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Rajmil O, Moreno-Sepulveda J. Recovery of spermatogenesis after androgenic anabolic steroids abuse in men. A systematic review of the literature. Actas Urol Esp 2024; 48:116-124. [PMID: 37567343 DOI: 10.1016/j.acuroe.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/10/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE This systematic review aims to evaluate the optimal treatment for male infertility resulting from Anabolic Androgenic Steroids (AAS) abuse. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies that compared different protocols for the recovery of spermatogenesis in patients after AAS use were included. RESULTS 13 studies investigating different protocols to restore spermatogenesis in patients with AAS abuse met the inclusion criteria. The available agents that showed restoration of spermatogenesis include injectable gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors, but their use is still poorly described in the literature. CONCLUSIONS Clinicians need to be aware of the detrimental effects of AAS on spermatogenesis. AAS-associated infertility may be reversible, but sperm production may take over a year to normalize. Both conservative and aggressive treatment can boost spermatogenesis with positive results. Further understanding of male reproductive endocrinology and high-quality data on the field of restoration of spermatogenesis after AAS abuse are warranted.
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Affiliation(s)
- O Rajmil
- Servicio de Andrología, Fundació Puigvert, Barcelona, Spain; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - J Moreno-Sepulveda
- Departmento de Obstetricia y Ginecología, Universitat Autònoma de Barcelona, Campus Universitario UAB, Barcelona, Spain; Clínica de la Mujer y Medicina Reproductiva, Viña del Mar, Chile.
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de Silva NL, Dissanayake H, Suarez C, Wickramarachchi RE, Ramasamy R, Dhillo WS, Minhas S, Corona G, Jayasena CN. Effect of oestrogen modulation on semen parameters in men with secondary hypogonadism: Systematic review and meta-analysis. Andrology 2024; 12:259-276. [PMID: 37306109 DOI: 10.1111/andr.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/02/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Selective oestrogen receptor modulators and aromatase inhibitors stimulate endogenous gonadotrophins and testosterone in men with hypogonadism. There are no systematic reviews/meta-analyses assessing the effects of selective oestrogen receptor modulators/aromatase inhibitors on semen parameters in men with secondary hypogonadism. OBJECTIVES To assess the effect of monotherapy or a combination of selective oestrogen receptor modulators/aromatase inhibitors on sperm parameters and/or fertility in men with secondary hypogonadism. MATERIALS AND METHODS A systematic search was conducted in PubMed, MEDLINE, Cochrane Library and ClinicalTrials.gov. Study selection and data extraction were performed by two reviewers independently. Randomised controlled trials and non-randomised studies of interventions reporting effects of selective oestrogen receptor modulators and/or aromatase inhibitors on semen parameters or fertility in men with low testosterone with low/normal gonadotrophins were selected. The risk of bias was assessed using ROB-2 and ROBINS-I tools. The results of randomised controlled trials were summarised using vote counting while summarising effect estimates where available. Non-randomised studies of intervention meta-analysis were conducted using the random-effect model. The certainty of evidence was assessed using GRADE. RESULTS Five non-randomised studies of interventions (n = 105) of selective oestrogen receptor modulators showed an increase in sperm concentration (pooled mean difference 6.64 million/mL; 95% confidence interval 1.54, 11.74, I2 = 0%) and three non-randomised studies of interventions (n = 83) of selective oestrogen receptor modulators showed an increase in total motile sperm count (pooled mean difference 10.52; 95% confidence interval 1.46-19.59, I2 = 0%), with very low certainty of evidence. The mean body mass index of participants was >30 kg/m2 . Four randomised controlled trials (n = 591) comparing selective oestrogen receptor modulators to placebo showed a heterogeneous effect on sperm concentration. Three included men with overweight or obesity. The results were of very low certainty of evidence. Limited pregnancy or live birth data were available. No studies comparing aromatase inhibitors with placebo or testosterone were found. DISCUSSION AND CONCLUSION Current studies are of limited size and quality but suggest that selective oestrogen receptor modulators may improve semen parameters in those patients, particularly when associated with obesity.
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Affiliation(s)
| | - Harsha Dissanayake
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Camila Suarez
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Ranjith Ramasamy
- Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Waljit S Dhillo
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Suks Minhas
- Department of Urology, Imperial College NHS Healthcare, London, UK
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Channa N Jayasena
- Section of Investigative Medicine, Imperial College London, London, UK
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3
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Tienforti D, Castellini C, Di Giulio F, Totaro M, Dalmazio G, Spagnolo L, Muselli M, Corona G, Baroni MG, Barbonetti A. Selective modulation of estrogen receptor in obese men with androgen deficiency: A systematic review and meta-analysis. Andrology 2023; 11:1067-1076. [PMID: 36604313 DOI: 10.1111/andr.13373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/17/2022] [Accepted: 12/26/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although selective estrogen receptor modulators have been proposed as a treatment for men with central functional hypogonadism, only a few data have been produced in men with obesity-related functional androgen deficiency. OBJECTIVE To determine whether and to what extent selective estrogen receptor modulators are an effective and safe therapy in men with obesity-related functional androgen deficiency. MATERIALS AND METHODS A thorough search of PubMed, Web of Science, Scopus, and Cochrane Library databases was performed to identify studies comparing testosterone levels before and after treatment. Mean differences with 95% coefficient intervals were combined using random effects models. Funnel plot, Egger's test, and trim-and-fill analysis were used to assess publication bias. RESULTS Seven studies met the inclusion criteria providing information on 292 men with obesity-related functional androgen deficiency treated with clomiphene citrate (12.5-50 mg daily) or enclomiphene citrate (12.5-25 mg daily) for 1.5-4 months. The pooled estimates indicated a significant increase in testosterone levels both with clomiphene (mean difference: 11.56 nmol/L; 95% coefficient interval: 9.68, 13.43; I2 = 69%, pfor heterogeneity = 0.01) and enclomiphene citrate (mean difference: 7.50 nmol/L; 95% coefficient interval: 6.52, 8.48; I2 = 4%, pfor heterogeneity = 0.37). After the exclusion of one study on severely obese men, who exhibited the highest response rate to clomiphene citrate, the heterogeneity disappeared (mean difference: 10.27 nmol/L; 95% coefficient interval: 9.39, 11.16; I2 = 0%, pfor heterogeneity = 0.66). No publication bias was revealed by Egger's test and trim-and-fill analysis. No treatment-related unexpected findings regarding safety profile were registered. DISCUSSION AND CONCLUSION Treatment with clomiphene citrate and enclomiphene citrate may be an effective and safe alternative to testosterone replacement therapy in men with obesity-related functional androgen deficiency. Further long-term studies are warranted to define clinical reflections of the selective estrogen receptor modulators-induced increase in testosterone levels and to better clarify the safety profile.
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Affiliation(s)
- Daniele Tienforti
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Chiara Castellini
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Francesca Di Giulio
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Maria Totaro
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Gilda Dalmazio
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Luca Spagnolo
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
| | - Mario Muselli
- Department of Life, Health and Environmental Sciences, Epidemiology Division, University of L'Aquila, L'Aquila, Italy
| | | | - Marco Giorgio Baroni
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
- Neuroendocrinology and Metabolic Diseases, IRCCS Neuromed, Pozzilli, Italy
| | - Arcangelo Barbonetti
- Department of Clinical Medicine, Life, Health and Environmental Sciences, Andrology Unit, University of L'Aquila, L'Aquila, Italy
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Thomas J, Suarez Arbelaez MC, Narasimman M, Weber AR, Blachman-Braun R, White JT, Ledesma B, Ghomeshi A, Jara-Palacios MA, Ramasamy R. Efficacy of Clomiphene Citrate Versus Enclomiphene Citrate for Male Infertility Treatment: A Retrospective Study. Cureus 2023; 15:e41476. [PMID: 37546076 PMCID: PMC10404117 DOI: 10.7759/cureus.41476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Infertility and hypogonadism in males can greatly affect their reproductive health and overall well-being. Since exogenous testosterone administration for hypogonadism management may disrupt the normal hormonal cascade necessary for spermatogenesis, clomiphene citrate (CC) and enclomiphene citrate (EC) are medications often used to manage hypogonadism and male infertility. This study aims to directly compare the effects of CC and EC on serum testosterone levels and semen parameters in men to determine which medication may have an advantage in managing these conditions. Materials and methods We retrospectively analyzed ≥18-year-old men presenting with primary infertility, abnormal semen parameters, or hypogonadism who received CC or EC monotherapy for at least three months between January 2021 and December 2022. We compared baseline and follow-up hormone levels, semen parameters, and demographics. Variables were compared using paired and unpaired t-tests. Significance was assessed at p<0.05. Results A total of 46 men received EC and 32 men received CC. The median age was 42 (IQR: 34-47.75) years in men who received EC and 41 (IQR: 36-44) years in men who received CC (p=0.450). The two treatment groups exhibited a significant increase in serum total testosterone, while only EC had a statistically significant increase in FSH and LH. Semen volume and concentration did not significantly change with either treatment. Sperm motility increased in both groups, but total motile sperm count (TMSC) only significantly increased in men who received EC. Conclusions Our study found that EC and CC are effective treatments in increasing total testosterone without negatively affecting spermatogenesis. EC demonstrated to be more effective in raising gonadotropin levels and TMSC.
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Affiliation(s)
- Jamie Thomas
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
| | | | - Manish Narasimman
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Alexander R Weber
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Joshua T White
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Braian Ledesma
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Armin Ghomeshi
- Urology, Florida International University/Herbert Wertheim College of Medicine, Miami, USA
| | | | - Ranjith Ramasamy
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, USA
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Desai A, Yassin M, Cayetano A, Tharakan T, Jayasena CN, Minhas S. Understanding and managing the suppression of spermatogenesis caused by testosterone replacement therapy (TRT) and anabolic–androgenic steroids (AAS). Ther Adv Urol 2022; 14:17562872221105017. [PMID: 35783920 PMCID: PMC9243576 DOI: 10.1177/17562872221105017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Use of testosterone replacement therapy (TRT) and anabolic–androgenic steroids
(AAS) has increased over the last 20 years, coinciding with an increase in men
presenting with infertility and hypogonadism. Both agents have a detrimental
effect on spermatogenesis and pose a clinical challenge in the setting of
hypogonadism and infertility. Adding to this challenge is the paucity of data
describing recovery of spermatogenesis on stopping such agents. The unwanted
systemic side effects of these agents have driven the development of novel
agents such as selective androgen receptor modulators (SARMs). Data showing
natural recovery of spermatogenesis following cessation of TRT are limited to
observational studies. Largely, these have shown spontaneous recovery of
spermatogenesis after cessation. Contemporary literature suggests the time frame
for this recovery is highly variable and dependent on several factors including
baseline testicular function, duration of drug use and age at cessation. In some
men, drug cessation alone may not achieve spontaneous recovery, necessitating
hormonal stimulation with selective oestrogen receptor modulators
(SERMs)/gonadotropin therapy or even the need for assisted reproductive
techniques. However, there are limited prospective randomized data on the role
of hormonal stimulation in this clinical setting. The use of hormonal
stimulation with agents such as gonadotropins, SERMs, aromatase inhibitors and
assisted reproductive techniques should form part of the counselling process in
this cohort of hypogonadal infertile men. Moreover, counselling men regarding
the detrimental effects of TRT/AAS on fertility is very important, as is the
need for robust randomized studies assessing the long-term effects of novel
agents such as SARMs and the true efficacy of gonadotropins in promoting
recovery of spermatogenesis.
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Affiliation(s)
- Ankit Desai
- Department of Andrology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
| | - Musaab Yassin
- Department of Andrology, Imperial Healthcare NHS Trust, London, UK
| | - Axel Cayetano
- Department of Andrology, Imperial Healthcare NHS Trust, London, UK
| | - Tharu Tharakan
- Department of Andrology, Imperial Healthcare NHS Trust, London, UK
| | - Channa N. Jayasena
- Department of Reproductive Endocrinology, Imperial Healthcare NHS Trust, London, UK
| | - Suks Minhas
- Department of Andrology, Imperial Healthcare NHS Trust, London, UK
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Abstract
ABSTRACT Hypogonadism is a clinical syndrome of testosterone deficiency that presents with nonspecific symptoms of sexual dysfunction, fatigue, and decreased strength or muscle mass. Men with obesity, diabetes, and other comorbidities are at higher risk for hypogonadism. Patients presenting with symptoms should be tested for low testosterone and treated with testosterone replacement. Testosterone therapy carries risks and must be closely monitored. Patients treated for hypogonadism may experience improvement of symptoms and quality of life.
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Affiliation(s)
- Gina Ugo-Neff
- Gina Ugo-Neff practices at Uropartners at Rush University in Chicago, Ill. Denise Rizzolo is an assistant clinical professor in the Pace Completion Program in the Department of Physician Assistant Studies in New York City and an assessment specialist at the Physician Assistant Education Association. The authors have disclosed no potential conflicts of interest, financial or otherwise
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7
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Mani SB, Clavijo RI. Medical Treatment of Hypogonadism in Men. Urol Clin North Am 2022; 49:197-207. [DOI: 10.1016/j.ucl.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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8
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Suarez A MC, Israeli JM, Kresch E, Telis L, Nassau DE. Testosterone therapy in children and adolescents: to whom, how, when? Int J Impot Res 2022; 34:652-662. [PMID: 34997199 DOI: 10.1038/s41443-021-00525-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 11/09/2022]
Abstract
Male production of testosterone is crucial for the development of a wide range of functions. External and internal genitalia formation, secondary sexual characteristics, spermatogenesis, growth velocity, bone mass density, psychosocial maturation, and metabolic and cardiovascular profiles are closely dependent on testosterone exposure. Disorders in androgen production can present during all life-stages, including childhood and adolescence, and testosterone therapy (TT) is in many cases the only treatment that can correct the underlying deficit. TT is controversial in the pediatric population as hypoandrogenism is difficult to classify and diagnose in these age groups, and standardized protocols of treatment and monitorization are still lacking. In pediatric patients, hypogonadism can be central, primary, or a combination of both. Testosterone preparations are typically designed for adults' TT, and providers need to be aware of the advantages and disadvantages of these formulations, especially cognizant of supratherapeutic dosing. Monitoring of testosterone levels in boys on TT should be tailored to the individual patient and based on the anticipated duration of therapy. Although clinical consensus is lacking, an approximation of the current challenges and common practices in pediatric hypoandrogenism could help elucidate the broad spectrum of pathologies that lie behind this single hormone deficiency with wide-ranging implications.
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Affiliation(s)
- Maria Camila Suarez A
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Leon Telis
- Department of Urology, Lenox Hill Hospital, Donald and Barbra Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel E Nassau
- Department of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL, USA.
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9
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Shahid MN, Khan TM, Neoh CF, Lean QY, Bukhsh A, Karuppannan M. Effectiveness of Pharmacological Intervention Among Men with Infertility: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2021; 12:638628. [PMID: 34483894 PMCID: PMC8415454 DOI: 10.3389/fphar.2021.638628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/09/2021] [Indexed: 01/18/2023] Open
Abstract
Background. Infertility is an emerging health issue for men. Comparative efficacy of different pharmacological interventions on male infertility is not clear. The aim of this review is to investigate the efficacy of various pharmacological interventions among men with idiopathic male infertility. All randomized control trials evaluating the effectuality of interventions on male infertility were included for network meta-analysis (NMA) from inception to 31 April 2020, systematically performed using STATA through the random effect model. The protocol was registered at PROSPERO (CRD42020152891). Results. The outcomes of interest were semen and hormonal parameters. Treatment effects (p < 0.05) were estimated through WMD at the confidence interval of 95%. Upon applying exclusion criteria, n=28 RCTs were found eligible for NMA. Results from NMA indicated that consumption of supplements increases sperm concentration levels [6.26, 95% CI 3.32, 9.21] in comparison to SERMs [4.97, 95% CI 1.61, 8.32], hormones [4.14, 95% CI 1.83, 6.46], and vitamins [0.15, 95% CI -20.86, 21.15)] with placebo, whereas the use of SERMs increased percentage sperm motility [6.69, 95% CI 2.38, 10.99] in comparison to supplements [6.46, 95% CI 2.57, 10.06], hormones [3.47, 95% CI 0.40, 6.54], and vitamins [-1.24, 95% CI -11.84, 9.43] with placebo. Consumption of hormones increased the sperm morphology [3.71, 95% CI, 1.34, 6.07] in contrast to supplements [2.22, 95% CI 0.12, 4.55], SERMs [2.21, 95% CI -0.78, 5.20], and vitamins [0.51, 95% CI -3.60, 4.62] with placebo. Supplements boosted the total testosterone levels [2.70, 95% CI 1.34, 4.07] in comparison to SERMs [1.83, 95% CI 1.16, 2.50], hormones [0.40, 95% CI -0.49, 1.29], and vitamins [-0.70, 95% CI -6.71, 5.31] with placebo. SERMs increase the serum FSH levels [3.63, 95% CI 1.48, 5.79] better than hormones [1.29, 95% CI -0.79, 3.36], vitamins [0.03, 95% CI -2.69, 2.76], and supplements [-4.45, 95% CI -7.15, -1.76] in comparison with placebo. Conclusion. This review establishes that all interventions had a significantly positive effect on male infertility. Statistically significant increased sperm parameters were noted in combinations of zinc sulfate (220 mg BID), clomiphene citrate (50 mg BID), and testosterone undecanoate and CoQ10; tamoxifen citrate and FSH were shown to improve the hormonal profile in infertile males.
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Affiliation(s)
- Muhammad Nabeel Shahid
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Tahir Mehmood Khan
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Chin Fen Neoh
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Qi Ying Lean
- Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Pulau Pinang, Malaysia
- Vector-Borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia
| | - Allah Bukhsh
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Mahmathi Karuppannan
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
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Whitaker DL, Geyer-Kim G, Kim ED. Anabolic steroid misuse and male infertility: management and strategies to improve patient awareness. Expert Rev Endocrinol Metab 2021; 16:109-122. [PMID: 33973822 DOI: 10.1080/17446651.2021.1921574] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
Introduction: Anabolic androgenic steroid use is an uncommon but important cause of male infertility. As paternal age and anabolic steroid use increases, providers are more likely than ever to encounter men with infertility and prior or concurrent anabolic steroid use. In this review, we outline the background, epidemiology and pathophysiology of anabolic steroid induced male infertility and provide recommendations regarding the diagnosis, management, and future prevention of this condition.Areas covered: Male reproductive physiology is a tightly regulated process that can be influenced by exogenous sources such as anabolic steroids and selective androgen receptor modulators (SARMs). Data suggest that a combination of selective estrogen receptor modulators (SERMs), human chorionic gonadotropin (hCG), aromatase inhibitors (AIs), and recombinant follicle-stimulating hormone (rFSH) may lead to spermatogenesis recovery.Expert opinion: Anabolic steroid and SARM users continue to exhibit lack of understanding regarding the potential side effects of their use on male fertility. Current literature suggests that spermatogenesis can be safely recovered using a combination of SERMs, hCG, AIs and rFSH although additional studies are necessary. While anabolic steroid prevention strategies have largely been focused on the individual level, further investigation is necessary and should be approached in a socioecological manner.
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Affiliation(s)
- Dustin L Whitaker
- Department of Urology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, United States
| | - Gabriella Geyer-Kim
- Department of Urology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, United States
| | - Edward D Kim
- Department of Urology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, United States
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11
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Mielewczyk J, Świętochowska E, Ostrowska Z, Miczek I. Diagnosis and Management of Testosterone Deficiency
in men: A review of the European and American Urology
Associations. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.8308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ambiguous data on both terminology, diagnostics, and treatment of testosterone deficiency in
men prompted us to attempt a critical analysis of existing knowledge on this subject.
Current guidelines of both American and European Association of Urology (AUA, EUA) define
testosterone therapy as effective and safe. However, media reports and some scientific reports
indicating negative effects of the abovementioned therapy arouse aversion to its use by doctors
and potential patients for fear of developing prostate cancer or cardiovascular incidents. The
peak of scepticism about testosterone therapy was observed after the publication in 2013 and
2014, respectively, two retrospective data analysis on this topic, which resulted in the discontinuation
of therapy in many patients with long histories of benefits from testosterone therapy.
In addition, in many men with indications for testosterone therapy, this treatment was not
used for fear of patient safety. However, the latest data on these concerns do not confirm any
negative effects. More than 100 recently published scientific studies have shown the beneficial effects of testosterone
therapy on many aspects of health. The American Society of Clinical Endocrinologists
(AACE) and the American College of Endocrinology (ACE) have jointly developed their own
literature assessment, stating that there is no convincing evidence that testosterone therapy
increases the risk of cardiovascular incidents. The same conclusions can be drawn from the
current EAU and AUA guidelines.
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Affiliation(s)
- Jarosław Mielewczyk
- Katedra i Zakład Biologii Medycznej i Molekularnej, Wydział Nauk Medycznych w Zabrzu, Śląski Uniwersytet Medyczny w Katowicach
| | - Elżbieta Świętochowska
- Katedra i Zakład Biologii Medycznej i Molekularnej, Wydział Nauk Medycznych w Zabrzu, Śląski Uniwersytet Medyczny w Katowicach
| | - Zofia Ostrowska
- Katedra i Zakład Biologii Medycznej i Molekularnej, Wydział Nauk Medycznych w Zabrzu, Śląski Uniwersytet Medyczny w Katowicach
| | - Igor Miczek
- Katedra i Zakład Biologii Medycznej i Molekularnej, Wydział Nauk Medycznych w Zabrzu, Śląski Uniwersytet Medyczny w Katowicach
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12
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Masterson TA, Turner D, Vo D, Blachman-Braun R, Best JC, Westfield G, Bryson N, Ramasamy R. The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone. Sex Med Rev 2020; 9:143-148. [PMID: 32912767 DOI: 10.1016/j.sxmr.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Testosterone (T) replacement therapy causes suppression of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that can lead to decrease in semen parameters and possible infertility. Different T formulations may have varying suppression on FSH and LH. OBJECTIVE To study whether shorter-acting T (multiple daily dosing) has less suppression on FSH and LH serum levels compared with longer-acting T (transdermal gel, injectable). METHODS A systematic literature search was conducted by following the protocol based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols. We comprehensively reviewed the literature by systematically searching manuscripts indexed in PubMed from 1995 to March 13, 2019 to identify studies reporting changes in FSH and LH in hypogonadal men treated with exogenous T which evaluated the effect of exogenous T on FSH and LH. RESULTS A total of 8 studies reported the effect of T on FSH and LH in 793 hypogonadal men: 2 used long-acting injectables (enanthate or undecanoate) in a total of 16 men, 5 used intermediate-acting daily topical gels or patches in a total of 471 men, and 1 used short-acting intranasal T (125 μL/nostril, twice a day or three times a day) in 306 men. Long-acting injectables decreased FSH by 86.3%, intermediate-acting daily gels/patches decreased FSH by 60.2%, and short-acting intranasal gel decreased FSH by 37.8%. Long-acting injectables decreased LH by 71.8%, intermediate-acting daily gels/patches decreased LH by 59.2%, and short-acting intranasal gel decreased LH by 47.3%. CONCLUSIONS Our findings suggest that short-acting T preparations do not decrease serum FSH or LH to the same extent as longer-acting transdermal gels and injectables. However, further clinical trial data are necessary to determine whether the effect of short-acting TRT on gonadotropins translates into similar changes in semen parameters and fertility. Masterson TA, Turner D, Vo D, et al. The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone. Sex Med Rev 2021;9:143-148.
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Affiliation(s)
- Thomas A Masterson
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darren Turner
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Duyen Vo
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ruben Blachman-Braun
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jordan C Best
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Nathan Bryson
- Acerus Pharmaceuticals Corporation, Mississauga, ON, Canada
| | - Ranjith Ramasamy
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.
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Oostingh EC, Huijgen NA, Koedooder R, Dohle GR, Stricker BH, Steegers-Theunissen RP. Potential benefits of the use of sympathomimetics for asthmatic disease, on semen quality in men of subfertile couples. Reprod Biomed Online 2019; 40:423-428. [PMID: 32122752 DOI: 10.1016/j.rbmo.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022]
Abstract
RESEARCH QUESTION Is there an association between the use of sympathomimetics for asthmatic disease and semen quality in humans? DESIGN Between 2007 and 2012 a prospective cohort study was conducted among couples visiting the preconception counselling clinic at a tertiary hospital in the Netherlands. The study included 882 men of subfertile couples and information on medication use was obtained from self-administered questionnaires. Moreover, data on semen parameters were retrieved from medical records. RESULTS The study population of men revealed a mean (± SD) age of 34 ± 4 years with a mean body mass index (BMI) of 26.1 ± 2.3 kg/m2, and sympathomimetic use was reported by 3.6%. The use of sympathomimetics was positively associated with a 10% higher sperm motility (beta 10.265; 95% confidence interval [CI] 3.258-17.272) after adjustment for smoking, alcohol use, age, geographic background, BMI, folic acid supplement use, the four astronomical seasons and asthma/bronchitis. Subgroup analysis between men with total motile sperm count (TMSC) < or ≥10 million showed that this association remained (P ≤ 0.001) after adjustment for these confounders. After adjustment for confounders the sperm concentration was also positively associated with the use of sympathomimetics, but only in men with TMSC ≥10 million (beta 0.300; 95% CI 0.032-0.568). CONCLUSIONS These preliminary data show the potential benefits of the use of sympathomimetics to improve sperm motility in men of subfertile couples, which needs further investigation.
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Affiliation(s)
- Elsje C Oostingh
- Department of Obstetrics and Gynecology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Nicole A Huijgen
- Department of Obstetrics and Gynecology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Rivka Koedooder
- Department of Obstetrics and Gynecology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Gert R Dohle
- Department of Urology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Bruno Hc Stricker
- Department of Epidemiology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Régine Pm Steegers-Theunissen
- Department of Obstetrics and Gynecology, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands.
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Awouters M, Vanderschueren D, Antonio L. Aromatase inhibitors and selective estrogen receptor modulators: Unconventional therapies for functional hypogonadism? Andrology 2019; 8:1590-1597. [DOI: 10.1111/andr.12725] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Marijke Awouters
- Department of Pediatrics University Hospitals Leuven Leuven Belgium
| | - Dirk Vanderschueren
- Department of Endocrinology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA) Laboratory of Clinical and Experimental Endocrinology KU Leuven Leuven Belgium
| | - Leen Antonio
- Department of Endocrinology University Hospitals Leuven Leuven Belgium
- Department of Chronic Diseases, Metabolism and Ageing (CHROMETA) Laboratory of Clinical and Experimental Endocrinology KU Leuven Leuven Belgium
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15
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Earl JA, Kim ED. Enclomiphene citrate: A treatment that maintains fertility in men with secondary hypogonadism. Expert Rev Endocrinol Metab 2019; 14:157-165. [PMID: 31063005 DOI: 10.1080/17446651.2019.1612239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/24/2019] [Indexed: 12/13/2022]
Abstract
Hypogonadism is an important issue among the male population. Treatments such as exogenous testosterone have become very popular. One of the adverse effects of testosterone is its suppression of fertility. This has lead to the use of alternative therapies such as selective estrogen receptor modulators (SERMs) that aim to correct hypogonadism without reducing fertility. Areas covered: The SERM, clomiphene citrate, which is approved by the FDA for the treatment of ovarian dysfunction, has been shown to have beneficial effects on male hypogonadism. Clomiphene citrate exists as a mixture of both the cis-isomer (zuclomiphene) and the trans-isomer (enclomiphene). The literature has suggested that most of the beneficial effects of clomiphene are due to the trans-isomer enclomiphene. Zuclomiphene contributes little to the intended outcomes. The purpose of this drug profile is to examine the available literature on the trans-isomer enclomiphene. Expert opinion: Enclomiphene has been shown to increase testosterone levels while stimulating FSH and LH production. Initial studies demonstrated that enclomiphene maintains the androgenic benefit of clomiphene citrate without the undesirable effects attributable to zuclomiphene. This article reviews the difficulties associated with the FDA approval of a new molecular entity related to the treatment of hypogonadism.
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Affiliation(s)
- Joshua A Earl
- a Department of Urology , University of Tennessee, Graduate School of Medicine , Knoxville , TN , USA
| | - Edward D Kim
- a Department of Urology , University of Tennessee, Graduate School of Medicine , Knoxville , TN , USA
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16
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Miller GD, Moore C, Nair V, Hill B, Willick SE, Rogol AD, Eichner D. Hypothalamic-Pituitary-Testicular Axis Effects and Urinary Detection Following Clomiphene Administration in Males. J Clin Endocrinol Metab 2019; 104:906-914. [PMID: 30295816 DOI: 10.1210/jc.2018-01159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/01/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Clomiphene is a performance-enhancing drug commonly abused by males in sport, but the extent to which testosterone increases in healthy males following its use is unknown. In addition, evidence suggests that clomiphene, a mixture of cis- and trans-isomers zuclomiphene and enclomiphene, is detectable in urine for months following use; the isomer-specific urinary detection window has yet to be characterized in a controlled study. OBJECTIVE To determine the effect of once-daily, 30-day clomiphene treatment on serum testosterone and gonadotropin levels in the subject population studied and the urinary clearance and detection window of clomiphene isomers following administration for antidoping purposes. PARTICIPANTS AND DESIGN Twelve healthy males aged 25 to 38 years, representing a recreational athlete population, participated in this open-label, single-arm study. INTERVENTION Oral clomiphene citrate (50 mg) was self-administered once daily for 30 days. Serum and urine samples were collected at baseline and at days 7, 14, 21, 28, 30, 32, 35, 37, 44, 51, and 58; urine collections continued periodically up to day 261. RESULTS Mean testosterone, LH, and FSH levels increased 146% (SEM, ±23%), 177% (±34%), and 170% (±33%), respectively, during treatment compared with baseline. Serum drug concentrations and urinary excretion were nonuniform among individuals as isomeric concentrations varied. The zuclomiphene urinary detection window ranged from 121 to >261 days. CONCLUSIONS Clomiphene significantly raised serum testosterone and gonadotropin levels in healthy men and thus can be abused as a performance-enhancing drug. Such abuse is detectable in urine for ≥4 months following short-term use.
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Affiliation(s)
- Geoffrey D Miller
- Sports Medicine Research and Testing Laboratory, Salt Lake City, Utah
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chad Moore
- Sports Medicine Research and Testing Laboratory, Salt Lake City, Utah
| | - Vinod Nair
- Sports Medicine Research and Testing Laboratory, Salt Lake City, Utah
| | - Brian Hill
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stuart E Willick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alan D Rogol
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Daniel Eichner
- Sports Medicine Research and Testing Laboratory, Salt Lake City, Utah
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
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17
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Testosterone Replacement Therapy Versus Clomiphene Citrate in the Young Hypogonadal Male. Eur Urol Focus 2018; 4:321-323. [PMID: 30131284 DOI: 10.1016/j.euf.2018.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/13/2018] [Accepted: 07/24/2018] [Indexed: 02/07/2023]
Abstract
The use of testosterone to treat hypogonadal symptoms has increased during the past decade. Consequently, one clinical challenge that has arisen is how to approach the young and treatment-naïve hypogonadal patient who is still within his reproductive years and may desire children in the future. Testosterone is known to suppress the hypothalamic-pituitary-gonadal axis resulting in suppressed spermatogenesis. There is a concern that, in some men, prolonged testosterone use may result in permanent spermatogenic failure. PATIENT SUMMARY: In this review, we discuss the risks and benefits of available treatment options for the young hypogonadal patient for whom future fertility is an important consideration. Fortunately, alternatives such as clomiphene citrate and human chorionic gonadotropin have been shown to increase endogenous testosterone production. However, their efficacy as treatments for hypogonadal symptoms is still under debate.
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18
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Kobayashi M, Hori T, Kawakami E. Therapeutic effects of oral clomiphene citrate in 2 dogs with low plasma testosterone levels and poor semen quality. J Vet Med Sci 2018; 80:1233-1235. [PMID: 29937459 PMCID: PMC6115249 DOI: 10.1292/jvms.18-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Two dogs with low plasma testosterone (T) levels and poor semen quality were administered
one tablet of 12.5 mg clomiphene citrate orally per day at 2-day intervals for 4 weeks.
Plasma T levels, total sperm count, and sperm motility in both dogs temporarily increased
between 3 and 6 weeks after the start of treatment. These results indicate that poor semen
quality in dogs with low plasma T level can be improved by oral administration of
clomiphene citrate.
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Affiliation(s)
- Masanori Kobayashi
- Laboratory of Reproduction, Faculty of Veterinary Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo 180-8602, Japan
| | - Tatsuya Hori
- Laboratory of Reproduction, Faculty of Veterinary Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo 180-8602, Japan
| | - Eiichi Kawakami
- Laboratory of Reproduction, Faculty of Veterinary Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo 180-8602, Japan
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19
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Khourdaji I, Lee H, Smith RP. Frontiers in hormone therapy for male infertility. Transl Androl Urol 2018; 7:S353-S366. [PMID: 30159242 PMCID: PMC6087845 DOI: 10.21037/tau.2018.04.03] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
For a significant number of couples worldwide, infertility is a harsh reality. As specialists in male infertility, much of our armamentarium lacks definitive, evidence-based therapies. For years, we have relied on manipulation of the male hormonal axis to treat those men who help carry the burden of infertility in their partnerships. Indeed, male factor infertility is the sole component of infertility in at least 20% of couples. Further compounding this dilemma is that 25% to 50% of males with infertility have no identifiable etiology and thus present a true management conundrum. This manuscript is an attempt to clarify what therapies exist for the treatment of male factor infertility. We have reviewed the relevant infertility literature honing, our focus on hormonal anomalies and their subsequent impact on fertility. Many of the therapies discussed have been utilized in practice for generations. Thus, this article attempts to provide the evidence-based literature to support the continued use of the current treatment paradigm. Furthermore, we recognize that any review beckons a discussion of what challenges and therapies await on the horizon. For instance, there has been significant interest in restoring spermatogenesis after testosterone replacement therapy (TRT). We explore the adverse long-term spermatogenic outcomes associated with TRT, which with the widespread use of TRT, will inevitably present a great challenge for male infertility specialists. Moreover, we discuss the role of varicocelectomy in the treatment of hypogonadism and infertility, review the association between growth hormone (GH) and male fertility and address the challenges presented by the rising prevalence of obesity.
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Affiliation(s)
- Iyad Khourdaji
- Department of Urology, University of Virginia Health System, Charlottesville, VA, USA
| | - Haerin Lee
- Department of Urology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ryan P Smith
- Department of Urology, University of Virginia Health System, Charlottesville, VA, USA
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20
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Alder NJ, Keihani S, Stoddard GJ, Myers JB, Hotaling JM. Combination therapy with clomiphene citrate and anastrozole is a safe and effective alternative for hypoandrogenic subfertile men. BJU Int 2018; 122:688-694. [PMID: 29873446 DOI: 10.1111/bju.14390] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of combination therapy with clomiphene citrate (CC) and anastrozole (AZ) for male hypoandrogenism. PATIENTS AND METHODS We identified patients treated with a combination of CC + AZ in the period 2014 to 2017. Data were gathered on patient characteristics and laboratory values at baseline. Total testosterone, bioavailable testosterone, oestradiol and testosterone:oestradiol ratio were measured before combination therapy (treatment with CC only) and at CC + AZ combination therapy follow-ups. Treatment side effects were recorded; prostatic-specific antigen and haematocrit levels were measured to assess safety after 6 months. As a secondary outcome, semen characteristics were compared at baseline and after at least 3 months of combination therapy when these data were available. Data were analysed using a paired t-test and Wilcoxon's signed-rank test. RESULTS A total of 51 men were included, with a mean age of 35.4 ± 7.4 years and a mean body mass index of 35.0 ± 8.0 kg/m2 . After CC treatment, total testosterone, bioavailable testosterone, and oestradiol levels all significantly increased. AZ was added in all patients with hyperoestrogenaemia (oestradiol >50 pg/mL) or a testosterone:oestradiol ratio <10. CC + AZ therapy maintained therapeutic total testosterone and bioavailable testosterone levels while also normalizing oestradiol levels and testosterone:oestradiol ratio. Eleven patients experienced side effects: anxiety/irritability, n = 5; decreased libido, n = 4; elevated (>54%) haematocrit, n = 2. CONCLUSION Combination therapy with CC + AZ is an effective and safe alternative for patients with elevated oestradiol level or low testosterone:oestradiol ratio.
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Affiliation(s)
- Nathan J Alder
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.,Andrology and IVF Laboratory, Department of Surgery (Urology), University of Utah, Salt Lake City, UT, USA
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21
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Rastrelli G, Maggi M, Corona G. Pharmacological management of late-onset hypogonadism. Expert Rev Clin Pharmacol 2018; 11:439-458. [DOI: 10.1080/17512433.2018.1445969] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Giulia Rastrelli
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
- I.N.B.B.—Istituto Nazionale Biostrutture e Biosistemi, Rome, Italy
| | - Giovanni Corona
- Sexual Medicine and Andrology Unit Department of Experimental Clinical and Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
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22
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Systematic review of hormone replacement therapy in the infertile man. Arab J Urol 2017; 16:140-147. [PMID: 29713545 PMCID: PMC5922183 DOI: 10.1016/j.aju.2017.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/10/2017] [Accepted: 11/18/2017] [Indexed: 01/08/2023] Open
Abstract
Objectives To highlight alternative treatment options other than exogenous testosterone administration for hypogonadal men with concomitant infertility or who wish to preserve their fertility potential, as testosterone replacement therapy (TRT) inhibits spermatogenesis, representing a problem for hypogonadal men of reproductive age. Materials and methods We performed a comprehensive literature review for the years 1978–2017 via PubMed. Also abstracts from major urological/surgical conferences were reviewed. Review was consistent with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) criteria. We used Medical Subject Heading terms for the search including ‘testosterone replacement therapy’ or ‘TRT’ and ‘male infertility’. Results In all, 91 manuscripts were screened and the final number used for the review was 56. All studies included were performed in adults, were written in English and had an abstract available. Conclusions Exogenous testosterone inhibits spermatogenesis. Hypogonadal men wanting to preserve their fertility and at the same time benefiting from TRT effects can be prescribed selective oestrogen receptor modulators or testosterone plus low-dose human chorionic gonadotrophin (hCG). Patients treated for infertility with hypogonadotrophic hypogonadism can be prescribed hCG alone at first followed by or in combination from the start with follicle-stimulating hormone preparations.
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23
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“Cherchez La Femme”: Modulation of Estrogen Receptor Function With Selective Modulators: Clinical Implications in the Field of Urology. Sex Med Rev 2017; 5:365-386. [DOI: 10.1016/j.sxmr.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/22/2022]
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24
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Abstract
The treatment of hypogonadism in men is of great interest to both patients and providers. There are a number of testosterone formulations currently available and several additional formulations under development. In addition, there are some lesser-used alternative therapies for the management of male hypogonadism, which may have advantages for certain patient groups. The future of hypogonadism therapy may lie in the development of selective androgen receptor modulators that allow the benefits of androgens whilst minimizing unwanted side effects.
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Affiliation(s)
- Arthi Thirumalai
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kathryn E Berkseth
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - John K Amory
- Center for Research in Reproduction and Contraception, Department of Medicine, University of Washington, Seattle, WA, USA
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25
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McBride JA, Coward RM. Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use. Asian J Androl 2017; 18:373-80. [PMID: 26908067 PMCID: PMC4854084 DOI: 10.4103/1008-682x.173938] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The use of testosterone replacement therapy (TRT) for hypogonadism continues to rise, particularly in younger men who may wish to remain fertile. Concurrently, awareness of a more pervasive use of anabolic-androgenic steroids (AAS) within the general population has been appreciated. Both TRT and AAS can suppress the hypothalamic-pituitary-gonadal (HPG) axis resulting in diminution of spermatogenesis. Therefore, it is important that clinicians recognize previous TRT or AAS use in patients presenting for infertility treatment. Cessation of TRT or AAS use may result in spontaneous recovery of normal spermatogenesis in a reasonable number of patients if allowed sufficient time for recovery. However, some patients may not recover normal spermatogenesis or tolerate waiting for spontaneous recovery. In such cases, clinicians must be aware of the pathophysiologic derangements of the HPG axis related to TRT or AAS use and the pharmacologic agents available to reverse them. The available agents include injectable gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors, but their off-label use is poorly described in the literature, potentially creating a knowledge gap for the clinician. Reviewing their use clinically for the treatment of hypogonadotropic hypogonadism and other HPG axis abnormalities can familiarize the clinician with the manner in which they can be used to recover spermatogenesis after TRT or AAS use.
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Affiliation(s)
| | - Robert M Coward
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7235, USA
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26
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Rubinow KB. Estrogens and Body Weight Regulation in Men. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1043:285-313. [PMID: 29224100 DOI: 10.1007/978-3-319-70178-3_14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Our understanding of the metabolic roles of sex steroids in men has evolved substantially over recent decades. Whereas testosterone once was believed to contribute to metabolic risk in men, the importance of adequate androgen exposure for the maintenance of metabolic health has been demonstrated unequivocally. A growing body of evidence now also supports a critical role for estrogens in metabolic regulation in men. Recent data from clinical intervention studies indicate that estradiol may be a stronger determinant of adiposity than testosterone in men, and even short-term estradiol deprivation contributes to fat mass accrual. The following chapter will outline findings to date regarding the mechanisms, whereby estrogens contribute to the regulation of body weight and adiposity in men. It will present emergent clinical data as well as preclinical findings that reveal mechanistic insights into estrogen-mediated regulation of body composition. Findings in both males and females will be reviewed, to draw comparisons and to highlight knowledge gaps regarding estrogen action specifically in males. Finally, the clinical relevance of estrogen exposure in men will be discussed, particularly in the context of a rising global prevalence of obesity and expanding clinical use of sex steroid-based therapies in men.
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Affiliation(s)
- Katya B Rubinow
- Division of Metabolism, Endocrinology, and Nutrition Department of Medicine, University of Washington, Seattle, WA, USA.
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27
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Abstract
Subfertility is defined as the condition of being less than normally fertile though still capable of effecting fertilization. When these subfertile couples seek assistance for conception, a thorough evaluation of male endocrine function is often overlooked. Spermatogenesis is a complex process where even subtle alterations in this process can lead to subfertility or infertility. Male endocrine abnormalities may suggest a specific diagnosis contributing to subfertility; however, in many patients, the underlying etiology is still unknown. Optimizing underlying endocrine abnormalities may improve spermatogenesis and fertility. This manuscript reviews reproductive endocrine abnormalities and hormone-based treatments.
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28
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A Comparison of Secondary Polycythemia in Hypogonadal Men Treated with Clomiphene Citrate versus Testosterone Replacement: A Multi-Institutional Study. J Urol 2016; 197:1127-1131. [PMID: 27984109 DOI: 10.1016/j.juro.2016.10.068] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 11/22/2022]
Abstract
PURPOSE We evaluated the relative prevalence of secondary polycythemia in hypogonadal men treated with clomiphene citrate or testosterone replacement therapy. MATERIALS AND METHODS In this retrospective, multi-institutional study, we included 188 men who received clomiphene citrate and 175 who received testosterone replacement therapy with symptomatic hypogonadism. The overall prevalence and ORs of secondary polycythemia for clomiphene citrate treatment vs testosterone replacement were primarily measured, as were baseline characteristics. Subset analysis included polycythemia rates for different types of testosterone replacement therapy. RESULTS Overall, men on testosterone replacement therapy were older than clomiphene citrate treated men (age 51.5 vs 38 years). Men on testosterone replacement had longer treatment duration than clomiphene citrate treated men (19.6 vs 9.2 months). For testosterone replacement therapy and clomiphene citrate the mean change in hematocrit was 3.0% and 0.6%, and the mean change in serum testosterone was 333.1 and 367.6 ng/dl, respectively. The prevalence of polycythemia in men on testosterone replacement was 11.2% vs 1.7% in men on clomiphene citrate (p = 0.0003). This significance remained on logistic regression after correcting for age, site, smoking history and pretreatment hematocrit. CONCLUSIONS The prevalence of polycythemia in men treated with clomiphene citrate was markedly lower than that in men on testosterone replacement therapy. The improvement in absolute serum testosterone levels was similar to that in men on testosterone replacement. There is no significant risk of polycythemia in men treated with clomiphene citrate for hypogonadism.
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Helo S, Mahon J, Ellen J, Wiehle R, Fontenot G, Hsu K, Feustel P, Welliver C, McCullough A. Serum levels of enclomiphene and zuclomiphene in men with hypogonadism on long-term clomiphene citrate treatment. BJU Int 2016; 119:171-176. [DOI: 10.1111/bju.13625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Sevann Helo
- Division of Urology; Albany Medical College; Albany NY USA
| | - Joseph Mahon
- Division of Urology; Albany Medical College; Albany NY USA
| | | | - Ron Wiehle
- Repros Therapeutics; The Woodlands TX USA
| | | | - Kuang Hsu
- Repros Therapeutics; The Woodlands TX USA
| | - Paul Feustel
- Department of Neuropharmacology and Neuroscience; Albany Medical College; Albany NY USA
| | - Charles Welliver
- Division of Urology; Albany Medical College; Albany NY USA
- Urological Institute of Northeastern New York; Division of Urology; Albany NY USA
| | - Andrew McCullough
- Division of Urology; Albany Medical College; Albany NY USA
- Urological Institute of Northeastern New York; Division of Urology; Albany NY USA
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Bertrand-Delepine J, Leroy C, Rigot JM, Catteau-Jonard S, Dewailly D, Robin G. Stimulation de la spermatogenèse : pour qui ? Pourquoi ? Comment ? ACTA ACUST UNITED AC 2016; 44:505-16. [DOI: 10.1016/j.gyobfe.2016.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/24/2016] [Indexed: 12/23/2022]
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Rodriguez KM, Pastuszak AW, Lipshultz LI. Enclomiphene citrate for the treatment of secondary male hypogonadism. Expert Opin Pharmacother 2016; 17:1561-7. [PMID: 27337642 DOI: 10.1080/14656566.2016.1204294] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Hypogonadism is a growing concern in an aging male population. Historically treated using exogenous testosterone, concerns about possible adverse effects of testosterone have led physicians to seek alternative treatment approaches. AREAS COVERED Enclomiphene citrate is the trans isomer of clomiphene citrate, a non-steroidal estrogen receptor antagonist that is FDA-approved for the treatment of ovarian dysfunction in women. Clomiphene citrate has also been used off-label for many years to treat secondary male hypogonadism, particularly in the setting of male infertility. Here we review the literature examining the efficacy and safety of enclomiphene citrate in the setting of androgen deficiency. EXPERT OPINION Initial results support the conclusion that enclomiphene citrate increases serum testosterone levels by raising luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, without negatively impacting semen parameters. The ability to treat testosterone deficiency in men while maintaining fertility supports a role for enclomiphene citrate in the treatment of men in whom testosterone therapy is not a suitable option.
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Affiliation(s)
| | - Alexander W Pastuszak
- b Center for Reproductive Medicine , Baylor College of Medicine , Houston , TX , USA.,c Scott Department of Urology , Baylor College of Medicine , Houston , TX , USA
| | - Larry I Lipshultz
- b Center for Reproductive Medicine , Baylor College of Medicine , Houston , TX , USA.,c Scott Department of Urology , Baylor College of Medicine , Houston , TX , USA
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Chandrapal JC, Nielson S, Patel DP, Zhang C, Presson AP, Brant WO, Myers JB, Hotaling JM. Characterising the safety of clomiphene citrate in male patients through prostate-specific antigen, haematocrit, and testosterone levels. BJU Int 2016; 118:994-1000. [PMID: 27226135 DOI: 10.1111/bju.13546] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the safety profile of clomiphene citrate (CC) in men being treated for hypogonadism or infertility by measuring prostate-specific antigen (PSA), haematocrit (Hct), and testosterone levels. PATIENTS AND METHODS We identified patients presenting to our institution who were placed on CC, 50 mg every day or every other day, for male infertility and/or symptomatic hypoandrogenism between September 2013 and April 2016. Patients with documented exogenous testosterone, human chorionic gonadotrophin, or anastrozole use within 2 weeks of baseline evaluations were excluded. Our primary outcomes were the effects of CC on PSA, Hct, and total testosterone levels evaluated at the 3, 6, 9, or 12 months of follow-up. Outcomes were averaged within patients across visits and summarised by mean, median, range, standard deviation (SD) and the 95% confidence interval (CI) for the mean. RESULTS A total of 77 patients had recorded PSA, Hct, and/or testosterone values. The mean (SD, range) age and body mass index was 34 (6, 22-51) years and 31 (6, 22-52) kg/m2 , respectively. The mean (SD) follow-up was 358 (29) days. Within this group, CC concentration was changed in 24 patients (31%) and was discontinued in 24 patients (31%). The median (range) duration of CC therapy before discontinuation was 127 (44-161) days. The use of CC significantly raised both mean total and bioavailable testosterone levels by 200 ng/dL and 126 ng/dL, respectively (P < 0.001). This increase in testosterone had significant clinical effects with improvements in Androgen Deficiency in Aging Male questionnaire scores (P < 0.01) but not Sexual Health Inventory for Men scores. CC had no effect on mean PSA (1 ng/dL, 95% CI 0.8-1.1) or Hct (49%, 95% CI 41-53) levels, which were within normal ranges. CONCLUSIONS As more men are placed on CC for infertility or hypogonadism, characterising the safety effect profile becomes important. Our study found that CC significantly increased testosterone levels without changing PSA or Hct values. Because the biochemical response to CC can vary, we suggest scheduling laboratory evaluation at regular intervals; however, ordering routine assessment of PSA and Hct may not be necessary.
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Affiliation(s)
| | - Spencer Nielson
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Darshan P Patel
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Chong Zhang
- Division of Epidemiology and Biostatistics, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Division of Epidemiology and Biostatistics, University of Utah, Salt Lake City, UT, USA
| | - William O Brant
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, University of Utah, Salt Lake City, UT, USA
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Ring JD, Lwin AA, Köhler TS. Current medical management of endocrine-related male infertility. Asian J Androl 2016; 18:357-63. [PMID: 27098657 PMCID: PMC4854080 DOI: 10.4103/1008-682x.179252] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 01/16/2023] Open
Abstract
Male factor contributes to 50%-60% of overall infertility but is solely responsible in only 20% of couples. Although most male factor infertility is ascertained from an abnormal semen analysis, other male factors can be contributory especially if the sample returns normal. Male infertility can be due to identifiable hormonal or anatomical etiologies that may be reversible or irreversible. This manuscript will highlight existing guidelines and our recommendations for hormone evaluation for male infertility and empiric therapies including multivitamins, estrogen receptor modulators (clomiphene), estrogen conversion blockers (anastrozole), and hormone replacement.
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Affiliation(s)
- Joshua D Ring
- Division of Urology, Department of Surgery, Southern Illinois University, Springfield, IL 62794, USA
| | - Aye A Lwin
- Division of Urology, Department of Surgery, Southern Illinois University, Springfield, IL 62794, USA
| | - Tobias S Köhler
- Division of Urology, Department of Surgery, Southern Illinois University, Springfield, IL 62794, USA
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Ramasamy R, Armstrong JM, Lipshultz LI. Preserving fertility in the hypogonadal patient: an update. Asian J Androl 2015; 17:197-200. [PMID: 25337850 PMCID: PMC4378070 DOI: 10.4103/1008-682x.142772] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An increasing number of young and middle-aged men are seeking treatment for symptoms related to deficient levels of androgens (hypogonadism) including depression, loss of libido, erectile dysfunction, and fatigue. The increase in prevalence of testosterone supplementation in general and anabolic steroid-induced hypogonadism specifically among younger athletes is creating a population of young men who are uniquely impacted by the testicular end-organ negative consequences of exogenous steroid use. Exogenous testosterone therapy can alter the natural regulation of the hypothalamic-pituitary-gonadal axis leading to impaired spermatogenesis with azoospermia being a serious possible result, thus rendering the individual infertile. For men of reproductive age who suffer from hypogonadal symptoms, preservation of fertility is an important aspect of their treatment paradigm. Treatment with human chorionic gonadotropin (hCG) has shown the ability not only to reverse azoospermia brought on by testosterone supplementation therapy but also to help maintain elevated intratesticular testosterone levels. In addition, selective estrogen receptor modulators, often used with hCG have been shown both to elevate total testosterone levels and to maintain spermatogenesis in hypogonadal men.
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Affiliation(s)
| | | | - Larry I Lipshultz
- Department of Urology, Baylor Collegesssss of Medicine, Houston, TX, USA
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Kim ED, McCullough A, Kaminetsky J. Oral enclomiphene citrate raises testosterone and preserves sperm counts in obese hypogonadal men, unlike topical testosterone: restoration instead of replacement. BJU Int 2015; 117:677-85. [DOI: 10.1111/bju.13337] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Edward D. Kim
- University of Tennessee Graduate School of Medicine; Knoxville TN USA
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Fontenot GK, Wiehle RD, Podolski JS. Differential effects of isomers of clomiphene citrate on reproductive tissues in male mice. BJU Int 2015. [DOI: 10.1111/bju.13244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chehab M, Madala A, Trussell J. On-label and off-label drugs used in the treatment of male infertility. Fertil Steril 2015; 103:595-604. [DOI: 10.1016/j.fertnstert.2014.12.122] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/15/2014] [Accepted: 12/19/2014] [Indexed: 12/16/2022]
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Corona G, Ratrelli G, Maggi M. The pharmacotherapy of male hypogonadism besides androgens. Expert Opin Pharmacother 2014; 16:369-87. [DOI: 10.1517/14656566.2015.993607] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Giovanni Corona
- 1University of Florence, Maggiore-Bellaria Hospital, Medical Department, Endocrinology Unit, Azienda-Usl Bologna, Bologna, Italy
| | - Giulia Ratrelli
- 2University of Florence, Department of Experimental, Clinical and Biomedical Sciences, Sexual Medicine and Andrology Unit, Florence, Italy; ;
| | - Mario Maggi
- 2University of Florence, Department of Experimental, Clinical and Biomedical Sciences, Sexual Medicine and Andrology Unit, Florence, Italy; ;
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Ross LS. Selective estrogen receptor modulators, male hypogonadism, and infertility. Fertil Steril 2014; 102:687-8. [DOI: 10.1016/j.fertnstert.2014.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 06/18/2014] [Indexed: 11/27/2022]
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