, p = 0.06). It is suggested that spermatogenesis-related feedback factor(s) may inhibit LH as well as FSH secretion. No role for oestradiol 17beta as a selective inhibitor of FSH secretion seemed likely as oestradiol 17beta levels were similar in the three groups and were correlated (r = 0.51, p less than 0.01) to TLS levels i.e. to leydig cell rather than spermatogenic function. Seminal fructose was negatively correlated (r = -0.26, p less than 0.01) with sperm count but not significantly with plasma TLS. It would thus seem unlikely that the tendency for seminal fructose levels to increase as sperm count decreases is due to increased androgen production or that seminal fructose can be used as an index of a patient's androgenic status. Patients with varicoceles had hormone levels similar to other patients of similar sperm count. Both sperm morphology and motility were strongly correlated to log sperm count (r = 0.84 and 0.55 respectively) and semen volume was significantly greater in oligozoospermic than normozoospermic patients (p less than 0.01).

The fertile eunuch syndrome. An isolated leydig-cell failure?

In two patients exhibiting eunuchoid features in association with normal sized testes and complete spermatogenesis concommittant with only occasional Leydig cells between the tubuli, (proven by testicular biopsy) an attempt was made to elucidate the factors leading to this condition. Both patients responded with significant rise in both plasma FSH and LH after administration of synthetic GnRH indicating pituitary responsiveness. However, no rise in either FSH or LH could be observed after administration of clomiphene citrate during three weeks of treatment indicating hypothalamic unresponsiveness to chemical stimuli. Although plasma testosterone levels rose significantly after administration of Human Chorionic Gonadotropin, estradiol remained unchanged during three weeks of HCG administration. A hypothesis is discussed which defines this syndrome in these two cases as primary Leydig cells failure, expressed in the inability of these to transform testosterone into estrogens, thus depriving pituitary and hypothalamus from a proper steroidal milieu necessary to adequate functioning.

Results of investigations on seminal fluid in so-called oligospermiogenesis

Diagnosis of ligospermiogenesis was made in 76 infertile subjects submitted to testicular biopsy. Histological examinations demonstrated a reduction in mature spermatids (Sc. Sd.-Clermont classification) in the tubular sections. Comparison of histological data with findings from seminal fluid analyses in these subjects revealed: a) a pathological seminal fluid pattern in all cases of oligospermiogenesis, b) these patients may show either an azoospermic or oligozoospermic seminal fluid pattern; statistical analyses confirmed an almost equal distribution of the two conditions.

Plasma gonadotrophic hormones, testicular biopsy and seminal analysis in the men of infertile marriages

The first step in the investigation of infertile men is to obtain 2 seminal analyses 3 days after the previous ejaculation. Clinical assessment of testicular size is an unreliable means of assessing spermatogenesis and is best done by performing bilateral testicular biopsies. Azoospermic men with grossly elevated FSH levels should be advised to consider AID or adoption. Those with normal or mildly elevated FSH levels should undergo testicular exploration in an attempt to correct an obstructive lesion. Azoospermic men with subnormal FSH levels may have an isolated hormone defect which will respond to treatment with Pergonal. Different treatment programmes for oligozoospermic men depending on the results of the FSH and LH assays may lead to a more rational approach to therapy. Infertility associated with varicocele may possibly be associated with a local disturbance of "inhibin" and FSH concentrations.

[Studies on the pituitary-testicular axis in male patients with chronic renal failure with different glomerular filtration rate (author's transl)]

In 32 male patients with chronic renal failure (age 22-60 yrs), of which 17 showed a creatinine clearance below 20 ml/min (group I) and 15 above 20 ml/min (group II), plasma levels of total testosterone (T) and total oestradiol-17beta (E2) were measured before and after stimulation with HCG i.m. LH and FSH were evaluated before and after stimulation with LH-RH i.v. Additionally, testosterone binding capacity (TeBG), free testosterone fraction (%FT) and "absolute" free testosterone (AFT) were determined. In comparison with normal persons T was clearly reduced before and after HCG in group I, whereas in group II it was reduced only after HCG. E2 showed normal basal values in both groups, but in group I it was decreased after HCG. Except for LH values after stimulation in group II, both groups showed increased LH and FSH levels before and after LH-RH in comparison with controls. TeBG and %FT did not show any changes in either group, whereas AFT was reduced in both of them. Comparing the results of group II and I we found in the latter decreased values for T before and after HCG and for E2 after HCG as well as decreased values for AFT, whereas LH and FSH before and after LH-RH were increased. There existed no significant correlation between any of the parameters T, AFT and E2 on the one hand and LH and FSH on the other hand. Significant correlations are found between creatinine clearance and T, AFT, LH and FSH. The results indicate a primary defect of the testis which gradually depends on the degree of renal insufficiency, but with well working feed-back mechanism. The possibility of an additional central regulation defect in the sense of a relative autonomy of the hypophyseal gonadotropin secretion is discussed.

Leydig-cell agenesis: a cause of male pseudohermaphroditism

We studied a 35-year-old patient with female external genitalia, primary amenorrhea and XY karytotype. Plasma testosterone was 10 ng per deciliter, which did not change after administration of human chorionic gonadotropin, increased to 22 ng per deciliter after ACTH, and decreased to 0.9 ng per deciliter after dexamethasone. Plasma delta 4-androstenedione, dehydroepiandrosterone and 17-hydroxyprogesterone were in the normal range. Plasma luteinizing hormone was high, but follicle-stimulating hormone normal (7.5 mlU per milliliter). There were two testes with epididymis and vas deferens, but no Mullerian structures. Microscopical examination showed hyalinization of tubules, which were lined by normal Sertoli cells and occasional immature germ cells. No Leydig cells were seen. After castration follicle-stimulating hormone increased to 43 mlU per milliliter. We conclude that this case of male pseudohermaphroditism was probably due to a Leydig-cell agenesis, that the epididymis and vas deferens can be developed in such a condition and the follicle-stimulating hormone secretion is regulated, at least in part, by a non-androgen substance secreted by Sertoli cells.

Testicular function after orchiopexy for unilaterally undescended testis

Testicular function was determined in 29 men, 21 to 35 years old, who had undergone orchiopexy for unilaterally undescended testis at four to 12 years of age. Serum testosterone and dialyzable testosterone concentrations of these men were not significantly different from those of a control group of 30 normal men, and their basal serum luteinizing hormone concentrations and serum luteinizing hormone responses to synthetic gonadotropin-releasing hormone were only slightly higher than those of the normal men. The mean sperm density of the patients, however, was only one third of that of the normal men (p less than 0.001). The mean serum follicle stimulating hormone response ro gonadotropin-releasing hormone of the patients was doubled that of the normal men (p less than 0.001). The data indicate that spermatogenesis may be abnormal after orchipexy, and suggest that men with unilaterally undescended testis may have bilateral testicular abnormality.

Response of luteinizing hormone and follicle-stimulating hormone to different doses of D-leucine-6-LH-RH ethylamide in oligospermic patients

The rise in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels after intramuscular administration of D-leucine-6-LH-RH ethylamide was studied in seven patients with idiopathic normogonadotropic oligospermia. Four tests with 2.5, 5.0, 10.0, and 20.0 mug of the analog, respectively, were carried out at 8 A.M. on each subject. The interval between tests was 1 week. Serum levels of LH and FSH were determined by radioimmunoassay before (-15 And 0 minutes) and 2, 4, 6, 12, and 14 hours after each injection. No differences in the basal values for either hormone were observed. D-Leucine-6-LH-RH ethylamide produced significant increases in LH and FSH levels for 6 to 12 hours after the injection. Peak values were obtained between 4 and 6 hours. A dose-response relationship for both gonadotropins was observed. The highest average levels of LH and FSH were obtained after injection of 20.0 mug of the drug. A great individual variation in magnitude of response was observed which seemed to be related to the functional reserve of the pituitary. It is suggested that doses of 10.0 to 20.0 mug of D-leucine-6-LH-RH ethlamide/day could be used for chronic treatment in male infertility.

Clomiphene citrate in the management of male infertility

There were 35 hypofertile men who underwent assay of serum follicle stimulating and luteinizing hormones, and testosterone, and were placed in a trial program using clomiphene citrate in a 25-day cycle, with 5-day rest periods. Therapy has been maintained for up to 9 months with a projected termination of 12 months. No relationship could be established between serum follicle stimulating hormone and spermatozoal number in this population. The spermatozoal count improved in 31 men while they were on therapy and 8 pregnancies have occurred. Clomiphene citrate seems to be effective in improving the quanttity of spermatozoa and the spermatozoal motility in these hypofertile men.

Immunologic studies of male infertility

Infertile men with azo- or oligospermia of unknown cause were investigated for evidence of testicular autoimmunity. Testicular germinal cell antibodies were found in 14% of the patients, compared with 5% of normal men, and 21% had spermatozoal antibodies, compared with 5% of the normal subjects. One-third had positive macrophage inhibitory factor tests, compared with 5% of normal subjects. However, of autoantibodies against thyroid, stomach, and nuclear material, only the prevalence of thyroid cytoplasmic antibodies was significantly greater than in normal subjects; serum IgG, IgM, and IgA levels were normal in all cases tested. Furthermore, there was no excess of lymphoid tissue on biopsy and no evidence of antibody deposition in the testicular tissue. The evidence for autoimmunity is less impressive than that for leprous orchitis, which has been proposed as a model for testicular organ-specific autoimmunity. Nevertheless, it is possible that certain germinal cell or spermatozoal antibodies may be directed against factors necessary for orderly spermatogenesis. If so, they may play a role in some cases of maturation arrest and shedding defects.

Investigations on pituitary and Leydig cell function in chronic hemodialysis and after renal transplantation

The hypothalamus-pituitary-Leydig cell axis was investigated in 20 male patients undergoing intermittent hemodialysis and in 21 male patients following renal transplantation compared to normal controls. Plasma testosterone as well as luteinizing hormone and follicle stimulating hormone were determined by radioimmunoassay under basal conditions and after stimulation with choriongonadotropic hormone and hypothalamus releasing hormone respectively. Suppressed Leydig cell function has been demonstrated in dialysed patients as well as in patients after renal transplantation. The Leydig cell insufficiency is more pronounced in the hemodialysed patients. None of these showed testosterone levels in the normal range. They are different in various dialysis schedules. In contrast Leydig cell function is much better in patients after renal transplantation compared to those undergoing intermittent hemodialysis. But even after renal transplantation a diminished Leydig cell function takes place. The degree of Leydig cell insufficiency however varies individually. In a few cases Leydig cell function is restored completely after transplantation. It remains uncertain whether the duration of the posttransplantation period or the function of the graft effects Leydig cell function. Anterior lobe insufficiency has been excluded since plasma concentrations of gonadotropins were slightly elevated before and after LH-RH stimulation as compared to normals.

Gonadal dysfunction in uremic men. A study of the hypothalamo-pituitary-testicular axis before and after renal transplantation

Evaluation of testicular function in 13 hemodialyzed patients revealed the following: plasma testosterone (ng/100 ml) was low (less than 300 ng/100 ml) in 6 and low normal in 7 patients; sperm counts ranged from 0 to 8 million/ml and motility from 0 to 8 per cent; testicular tissue from 2 patients showed an abnormal histologic picture ranging from hypospermatogenesis to germinal cell aplasia. Follicle-stimulating hormone (FSH, ng/ml) was normal in eight (10 to 217 ng/ml), and persistently eveated in five patients (265 to 760 ng/ml). Of the latter five patients, two were azzoospermic, one had germinal cell aplasia on postmortem examination, one had virtually no viable sperms, and the other was never able to furnish ejaculate for examination. Luteinizing hormone (LH, mg/ml) was high (more than 210 ng/ml) in five and normal in eight patients. Six patients when given clomiphene showed the normal response of increased FSH and LH release. Four of the 13 patients, when restudied 6 to 12 months later and while still on dialysis, showed further deterioration of plasma testosterone and sperm counts. Four of the patients subsequently underwent successful renal transplantation. All showed improvement in sperm counts (20 to 40 million/ml, motility 40 to 90 per cent) and plasma testosterone (440 to 850 ng/100 ml). These data suggest that both germinal cell and leydig cell functions were impaired among uremic men. These dysfunctions were not correctable by hemodialysis, but were completely reversed by renal transplantation. The high FSH among patients with azzospermia indicates a responsive pituitary. The positive response to clomiphene suggests that storage as well as release of both hypothalamic and pituitary hormones were normal. Attempts to localize a single defect at the testis failed to explain the post-transplant surge of FSH which invariably proceded improvement in spermatogenesis. It is therefore postulated that a defect in that portion of the hypothalamus involved in the receipt and/or interpretation of message might be at fault in uremia.

Indices of gonadal function in the human male. I. Plasma levels of unconjugated steroids and gonadotrophins under normal and pathological conditions

A radioimmunoassay technique for the simultaneous measurement of eight unconjugated steroids (progesterone, pregnenolone, dehydroepiandrosterone, androstenedione, testosterone, dihydrotestosterone, oestrone and oestradiol) in the peripheral plasma of human males is described. Determinations of these steroids and of immunoreactive FSH and LH were carried out on the plasma of twenty-one normal individuals and the levels were compared to those of eleven and ten males exhibiting oligospermia and azoospermia, respectively. Mean values and tolerance limits for each hormone, based on a lognormal distribution of individual values, are presented for all groups. Oligospermia was associated with a significant reduction in plasma dihydrotestosterone and testosterone levels. Azoospermic subjects also exhibited decreased dihydrotestosterone levels but a normal range of testosterone concentrations. Mean peripheral plasma levels of FSH were significantly elevated in both pathological groups and this was paralleled in the azoospermic men by increased concentrations of plasma LH.

Response of luteinizing hormone and follicle-stimulating hormone to different doses of synthetic luteinizing hormone-releasing hormone by intramuscular administration in normal and oligospermic men: preliminary report

The response of LH and FSH levels to intramuscularly administered synthetic LH-RH was studied in two healthy volunteers and three oligospermic patients. Four tests with 50, 100, 250, and 500 mug of LH-RH, respectively, were carried out on each subject at 8 am; the interval between tests was one week. The serum levels of LH and FSH were determined by radioimmunoassay (double-antibody method) before each injection, and 60, 120, 180, and 240 minutes after each injection. No differences in the basal values of either hormone were observed. In both oligospermic and normal men, maximal responses were obtained with doses between 100 and 250 mug. With 500 mug, levels decreased rather than increased. Maximal peaks occurred between 60 and 180 minutes after injection. In the two normal subjects, the responses of LH and FSH were similar. Two of the three oligospermic patients showed discordant responses. From the results, we can assume that LH-RH doses between 100 and 250 mug should be used as a basis for chronic treatment.

Use of synthetic luteinizing hormone-releasing hormone in treatment of oligospermic men: a preliminary report

Synthetic luteinizing hormone-releasing hormone (LH-RH) was administered to four normogonadotropic, oligospermic men (24 to 39 years of age) who had no endocrinologic, urologic, or associated vascular disease, to assess its possible therapeutic value in male infertility. Previous testicular biopsies of these subjects indicated alteration of spermiogenesis only. LH-RH (mean dose, 500 mug/day) was administered intramuscularly for 100 to 135 days. Each patient had at least two sperm count before starting therapy and had one every 20 to 30 days during and for two to five months after treatment. The sperm count, semen volume, sperm motility and morphology, and seminal plasma concentrations of fructose and citric acid were studied in each semen sample. In three of the four patients, urinary LH and FSH excretion and plasma testosterone levels were also measured. The sperm count increased clearly in two subjects 30 to 80 days after therapy started; the response was small in the third subject and negative in the fourth. The remaining parameters followed variable courses. Libido increased in all subjects. In the post-treatment period, the two patients who had shown the best response during treatment experienced a new and abrupt increase in the sperm count which remained well above initial values at the end of follow-up. LH-RH appears to be of value in the treatment of certain types of oligospermia, but several issues remain unsettled.