Medical Treatment of the Subfertile Male

Regulation of activin and inhibin in the adult testis and the evidence for functional roles in spermatogenesis and immunoregulation

Activin A provides a unique link between reproduction and immunity, which is especially significant in the adult testis. This cytokine, together with inhibin B and follistatin acting as regulators of activin A activity, is fundamentally involved in the regulation of spermatogenesis and testicular steroidogenesis. However, activin A also has a much broader role in control of inflammation, fibrosis and immunity. In the Sertoli cell, activin A is regulated by signalling pathways that normally regulate stress and inflammation, signalling pathways that intersect with the classical hormonal regulatory pathways mediated by FSH. Modulation of activin A production and activity during spermatogenesis is implicated in the fine control of the cycle of the seminiferous epithelium. The immunoregulatory properties of activin A also suggest that it may be involved in maintaining testicular immune privilege. Consequently, elevated activin A production within the testis during inflammation and infection may contribute to spermatogenic failure, fibrosis and testicular damage.

Ocular adverse effects of human chorionic gonadotropin

This is the first case report of blurred vision and scotomas associated with hCG injections. Similar visual disturbances have been caused by clomiphene, which is similar to hCG in enhancing LH activity and increasing testosterone levels.

The role of testicular biopsy in the investigation of male infertility

Sixty-five testicular biopsies from infertile men were assessed retrospectively. In 21 patients infertility was attributed to varicoceles. In the remaining cases the testicular histology was classified into 3 major groups. Normal, hypospermatogenesis and germ cell aplasia. These histological categories were correlated with serum gonadotrophic hormone levels and sperm counts. All cases of germ cell aplasia showed azoospermia or severe oligospermia, but sperm counts alone were not reliable indicators of spermatogenesis. Patients with very low sperm counts and raised levels of serum FSH invariably had germ cell aplasia. These patients made up a group in whom testicular biopsies were of limited value in assessment. In all other instances the testicular biopsy was still an important tool in the assessment and prognostication for fertility in the subfertile male.

Clomiphene treatment of the idiopathic hypofertile male: high-dose, alternate-day therapy

Increasing reports suggest that clomiphene citrate (clomid) is useful in the treatment of idiopathic hypofertile males. Recent studies have advocated low-dose, cyclic therapy (25 mg daily for 25 days, 5 days' rest) and, although significant clinical responses have been reported, the hormone response has been erratic. This study of 53 patients, given high-dose, alternate-day therapy (100 mg three times/week), shows an over-all positive response rate of 66% and a pregnancy rate of 26%. Significant gonadotropin and testosterone surges were seen in the responders, but a selective lack of a follicle-stimulating hormone surge was noted in a small group of nonresponders. Clomiphene given in this dosage seems to be safe for periods of up to 15 months and appears to be a rational and useful agent for the treatment of this patient group.

Reappraisal of the value of testicular biopsy in the investigation of infertility

One hundred and forty-two biopsies were reviewed to reappraise the value and indications for testicular biopsy in the investigation of infertility. These biopsies were categorized within the following morphologic patterns: normal, hypospermatogenesis, maturation arrest, Sertoli cell-only syndrome, and Klinefelter's syndrome. The morphology of the biopsies was correlated with the available sperm count, and the contribution of the biopsy to the patient's treatment was assessed. Testicular biopsy has proved most useful in azoospermia for the identification of obstruction. In oligospermia, biopsy appears to be of little use.