The behavior of epididymis, processus vaginalis and testicular descent in cryptorchid boys treated with buserelin

Advocating hormonal treatment to prevent adult in-fertility in patients diagnosed with congenital un-descended testes

In 2007 the Nordic group came to the following unanimous conclusions: In general, hormonal treatment is not recommended, considering the poor immediate results and the possible long-term adverse effects on spermatogenesis. Thus, surgery is to be preferred. However, defective mini puberty inducing insufficient gonadotropin secretion is one of the most common causes of nonobstructive azoospermia in men suffering from congenital isolated unilateral or bilateral cryptorchidism. The extent of alteration in the unilateral undescended testis correlate with the contralateral descended testis, indicating that unilateral cryptorchidism is a bilateral disease. Idiopathic central hypogonadism explains the phenomenon of defective mini puberty in otherwise healthy cryptorchid boys. We therefore recommend hormonal treatment for cryptorchid boys with defective mini puberty. Gonadotropin releasing hormone agonist (GnRHa) treatment following surgery to correct cryptorchidism restores mini puberty via endocrinological and transcriptional effects and prevents adult infertility in most cases. Several genes are important for central hypogonadotropic hypogonadism in mammals, including many that are transcribed in both the brain and testis. At the molecular level, there is no convincing evidence that heat shock is responsible for the observed pathological testicular changes. Thus, impaired transformation of gonocytes is not the result of temperature stress but rather a hormonal imbalance. Cryptorchidism should therefore be considered a serious andrological problem that cannot be successfully treated by early orchidopexy alone.

A novel role for CFTR interaction with LH and FGF in azoospermia and epididymal maldevelopment caused by cryptorchidism

Cryptorchidism occurs frequently in children with cystic fibrosis. Among boys with cryptorchidism and abrogated mini-puberty, the development of the epididymis and the vas deferens is frequently impaired. This finding suggests that a common cause underlies the abnormal development of Ad spermatogonia and the epididymis. The cystic fibrosis transmembrane conductance regulator (CFTR) is an ATP-binding cassette transporter protein that acts as a chloride channel. The CFTR gene has been associated with spermatogenesis and male fertility. In boys with cryptorchidism, prepubertal hypogonadotropic hypogonadism induces suboptimal expression of the ankyrin-like protein gene, ASZ1, the P-element induced wimpy testis-like gene, PIWIL, and CFTR. The abrogated expression of these gene leads to transposon reactivation, and ultimately, infertility. Curative gonadotropin-releasing hormone agonist (GnRHa) treatment stimulates the expression of CFTR and PIWIL3, which play important roles in the development of Ad spermatogonia and fertility. Furthermore, GnRHa stimulates the expression of the epididymal androgen-sensitive genes, CRISP1, WFDC8, SPINK13, and PAX2, which thereby promotes epididymal development. This review focuses on molecular evidence that favors a role for CFTR in cryptorchidism-induced infertility. Based on information available in the literature, we interpreted our RNA-Seq expression data obtained from samples before and after randomized GnRHa treatment in boys with bilateral cryptorchidism. We propose that, in boys with cryptorchidism, CFTR expression is controlled by luteinizing hormone and testosterone. Moreover, CFTR regulates the activities of genes that are important for fertility and Wolffian duct differentiation.

Fertility of Cryptorchid Testis-An Unsolved Mistery

Cryptorchidism (undescended testis) is one of the most common diagnoses in the pediatric urologist office. Even in the modern era, there still are a lot of debates regarding the optimal time for surgery related to the expected results in relation with the testicular function, including fertility. The review below intends to clarify issues regarding the impact of cryptorchidism on testicular histology and function, semen analysis, the relation between hormonal and surgical treatment, future fertility, and paternity rate.

Effect of adjunctive hormonal therapy on testicular descent and spermatogenic function among children with cryptorchidism: a systematic review and meta-analysis

OBJECTIVES

To systematically evaluate the effect of adjunctive hormonal therapy on testicular descent and spermatogenic function among children with cryptorchidism.

METHODS

A comprehensive literature search of electronic databases up to February 21, 2019 was performed. Continuous data of fertility indices were evaluated using weighted mean difference (WMD) with 95% confidence interval (CI), while nominal data of fertility indices and the complete descent rates were analyzed by risk ratio (RR) with 95% CI. A fixed effect or random effect model was used.

RESULTS

A total of 27 previous studies were included for the current analysis. Hormonal therapy increased complete testicular descent rate, reaching statistical significance (RR = 3.74; 95% CI, 2.78-5.04; P < 0.001). The success rate was 22.43%. A similar result was found in subgroup analysis of hormonal category and effect on unilateral or bilateral cryptorchidism. Studies reporting primary outcome as continuous data showed that cryptorchid males have significantly increased germ cell numbers per tubule (WMD = 0.10; 95% CI, 0.01-0.20, P = 0.032) after hormonal therapy. The nominal data of pooled studies showed no significant difference (RR = 1.62; 95% CI, 0.65-4.00, P = 0.298). In addition, a significant result was noted in the luteinizing hormone-releasing hormone (LHRH) therapy group but not in those undergoing human chorionic gonadotropin (hCG) treatment.

CONCLUSIONS

Our findings have demonstrated that hormonal therapy can effectively increase the success rate of complete testicular descent, while some boys may benefit as regards improvement of the fertility index.

Is Hormonal Treatment of Congenital Undescended Testes Justified? A Debate

Abnormal germ cell development in cryptorchidism is not a result of a congenital dysgenesis but is preceded by a hormone imbalance and perturbation in germ cell-specific gene expression during abrogated mini-puberty. Adequate treatment with low doses of GnRHa enables 86% of men to achieve a normal sperm count and, most importantly, prevent development of azoospermia. GnRHa treatment induces a significant transcriptional response, including protein coding genes involved in pituitary development, the hypothalamic-pituitary-gonadal axis, and testosterone synthesis. Furthermore, hormonal treatment to achieve epididymo-testicular descent as a first choice of treatment of cryptorchidism has a long tradition in Europe. It eliminates the necessity of subsequent surgery. Moreover, in the cases of non-responders it facilitates orchidopexy and contributes considerably to a reduced incidence of unilateral and the more serious bilateral complete post-surgical testicular atrophy.

Curative GnRHa treatment has an unexpected repressive effect on Sertoli cell specific genes

Background

Follicle stimulating hormone and testosterone stimulate Sertoli cells to support germ cell function and differentiation. During mini-puberty, when gonadotropin (GnRH) stimulates increases in plasma luteinizing hormone (LH) and testosterone levels, gonocytes are transformed into Ad spermatogonia. In cryptorchidism, impaired gonadotropin secretion during mini-puberty results in insufficient LH and testosterone secretion, impaired gonocyte transition to Ad spermatogonia, and perturbed Sertoli cell proliferation. Treatment with a gonadotropin-releasing hormone agonist (GnRHa/Buserelin) induced gonocytes to differentiate into Ad spermatogonia and rescued fertility. The present study evaluated the impact of low LH secretion on Sertoli cell function by comparing differential gene expression data between testes with low LH that lacked Ad spermatogonia (Ad-) and testes that completed mini-puberty (Ad+). Furthermore, we analyzed changes in the transcription of selected Sertoli cell specific genes in response to GnRHa treatment.

Results

Ad- testes showed reduced expression of nine out of 40 selected Sertoli cell specific genes compared to Ad+ testes. GnRHa treatment repressed most of the Sertoli cell specific genes, including the inhibins, but it increased the expression of genes that regulate apoptosis (FASLG) and proliferation (GDNF).

Conclusions

Impaired-minipuberty with decreased LH and testosterone levels affected Ad and Sertoli cell development through positive and negative regulation of morphoregulatory and apoptotic genes. GnRHa treatment had a repressive effect on most Sertoli cell specific genes, which suggested that Sertoli cells underwent a cellular rearrangement. We propose that gonadotropin-dependent increases in FASLG and GDNF expression drove Sertoli cell proliferation and germ cell self-renewal and supported the transition of gonocytes to Ad spermatogonia, independent of inhibins.

On the descent of the epididymo-testicular unit, cryptorchidism, and prevention of infertility

This comprehensive review provides in-depth coverage of progress made in understanding the molecular mechanisms underlying cryptorchidism, a frequent pathology first described in about 1786 by John Hunter. The first part focuses on the physiology, embryology, and histology of epididymo-testicular descent. In the last 20 years epididymo-testicular descent has become the victim of schematic drawings with an unjustified rejection of valid histological data. This part also includes discussion on the roles of gonadotropin-releasing hormone, fibroblast growth factors, Müllerian inhibiting substance, androgens, inhibin B, and insulin-like 3 in epididymo-testicular descent. The second part addresses the etiology and histology of cryptorchidism as well as the importance of mini-puberty for normal fertility development. A critical view is presented on current clinical guidelines that recommend early orchidopexy alone as the best possible treatment. Finally, by combining classical physiological information and the output of cutting-edge genomics data into a complete picture the importance of hormonal treatment in preventing cryptorchidism-induced infertility is underscored.

A systematic review and meta-analysis of comparative studies assessing the efficacy of luteinizing hormone-releasing hormone therapy for children with cryptorchidism

PURPOSE

To assess the efficacy of intranasal luteinizing hormone-releasing hormone (LHRH) therapy for cryptorchidism.

MATERIALS AND METHODS

Eligible studies were identified by two reviewers using PubMed, Embase, and Web of Science databases. Primary outcomes were complete testicular descent rate, complete testicular descent rate for nonpalpable testis, and pre-scrotal and inguinal testis. Secondary outcomes included testicular descent with different medicines strategy and a subgroup analysis.

RESULTS

Pooled data including the 1255 undescended testes showed that complete testicular descent rate was 20.9 % in LHRH group versus 5.6 % in the placebo group, which was significantly different [relative risk (RR) 3.94, 95 % confidence interval (CI) 2.14-7.28, P < 0.0001]. There was also a significant difference in the incidence of pre-scrotal and inguinal position testis descent, with 22.8 % in the LHRH group versus 3.6 % in the placebo group (RR 5.79, 95 % CI 2.94-11.39, P < 0.00001). However, side effects were more frequent in the LHRH group (RR 2.61, 95 % CI 1.52-4.49, P = 0.0005). There were no significant differences for nonpalpable testes.

CONCLUSIONS

LHRH had significant benefits on testicular descent, particularly for inguinal and pre-scrotal testes, which was also accompanied by temporary slight side effects.

Involvement of Fibroblast Growth Factors and Their Receptors in Epididymo-Testicular Descent and Maldescent

Maldescent of the epididymo-testicular unit can occur as an isolated event or as a component of various syndromes. When part of a syndrome, crypto-epididymis is usually accompanied by other genital and/or extragenital features. Epididymis development is primarily regulated by androgens, and successful epididymo-testicular unit development and descent requires an intact hypothalamic-pituitary-gonadal axis. The developing gonadotropin-releasing hormone system is essential for epididymo-testicular descent and is highly sensitive to reduced fibroblast growth factor (FGF) signaling. Our understanding of the impact of FGFR1 in the process of epididymo-testicular descent has recently improved. At later stages of embryonic development, the undifferentiated epididymal mesenchyme is a specific domain for FGFR1 expression. The majority of individuals with syndromic crypto-epididymis, as well as individuals with isolated maldescent of the epididymo-testicular unit, exhibit some disturbance of FGF, FGFR1 and/or genes involved in hypothalamic-pituitary-gonadal axis regulation. However, the mechanisms underlying FGF dysregulation may differ between various syndromes.

Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review

BACKGROUND AND OBJECTIVE

Controversy remains concerning the optimal treatment approach for cryptorchidism. The objective of this study was to assess effectiveness of hormone therapy or surgery for cryptorchidism.

METHODS

We searched Medline and other databases from 1980 to February 2012. Two reviewers independently assessed studies against predetermined criteria. Two reviewers independently extracted data and assigned overall quality and strength of evidence ratings using predetermined criteria.

RESULTS

Fourteen studies addressed effectiveness of hormonal treatments, and 26 studies addressed surgical intervention outcomes. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by >10%. Surgical treatment is associated with success rates of testicular descent ranging from 33% to 100%, depending on surgery. Weighted success averages were 78.7% for 1-stage Fowler-Stephens (FS), 86% for 2-stage FS, and 96.4% for primary orchiopexy. Descent rates were similar among studies comparing laparoscopic and open surgeries. Reported harms of hormonal treatments were mild and transient. Adverse effects specifically associated with surgical repair were rare.

CONCLUSIONS

The body of the reviewed literature comprises primarily fair- and poor-quality studies, limiting our ability to draw definitive conclusions. Hormonal treatment is marginally effective relative to placebo but is successful in some children and with minimal harms, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for FS procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

Complete testis-epididymis nonfusion anomaly: a typical association with cryptorchid testis

INTRODUCTION

Fusion anomalies of the testis and epididymis are associated with cryptorchidism. We present an analysis of the fusion anomalies of the epididymis in cryptorchid boys.

PATIENTS AND METHODS

We performed a retrospective review of patients presenting with undescended testes between 1986 and 1993. Patients were stratified among four groups based on the degree of testis-epididymis nonfusion.

RESULTS

A total of 880 testes were eligible for review, of which 93% (815/880) had normal fusion, 3.6% (32/880) had epididymal head nonfusion, 2% (19/880) had epididymal tail nonfusion, and 1.6% (14/880) had complete nonfusion. Increasing degree of nonfusion was associated with higher perioperative testes position. Head and tail nonfusion were observed together with a contralateral descended testis, but less frequently than in bilateral undescended testes (p = 3.89 × E-10). Complete nonfusion was not observed in the contralateral descended testes in unilateral cryptorchid boys.

CONCLUSIONS

Different degrees of fusion anomalies of the epididymis are associated with unilateral and bilateral undescended testis, indicating that nonfusion anomalies interact with epididymal-testicular descent because of impaired epididymal function.

Insulin 3-like hormone and its role in epididymo-testicular descent

PURPOSE

The role of insulin 3-like (Insl3) hormone signaling in the testicular descent process has been demonstrated. The purpose of the present study was to evaluate epididymal development in Insl3-deficient mice.

MATERIALS AND METHODS

Heterozygous and homozygous Insl3 mutants of a mixed CD1 X 129/Sv genetic background were generated by breeding Insl3-/- females with Insl3+/- males, and their genotypes were determined by polymerase chain reaction. On the first postnatal day, newborn males were sacrificed, embedded in paraffin, and cut in 4 mm sections. Sections were stained with hematoxylin/eosin and immunoreacted with anti-alpha actin antibody.

RESULTS

An analysis of stained sections indicated an arrest in the development of the epididymis in all homozygous mice. The cauda and corpus of the epididymis were undersized. Compared to the heterozygous epididymis, the homozygous epididymis had fewer peritubular layers and dwarfish musculature. We confirmed this with immunostaining with monoclonal antibodies against alpha-smooth muscle actin.

CONCLUSION

Defective development of the smooth musculature in the epididymis of Insl3 homozygous mutant mice, combined with its high intraabdominal undescended position, supports previous observations regarding the importance of intact epididymis morphology and function for descent of the epididymo-testicular unit.

Analysis of anomalies of the epididymis and processus vaginalis in human fetuses and in patients with cryptorchidism treated and untreated with human chorionic gonadotrophin

OBJECTIVE

To analyse the incidence of epididymal anomalies and the structure of the processus vaginalis (PV) in patients with cryptorchidism treated or not with human chorionic gonadotrophin (hCG), and to compare these findings with human fetuses with testes in the scrotum.

PATIENTS, MATERIALS AND METHODS

We assessed 24 fetuses with a gestational age of 23-35 weeks, and 114 cryptorchid patients (mean age 10.3 years). The patients were divided into two groups of those who used hCG (55, 65 testes) and those who did not (59, 75 testes). The sample was divided into six groups of possible anatomical relationships between the testis and the epididymis, according to a previous classification. Two situations were considered to analyse the PV: (a) total obliteration between the internal inguinal ring and the upper pole of the testis; and (b) total patency.

RESULTS

Epididymal anomalies were found in 35% of patients with cryptorchidism and in only 4% of normal fetuses. Of the 47 cases of epididymal anomalies in patients with cryptorchidism 23 (49%) were treated with hCG and 24 (51%) were not. The PV was patent in 58% of patients with cryptorchidism and in only 5% of fetuses. Considering the three groups, the epididymal anomalies were more frequent when the PV was patent.

CONCLUSIONS

Patency of the PV and the incidence of epididymal anomalies were more frequent in patients with cryptorchidism. The existence of epididymal anomalies did not influence testicular migration in patients treated with hCG.

Relationship between the persistence of the processus vaginalis and age in patients with cryptorchidism

OBJECTIVES

To assess if there is an age group where the occurrence of persistent processus vaginalis is more frequent in patients with cryptorchidism.

MATERIALS AND METHODS

We studied 24 fetuses with gestational age between 23 and 35 weeks postconception (control group) and 102 patients (137 testes) with cryptorchidism aged between 1 and 33 years (mean 10.3 years). We considered 2 situations for analysis of the processus vaginalis: a) complete persistence of processus vaginalis and, b) complete obliteration of the processus vaginalis between the internal inguinal ring and the upper pole of the testis.

RESULTS

Of the 137 cases of cryptorchidism, the processus vaginalis was patent in 79 (57.6%) and obliterated in 58 (42.4%). Of the 55 patients between 1 and 4 years old, 37 (67.2%) had a patent processus vaginalis and 18 (32.8%) an obliterated one. Of the 37 patients between 5 and 8 years, 17 (45.9%) had patent processus vaginalis and 20 (54.1%) had an obliterated process. In the 45 patients over 9 years of age, in 25 (55.5%) the processus vaginalis was patent and in 20 (44.5%) it was obliterated. In the fetuses, we found 4 cases (8.3%) of persistence of the processus vaginalis.

CONCLUSIONS

There was no difference in the occurrence of patent processus vaginalis between the various age ranges under study. Patent processus vaginalis was more frequent in patients with cryptorchidism than in fetuses.

Update on cryptorchidism: endocrine, environmental and therapeutic aspects

Cryptorchidism is the most frequent developmental abnormality in boys, present in more than 1% of infants above three months of age. It is associated with an increased risk of infertility and testicular cancer. The etiological quest is often disappointing, except in bilateral cases or associated malformations. Recent focus is on genetic and environmental aspects. Animal models have revealed the role of genes encoding for proteins implicated in testicular migration (InsI3, Hoxa 10), but in humans results are less convincing. While some degree of endogenous hormonal abnormality is suspeeted in some patients, the endocrine disruptor hypothesis is also tested. It is unclear whether the incidence of cryptorchidism has really increased, or whether there is only a better screening for this condition. However, other male reproductive problems, such as subfertility, hypospadias and testicular cancer seem on the rise. This secular trend suggests the possible in utero impact of hormonally active environmental factors, such as pesticides with estrogenic or antiandrogenic effect, and is consistent with the increased risk of cryptorchidism observed in the sons of mothers exposed to diethylstilbestrol during pregnancy. From a therapeutic point of view, there is an agreement that the correction of cryptorchidism is needed, but there is controversy on the best medical and/or surgical approach and on the optimal timing. There is a recent trend in proposing early therapeutic intervention, before 1 yr of age, in the hope of improving fertility; however, there is no proof that such a strategy can reduce the risk of testicular cancer.