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

Endocrine manipulation in male infertility

Endocrine therapy for male infertility is broadly categorized as specific or nonspecific therapy. Although uncommon, primary endocrine diagnoses in infertile men are amenable to targeted therapy. The efficacy of empiric endocrine therapy for idiopathic male infertility, however, has not been demonstrated conclusively by clinical trials. With better understanding of the underlying pathophysiology of idiopathic male infertility, careful evaluation of endocrine therapy in well-selected treatment groups and well-designed randomized, controlled trials is warranted. Although empiric endocrine therapy for idiopathic male infertility has been largely replaced by assisted reproductive techniques, both treatment modalities could play a role, perhaps as combination therapy.

A new look at the medical management of infertility

Effective therapies are available for the treatment of infertility owing to specific causes. Most hormonal imbalances can be readily identified and successfully treated. The treatment of men with unexplained idiopathic infertility remains difficult. The availability of a multitude of agents ranging from hormones to nutritional supplements emphasizes the fact that none are consistently effective. There is no good way to predict which patients will respond to a specific treatment. Idiopathic infertility may result from multiple discrete defects in sperm generation and maturation that are as yet unidentified. A better understanding of these defects will yield more effective treatment options and appropriate triage of patients to specific therapeutic regimens. Assisted reproductive techniques remain an option for patients with idiopathic male infertility; however, they are expensive and treat the female partner for a male problem. Multiple gestations and other complications are not infrequent. Initial management should be directed at improving the quality of semen to facilitate natural conception. Specific abnormalities should be corrected. If empiric pharmacologic therapy is to be used, treatment should last at least 3 to 6 months to incorporate a full 74-day spermatogenic cycle. The infertile couple should be advised of the inconsistent response to therapy and the low conception rate that may follow when compared with the results of ART. When empiric therapy is decided upon, antiestrogens may be used and are effective in a subset of patients. The authors prefer to use clomiphene citrate, 25 mg per day. The dose may be increased to 50 or 75 mg to raise testosterone levels to the upper normal range. Lack of a significant improvement in semen parameters or of a pregnancy after a 3- to 6-month treatment period may be an indication to proceed with ART.

Effects of pentoxifylline on sperm motility in normogonadotropic asthenozoospermic men

Forty-seven normogonadotropic men with idiopatic asthenozoospermic were divided at random: group I (N = 22) received placebo and group II (N = 25) received 1200 mg of pentoxifylline/day during 6 months. Semen analysis was performed basal and at 3 and 6 months of the study period. No statistical changes in serum hormone concentration were found, nor in volume, sperm counts, viability, and morphology before and after treatment. Sperm motility increased following pentoxifylline treatment after 3 and 6 months from 25.5 (21.0-30.0) to 35.5 (31.5-39.0) (p < .00001) and to 42.0 (38.0-46.0) (p < .00001), respectively. Although in the placebo control cases some changes were observed in the sperm motility, they were less significant. Furthermore, progressive motility only in grade A increased with pentoxifylline from 2.5 (0.0-6.0) to 12.0 (6.0-19.5) (p < .001) at 3 months and to 22.5 (17.0-26.0) at 6 months (p < .00001). In conclusion, pentoxifylline had an additional effect rather than placebo and was useful treatment in these cases of male factor infertility.

A prospective pilot study of co-treatment with growth hormone and gonadotropins for improving spermatogenesis in normogonadotropic patients with severe oligoteratoasthenospermia

The objective of this study was to induce spermatogenesis by co-treatment with growth hormone and gonadotropins in normogonadotropic patients with severe oligoteratoasthenospermia (OTA) who had failed to respond adequately to conventional therapy. A prospective study in which co-treatment with growth hormone (4 IU) and human menopausal gonadotropin (hMG; 150 IU of follicle-stimulating hormone (FSH) and 150 IU of luteinizing hormone (LH)), three times a week, and human chorionic gonadotropin (hCG; 2500 IU), two times a week for 24 weeks, were administered after unsuccessful treatment for at least 12 weeks with gonadotropins. Four patients who had failed to respond to conventional treatment with gonadotropins participated in the study. Semen volume, sperm production, serum testosterone, LH, FSH, insulin-like growth factor-I (IGF-I) and growth hormone-binding protein concentrations were used to measure outcome. In all four patients, there was no improvement in sperm quality as compared to baseline measurements. Serum testosterone concentrations remained within normal limits. A significant increase in both serum IGF-I and growth hormone-binding protein was found following treatment with growth hormone. Our results do not encourage the use of co-treatment of gonadotropins with growth hormone in cases of normogonadotropic OTA syndrome patients who fail to respond adequately to the conventional therapy with gonadotropins.

Long-term, pulsatile, low dose, subcutaneous luteinizing hormone-releasing hormone administration in men with idiopathic oligozoospermia. Failure of therapeutic and hormonal response

In four normal men with a history of long standing infertility, severely disturbed sperm qualities (determined in at least three spermiograms), normal serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels (measured over a time period of 90 minutes), and lack of evidence of further andrological or other obvious endocrine disorders the effectiveness of luteinizing hormone-releasing hormone (LH-RH) treatment was investigated. LH-RH was administered subcutaneously with a portable, comterized infusion pump (Zyclomat) for 3 months, with administration intervals of 90 minutes and bolus dosages of 5 micrograms (three patients) and 20 micrograms (one patient). Semen qualities during and after LH-RH treatment, as compared to pretreatment values, showed no improvement in volume of ejaculate, number of sperms per milliliter and motility. During or at the end of the treatment period no evident differences were observed in serum LH, FSH and testosterone levels (measured over a 90 minutes period) compared with hormonal values before LH-RH therapy, nor at the low-dose (5 micrograms) neither at the high-dose (20 micrograms) administration schedule. It is concluded that pulsatile subcutaneous LH-RH treatment in normogonadotropic, oligozoospermic men does not seem to improve the therapeutical arsenal.

Gonadotrophin regulation and clinical applications of GnRH

Gonadotrophin secretion is determined by the interplay of neural and gonadal influences. The neural influence is mediated for both LH and FSH by the decapeptide GnRH which is secreted into the hypophyseal portal vessels. LH is secreted in a pulsatile fashion apparently driven by episodic release of GnRH. Unremitting exposure of the pituitary to GnRH eventually abolishes gonadotrophin secretion. In primates, as opposed to the rat, GnRH appears to have a permissive role in the regulation of gonadotrophin secretion, priming the pituitary to secrete and show both negative and positive feedback responses to oestrogen in adult females. Striking physiological changes occur from fetal life to puberty in gonadotrophin regulation. GnRH acts on surface receptors. Chemical dissection of the GnRH molecule has disclosed a structure-activity relationship, allowing the development of both antagonist and 'superagonist' analogues. The initial stage in activation of gonadotrophs by GnRH appears to be binding to and clustering--probably dimerization--of GnRH receptors. Subsequent intracellular events are not fully clarified but grounds exist to suggest the involvement of both cyclic AMP and calcium fluxes within the cell. There is strong evidence that GnRH secretion influences the number of its own receptors in various situations in the rat. The phenomenon of pulsatile GnRH release in experimental animals survives hypothalamic deafferentation. Catecholamines are probably intimately involved in the generation of GnRH pulses--which for noradrenaline poses a paradox as all noradrenergic cell bodies lie outside the MBH. LH pulse frequency can be absent or altered in various states (e.g., Kallman's syndrome, hyperprolactinaemia and exposure to opiates--exogenous or apparently endogenous). The existence of GnRH receptors in gonadal tissue has been described but it is debatable whether this is true in man. Therapeutic uses of GnRH initially was aimed at correcting hypogonadotrophic hypogonadism. Development of GnRH superagonists demonstrated desensitization and thus their paradoxical application to the areas of contraception, precocious puberty and endocrine-dependent cancers. The development of miniaturized programmable infusion pumps has made pulsatile GnRH therapy a practical prospect. It holds considerable therapeutic promise in selected cases of hypogonadotrophic hypogonadism, especially in women.

An evaluation of human sperm as indicators of chemically induced alterations of spermatogenic function. A report of the U.S. Environmental Protection Agency Gene-Tox Program

To evaluate the utility of sperm tests as indicators of chemical effects on human spermatogenesis, the literature on 4 sperm tests used to assess chemically induced testicular dysfunction was reviewed. The tests surveyed included sperm count, motility, morphology (seminal cytology), and double Y-body (a fluorescence-based test thought to detect Y-chromosomal nondisjunction). There were 132 papers that provided sufficient data for evaluation. These reports encompassed 89 different chemical exposures: 53 were to single agents; 14 to complex mixtures; and 22 to combinations of 2 or more identified agents. Approximately 85% of the exposures were to experimental or therapeutic drugs, 10% were to occupational or environmental agents, and 5% were to drugs for personal use. The most common sperm parameter studied was sperm count (for 87 of the 89 exposures reviewed). Sperm motility was evaluated for 59 exposures, morphology for 44, and double Y-bodies for only 4. The 89 exposures reviewed were grouped into 4 classes: those which adversely effected spermatogenesis, as measured by one or more of the sperm tests (52); those suggestive of improving semen quality (11); those showing inconclusive evidence of adverse effects from exposure (14); and those showing no significant changes (12). Since the reviewed reports had a large variety of study designs, and since every attempt was made to include all reports with interpretable data, these classifications were based on reviewing committee decisions rather than on uniform statistical criteria. This review gives strong evidence that human sperm tests can be used to identify chemicals that affect sperm production, but because of our limited understanding of underlying mechanisms, the extent to which they can detect mutagens, carcinogens or agents that affect fertility remains uncertain. For the very few agents studied with both human and mouse sperm tests, similar test-responses were seen; thus sperm tests in mice and other laboratory mammals may have a potential role in hazard identification. An overall comparison of the 4 human sperm tests suggests that no one test is biologically more responsive than another; all of them may thus be needed when testing for chemically induced changes from agents of unknown activity. This review also gives evidence that sperm tests can be used to assess the extent and the potential reversibility of induced spermatogenic damage. The reviewing committee recommends further studies to determine (a) the dose-response characteristics of the human sperm tests, (b) details of the reversibility of induced changes with time after exposure, (c) the relative responses in the 4 sperm tests in exposed individuals, (d) the mechanism of action, (e) the biological and genetic implications of chemically induced effects, and (f) the comparison of responses among different species for risk assessment. The reviewing committee outlines specific considerations for planning new sperm studies on chemically exposed men.

D-Tryptophan-6-luteinizing hormone-releasing hormone in the treatment of normogonadotropic oligoasthenozoospermia

D-Tryptophan-6-LH-RH was assessed in the treatment of patients with normogonadotropic oligoasthenozoospermia in 18 subjects selected on the basis of at least 3 spermiograms, long standing infertility, normal LH, FSH, prolactin and testosterone serum levels and lack of evidence of any other pathologic involvement. Testicular biopsies performed on these patients showed hypospermatogenesis with foci of alteration at the spermatid stage in some of them. D-Trp-6-LH-RH was administered im for 90 days at a dose of 5 micrograms every 2 days, 10 micrograms daily or 10 micrograms every 2 days. There was no significant improvement in the concentration of spermatozoa or in the motility and vitality parameters. Moreover, in 5 patients who received 10 micrograms daily, basal levels of LH and FSH and the response to LH-RH, decreased significantly during treatment. D-Trp-6-LH-RH at the dose used in this study does not seem useful for the treatment of oligoasthenozoospermia normogonadotropic patients.

The effect of a treatment with doxycycline on semen of asthenozoospermic patients with T-mycoplasma genital infection

The pathogenic role of T-Mycoplasma seminal infection in male sterility is a matter of controversy. The aim of this study was to observe the effect of a specific treatment in asthenozoospermic patients in which the only finding was the presence of T-Mycoplasma in semen. Twenty five patients (age 24 to 49 years) were incorporated. Average time of known infertility was 4.0 +/- 0.5 years. Asthenozoospermia was diagnosed by at least three previous spermatograms. All other studies were negative with the only exception of the tests to study the presence of T-Mycoplasma in semen. Each patient was treated with doxycycline (200 mg/day) during 20 days. Control spermatograms were performed at 30 and 90 days from the initiation of treatment. After treatment the tests to detect the presence of T-Mycoplasma in semen were negative in all patients. A significant increase of the percentages of forwardly progressive spermatozoa and of live and motile spermatozoa was observed together with a significant decrease of the percentage of non motile spermatozoa. Qualitatively eleven patients (44%) achieved a normalization of the spermogram; five patients (20%) obtained significant improvements while nine patients (36%) did not experience any significant change. Although the real significance of T-Mycoplasma in the determination of male sterility is still a matter of controversy, its presence in semen in asthenozoospermic patients should be considered and, consequently, treated.

Hormonal and behavioral response of male chimpanzees to a long-acting analogue of gonadotropin-releasing hormone

A long-acting preparation of gonadotropin-releasing hormone (GnRH) was administered to three adult male chimpanzees living in a socially integrated group. Hormonal changes and behavioral responses were monitored for 8 days. Blood serum levels of luteinizing hormone peaked at about 8 hr and returned to baseline at 48 hr. Total serum testosterone reached the highest levels of 140% above baseline at 24 hr and returned to baseline after 48 hr. Out of a wide variety of behaviors observed in detail, only one cluster of three related behaviors showed even a suggestion of response: The two measures of activity, lone travel (p < 0.05) and distance traveled (p < 0.1), decreased on the day of hormone administration followed by an increase on the 2 subsequent days, and idle time (p < 0.1) revealed the reciprocal pattern. In view of various reports of behavioral effects of GnRH in other species, it is particularly noteworthly that parameters of sexual and agonistic behavior of male chimpanzees definitely did not change.

Pentoxifylline (BL 191) by oral administration in the treatment of asthenozoospermia

The aim of this trial was to study the effects on semen of pentoxifylline administered chronically per os to patients with normogonadotropic asthenozoospermia. Fifteen infertile men (age 22 to 44 years) were incorporated. Each subject was submitted to a treatment with pentoxifylline per os at a dose of 1,200 mg per day during no less than four months (x plus or minus SE 6.6 plus or minus 0.7 months). Assessment of the results was performed by serial spermatograms performed during and up to three months after treatment. The results showed a significant improvement of the percentages of forwardly progressive spermatozoa and of live and motile spermatozoa. Five of the patients achieved a normalization of semen (frank improvement) and seven a significant improvement in comparison to the initial values. Pregnancy was obtained by two patients. Pentoxifylline could be a useful alternative for the treatment of patients with normogonadotropic asthenozoospermia.

Ovulation induction with luteinizing hormone--releasing hormone in amenorrheic, infertile women

Thirteen women with infertility thought due to anovulation were treated with LRH. Etiologic diagnoses of amenorrhea included hypothalamic or "idiopathic" and PCOD. All patients had normal gonadotropins and otherwise normal endocrinologic and infertility evaluations; none had ovulated with clomiphene. Patients were studied for six 35 day cycles, single blind, and received LRH or placebo by subcutaneous injections for 28 days/cycle (LRH dosage 1.0 mg 2 or 3 times each day). Frequent assessments of physical status, cervical mucus, vaginal cytology, and serum LH, FSH, estrogen, and progesterone were performed. Ovulation was documented by basal temperature, serum progesterone and, on occasion, endometrial biopsy. Follow-up was continued for 6 months after therapy. Of the 13 patients treated, eight have ovulated and five have conceived. There were no complications of therapy.

Recent progress in pharmacological therapy of male subfertility--a review

A review of pharmacological therapy in male infertility shows that apart from specific therapy with gonadotropins in hypogonadotropic hypogonadism, treatment in normogonadotropic idiopathic oligozoospermia and asthenozoospermia is still empirical and often unsuccessful. Modern therapy is based on three pharmacological groups of compounds: gonadotropins, androgens and kininogenases, the latter releasing pharmacologic active kinin peptides from kininogen. In addition, antiestrogens and gonadotropin-releasing hormones seem to be promising agents for the near future. The use of antibiotics is of great importance in the therapy of male genital tract infections which often to a reduced fertility. Several other drugs (amino acids, psychopharmaceuticals, spasmolytic agents, trijodothyronine, glucocorticoids, vitamins) seem to be suitable in individuals cases, but in greater group of patients these agents do not improve fertility. Using the mentioned hormonal and nonhormonal pharmacological agents considerable progress can be demonstrated in the therapy of male infertility. However, before initiating any therapy it is important to exclude patients whose cause of infertility is untreatable or those who require surgery. Finally, it is hoped that additional progress in treatment of male infertility will soon be made possible by further improvement of fundamental research in andrology. Especially important is the development of better criteria for selection of patients for any form of therapy in order to make more specific and less empirical approaches for treatment of male infertility available.

D-leucine-6-luteinizing hormone-releasing hormone ethylamide in the treatment of normogonadotropic oligoasthenospermia

The effectiveness of D-leucine-6-luteinizing hormone-releasing hormone ethylamide (D-Leu-6-LH-RH-EA) in the treatment of idiopathic normogonadotropic oligoasthenospermia was assessed in 17 patients selected on the basis of at least three previous sperm counts; a history of long-standing infertility; normal serum levels of luteinizing hormone, follicle-stimulating hormone, and testosterone; and lack of any evidence of other pathologic involvement. On testicular biopsy all patients showed hypospermatogenesis or arrest at the spermatid stage with the exception of two with more severe disorders. D-Leu-6-LH-RH-EA- was administered intramuscularly for 90 days at a daily dose of 5 microgram (four patients), 10 microgram (four patients), 20 microgram (five patients), and 200 microgram (four patients). The results showed no significant improvement in the parameters considered (number of spermatozoa per milliliter, percentage of live and motile spermatozoa, and percentage of forwardly progressive spermatozoa). D-Leu-6-LH-RH-EA does not seem promising for the treatment of oligoasthenospermic patients.

Treatment of idiopathic normogonadotropic oligoasthenospermia with synthetic luteinizing hormone-releasing hormone

An assessment of the effectiveness of synthetic luteinizing hormone-releasing hormone (LH-RH) in the treatment of idiopathic normogonadotropic oligoasthenospermia was made in 21 subjects selected on the basis of at least three previous sperm counts; a history of long-standing infertility; normal urinary gonadotropin excretion; normal serum levels of luteinizing hormone, follicle-stimulating hormone, and testosterone; and lack of any evidence of other clinical, endocrine, vascular, infectious, and/or urologic involvement. On testicular biopsy, 14 patients showed hypospermatogenesis or arrest up to the spermatid stage (group 1), while the remaining 7 had more severe spermatogenetic disorders (group 2). Libido and/or potency were previously unaltered in all subjects. Five patients in group 1 and five patients in group 2 received intramuscular injection of 100 to 500 mug of LH-RH daily for no less than 60 days (long-term treatment); the remainder received the drug for 30-day periods, with 30-day intervals (short-term treatment). Qualitative and quantitative assessment of the results during and after treatment showed frank improvement in spermatozoal concentration, vitality, and motility in group 1 patients, particularly in those undergoing long-term treatment (three of five patients under these conditions were able to impregnate their wives). The long-term regimen also resulted in predomantly qualitative improvements in group 2 (one of five patients impregnated his wife). The short-term regimen was less effective. Improvements under either regimen usually occurred at the end of, or after, treatment. Six of seven patients in group 1 who were followed for a long period retained values above preliminary values for 90 to 150 days after the drug was discontinued. Increased libido and potency were spontaneously reported by 15 patients, 20 to 30 days after the start of administration of synthetic LH-RH.

Clinical investigations for emotional effects of neuropeptide hormones

After the demonstration that hypothalamic peptides can have a direct effect on the central nervous system, a series of studies was initiated to investigate the hypothesis that hypothalamic peptides could have an effect on emotions and affect. TRH was administered to 6 patients with endogenous depressions in a double-blind, cross-over design with transient improvements in the mental depression of 4 of the 6 patients. In a second study involving 8 seriously depressed patients given 1000 mug of TRH for 10 days, no significant antidepressant effect of TRH was observed. In a pilot, double-blind study of 18 women with endogenous depressions, the group receiving MIF-1 60 mg per day in a single daily dose for 6 days responded better than the placebo group, which in turn responded better than the group receiving MIF-1 150 mg per day. In a second, double-blind study testing MIF-1 in endogenous depressions, 5 patients met the criteria for substantial improvement out of a total of 8 receiving MIF-1 75 mg per day. In contrast, only one patient met these criteria in each of the remaining 2 groups, consisting of 10 patients receiving MIF-1 750 mg per day and 5 patients receiving placebo. Finally, 6 men complaining of decreased libido and/or potency were given intravenous injections of LHRH 700 mug or saline once daily for 3 consecutive days per week in a double-blind, cross-over design. In addition, 3 men were given much higher doses of LHRH in a single-blinded study. No substantial effect on libido or sexual performance was observed.