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Pelusi C, Bartolomeo N, Lisco G, Baccini M, Fanelli F, De Pergola G, Triggiani V, Pagotto U, Giagulli VA. Overall sexual function in dysmetabolic obese men with low testosterone levels treated with clomiphene citrate. Endocr Metab Immune Disord Drug Targets 2022; 22:874-880. [PMID: 35249510 DOI: 10.2174/1871530322666220304110958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/20/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sexual disorders are the most common clinical manifestations of hypogonadism. Functional hypogonadism is the most frequent form, and clomiphene citrate (CC) has been recently introduced as a possible off-label therapeutic option for these patients. OBJECTIVES This study aims to evaluate the effects of CC on the overall sexual function in dysmetabolic obese men with low testosterone(T) levels. METHODS This was a sub-study of a randomized, double-blind, cross-over, placebo-controlled trial that included twenty-four obese or overweight subjects, with impaired glucose tolerance, or type 2 diabetes, and confirmed low total T (≤10.4 nmol/l) levels. Subjects were treated with CC or placebo (Plac) for 12 weeks, with an interval wash-out period of 6 weeks between treatments. All subjects were on metformin 2gr/day and a low-calorie diet. The between-treatment difference in the overall sexual function was assessed by IIEF-15 and a qADAM questionnaire. RESULTS IIEF-15 and qADAM questionnaire data were available for 18 individuals. In unadjusted analyses, CC was associated with lower IIEF-15 total, erectile function, and intercourse satisfaction domain scores than Plac. After adjustments for multiple variables, CC was associated with a higher IIEF-15 sexual desire domain score (+0.9 ± 0.8; p<.001) despite a lower qADAM score (-2.1 ± 0.9; p=.008) with respect to Plac. No differences were found for the other domains between groups. DISCUSSION The clinical significance of the absolute changes in IIEF-15 and qADAM scores during CC versus Plac is limited. However, CC has a reliable effect on sexual desire, and is also as safe as Plac. According to the sample size, duration of follow-up, and inclusion criteria defined for the main study, further studies are therefore needed to assess the long-term efficacy of CC. CONCLUSION Compared to Plac, CC was associated with a neutral effect on overall sexual function.
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Affiliation(s)
- Carla Pelusi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nicola Bartolomeo
- Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Giuseppe Lisco
- Interdisciplinary Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases. University of Bari "Aldo Moro", School of Medicine, Policlinico, Bari, Italy
| | - Margherita Baccini
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Flaminia Fanelli
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giovanni De Pergola
- National Institute of Gastroenterology \'Saverio de Bellis\', Research Hospital, Castellana Grotte, Bari, Italy
- Clinical Nutrition Unit, Medical Oncology, Department of Biomedical Science and Human Oncology, University of Bari, School of Medicine, Policlinico, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases. University of Bari "Aldo Moro", School of Medicine, Policlinico, Bari, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Vito Angelo Giagulli
- Interdisciplinary Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases. University of Bari "Aldo Moro", School of Medicine, Policlinico, Bari, Italy
- Outpatients Clinic of Endocrinology and Metabolic Disease, Conversano Hospital, Conversano, Bari, Italy
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Trinh TS, Hung NB, Hien LTT, Tuan NA, Pho DC, Dung QA, Do DA, Quang HD, Ai HV, Hung PN. Evaluating the Combination of Human Chorionic Gonadotropin and Clomiphene Citrate in Treatment of Male Hypogonadotropic Hypogonadism: A Prospective Study. Res Rep Urol 2021; 13:357-366. [PMID: 34164348 PMCID: PMC8214562 DOI: 10.2147/rru.s315056] [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] [Received: 04/13/2021] [Accepted: 05/28/2021] [Indexed: 11/25/2022] Open
Abstract
Background In this study, we evaluated MHH patients who wished to preserve fertility, assessing the efficacy of a short course (12 months) of a combined hCG +clomiphene citrate. Materials and Methods The cross-sectional study included 19 patients with hypogonadotropic hypogonadism who were admitted to the Andrology and Fertility Hospital of Hanoi between March 2016 and March 2018. Using hCG every three days in combination with clomiphene citrate 25mg per day until normal testosterone levels are reached, maintain the dose until spermatozoa are present. Results The mean age was 30.2 ± 5.6. Differences in penis length between the time before and after treatment were significant (p=0.005). The average dose of hCG using in our study was 5579 ± 1773.7 IU. After treatment 6 months and 12 months, the changes in clinical features in all patients and the total hypogonadotropic hypogonadism group were statistically significant (p<0.001). In particular, the differences in testosterone hormone levels in the partial hypogonadotropic hypogonadism group were also statistically significant (p=0.03). No adverse event was observed in our study. The number of patients appearing sperm in the semen is 9 patients (47.4%) after 12 months, but most of the sperm were completely deformed (<1%), and the average motility in the progressive motility group was below 8%. Conclusion In conclusion, a combination of hCG and clomiphene citrate may be an option for MHH patients who desired fertility. After 12 months, 47.4% of patients have sperm in semen but almost all of them were deformity. Hormone profile and secondary sexual characteristics improved significantly. There was no adverse event in our study that considered it as safe therapy.
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Affiliation(s)
- The Son Trinh
- Military Institute of Clinical Embryology and Histology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Ba Hung
- Andrology and Fertility Hospital of Hanoi - AF Hanoi, Hanoi, Vietnam.,Vinmec Times City International Hospital, Hanoi, Vietnam
| | - Le Thi Thu Hien
- Andrology and Fertility Hospital of Hanoi - AF Hanoi, Hanoi, Vietnam
| | - Ngo Anh Tuan
- Department of Health Economics, Vietnam Military Medical University, Hanoi, Vietnam
| | - Dinh Cong Pho
- Department of Infection Control, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Quan Anh Dung
- Faculty of Medicine, Vietnam Military Medical University, Hanoi, Vietnam
| | - Duc Anh Do
- Faculty of Medicine, University of Medical Sciences of Revolutionary Armed Force (UCIMED de Las FAR), Marianao, Havana, Cuba
| | - Ha Duc Quang
- Andrology and Fertility Hospital of Hanoi - AF Hanoi, Hanoi, Vietnam
| | - Hoang Van Ai
- Military Institute of Clinical Embryology and Histology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Pham Ngoc Hung
- Department of Epidemiology, Vietnam Military Medical University, Hanoi, Vietnam.,Department of Training, Vietnam Military Medical University, Hanoi, Vietnam
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Efficacy of Non-Testosterone-Based Treatment in Hypogonadal Men: A Review. Sex Med Rev 2021; 9:381-392. [PMID: 33933392 DOI: 10.1016/j.sxmr.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although testosterone replacement therapy is an effective treatment for hypogonadism, there are safety concerns regarding potential cardiovascular risks and fertility preservation. OBJECTIVE To assess the effect of selective estrogen receptor modulator (SERM), aromatase inhibitor, and human chorionic gonadotropin (hCG) on total testosterone (TT) levels and hypogonadism. METHODS We performed a systematic literature review from 1987 to 2019 via PubMed, Cochrane review, and Web of Science. Terms used were infertility, hypogonadism, alternative to testosterone therapy, selective estrogen receptor modulator, aromatase inhibitor, and human chorionic gonadotropin. Studies that reported an effect of TT and hypogonadism after treatment of each medication were selected. Hypogonadal symptoms were assessed by the Androgen Deficiency of The Aging Male (ADAM) questionnaire. Aggregated data were analyzed via Chi-squared analysis. RESULTS From literature, 25 studies were selected; of which, 12 evaluated efficacy of aromatase inhibitor, 8 evaluated SERMs, and 5 evaluated hCG effects. For SERMs, 512 patients with mean age 42.3 ± 1.94 years showed mean TT before treatment vs after treatment (167.9 ± 202.8 [ng/dl] vs 366.2 ± 32.3 [ng/dl], P < .0001 [180.5-216.1 95% confidence interval {CI}]). For aromatase inhibitor, 375 patients with mean age 54.1 ± 0.67 years showed mean TT before treatment vs after treatment (167.9 ± 202.8 [ng/dl] vs 366.2 ± 32.3 [ng/dl], P < .0001 [180.5-216.1 95% CI]). SERMs also showed ADAM before treatment vs after treatment (4.95 ± 0.28 vs 5.50 ± 0.19, P < .0001 [0.523-0.581 95% CI]). For hCG, 196 patients with mean age 41.7 ± 1.5 years showed mean TT before treatment vs after treatment (284.5 ± 13.6 [ng/dl] vs 565.6 ± 39.7 [ng/dl], P < .0001 [275.2-287.0 95% CI]). In addition, hCG also showed ADAM before treatment vs after treatment (28.1 ± 2.0 vs 30.9 ± 2.3, P < .0001 [2.313 95% CI]). CONCLUSIONS Non-testosterone therapies are efficacious in hypogonadal men. Our results show statistically significant improvement in TT and ADAM scores in all 3 medications after treatment. Future studies are warranted to elucidate the relationship between improved hypogonadism and erectile function in the setting of non-testosterone-based treatment. Raheem OA, Chen TT, Le TV, et al. Efficacy of Non-Testosterone-Based Treatment in Hypogonadal Men: A Review. Sex Med Rev 2021;9:381-392.
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Fietz D, Pilatz A, Diemer T, Wagenlehner F, Bergmann M, Schuppe HC. Excessive unilateral proliferation of spermatogonia in a patient with non-obstructive azoospermia - adverse effect of clomiphene citrate pre-treatment? Basic Clin Androl 2020; 30:13. [PMID: 32884817 PMCID: PMC7461256 DOI: 10.1186/s12610-020-00111-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/19/2020] [Indexed: 01/14/2023] Open
Abstract
Background Clomiphene citrate has been proposed as pre-treatment for infertile men with non-obstructive, testicular azoospermia (NOA) before surgery for testicular sperm extraction (TESE), especially when serum testosterone is low. Case presentation Here, we report on a 33-year old azoospermic patient with a previous history of repeated "fresh" TESE and clomiphene citrate therapy (50 mg/day over 6 months) before undergoing microscopically assisted, bilateral testicular biopsy. Comprehensive histological and immunohistochemical work-up revealed a heterogeneous spermatogenic arrest at the level of spermatogonia or primary spermatocytes, with focally preserved spermatogenesis up to elongated spermatids in the right testis. In the left testis, the majority of tubules (> 70%) showed no tubular lumen or regular seminiferous epithelium but a great number of spermatogonia-like cells. These cells proved to be normally differentiated spermatogonia (positive for melanoma associated antigen 4 (MAGEA4), negative for placental alkaline phosphatase (PlAP)) with increased proliferative activity (positive for proliferating cell nuclear antigen (PCNA)) and a slightly higher rate of apoptotic cells. When compared to a tissue control with normal spermatogenesis, expression of sex hormone receptors androgen receptor (AR), estrogen receptor (ER) alpha, and G-protein coupled estrogen receptor 1 (GPER1) was not altered in patient samples. Sertoli cells appeared to be mature (positive for vimentin, negative for cytokeratin 18), whereas the expression of zona occludens protein 1 (ZO-1), claudin 11, and connexin 43 was absent or dislocated in the tubules with abundance of spermatogonia. Conclusion This result suggests that formation of the blood-testis barrier is disturbed in affected tubules. To our knowledge this is the first observation of excessive, non-malignant proliferation of spermatogonia in a NOA patient. Although underlying molecular mechanisms remain to be elucidated, we hypothesize that the unusual pathology was triggered by the high-dose clomiphene citrate treatment preceding testicular biopsy.
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Affiliation(s)
- Daniela Fietz
- Institute for Veterinary Anatomy, Histology and Embryology, Justus Liebig University Giessen, Frankfurter Straße 98, 35392 Giessen, Germany.,Hessian Centre of Reproductive Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Adrian Pilatz
- Hessian Centre of Reproductive Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany.,Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Thorsten Diemer
- Hessian Centre of Reproductive Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany.,Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Florian Wagenlehner
- Hessian Centre of Reproductive Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany.,Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Martin Bergmann
- Institute for Veterinary Anatomy, Histology and Embryology, Justus Liebig University Giessen, Frankfurter Straße 98, 35392 Giessen, Germany
| | - Hans-Christian Schuppe
- Hessian Centre of Reproductive Medicine, Justus Liebig University Giessen, 35392 Giessen, Germany.,Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, 35392 Giessen, Germany
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5
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Keihani S, Wright LN, Alder NJ, Jiang J, Cheng PJ, Stoddard GJ, Pastuszak AW, Deibert CM, Hotaling JM. Baseline Gonadotropin Levels and Testosterone Response in Hypogonadal Men Treated With Clomiphene Citrate. Urology 2020; 142:119-124. [PMID: 32353397 DOI: 10.1016/j.urology.2020.04.074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the role of baseline gonadotropins in predicting the biochemical response to clomiphene citrate (CC) treatment. METHODS We conducted a retrospective review of data from hypogonadal men treated with CC in 2 high-volume fertility centers between 2013 and 2018. Patient age, body mass index, and baseline hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], and total testosterone [TT]) were obtained. Response to treatment was measured as changes in TT levels within 6 months of initiating CC treatment. Linear regression models adjusted for age, body mass index, and time on CC therapy were fitted to assess the associations between baseline LH and FSH levels with treatment response. RESULTS A total of 332 men with mean ± standard deviation age of 36.2 ± 8.2 years were included. Median time to initial follow-up was 6 weeks (25th-75th interquartile range [IQR]: 4-9 weeks). TT levels increased significantly on CC treatment (mean change: 329.2 ng/dL, 95% CI: 307.4-351.0) with 73% of men having at least 200 ng/dL increase over baseline TT levels. In univariable linear regression models, only age was significantly associated with TT response. Neither the baseline LH nor FSH significantly predicted TT response in linear regression models. CONCLUSION CC treatment results in significant increases in testosterone levels in most men. Baseline gonadotropins are not strong predictors for treatment response to CC. Adequate biochemical response with CC trial can be expected in most patients with normal or slightly elevated baseline gonadotropin levels.
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Affiliation(s)
- Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT.
| | - Lindsey N Wright
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Nathan J Alder
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jinfeng Jiang
- Division of Urologic Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Philip J Cheng
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | | | | | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
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6
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Thaker H, Ko EY, Sabanegh ES, Brannigan RE, Alukal JP, Samplaski MK. Empirical medical therapy for idiopathic male infertility. F S Rep 2020; 1:15-20. [PMID: 34223207 PMCID: PMC8244321 DOI: 10.1016/j.xfre.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 12/02/2022] Open
Abstract
Objective To determine if there has been a change in empirical medical therapy (EMT) practices since a 2010 American Urological Association survey reported that 25% of urologists treated infertile men who were pursuing a pregnancy with testosterone (T). Design Survey-based cohort study of AUA members. Setting Practice patterns were evaluated of urologists in academic and nonacademic hospital centers. Patient(s) Practice patterns were evaluated in the treatment of men with idiopathic infertility. Interventions(s) None. Main Outcome Measure(s) Subgroup analysis by means of univariate analysis between means (Fisher exact test) and descriptive proportions was used to compare male infertility fellowship–trained urologists (RUs) to general urologists (non-RUs). Result(s) A total of 191 urologists responded (4.7%). Excluding trainees, 164 responses (85.9%) were analyzed: 134 (82.3%) were from non-RUs and 29 from (17.7%) RUs. Over all, 65.9% treated male infertility with a combination of EMT and surgery (93.1% of RU vs. 60.4% of non-RUs). The most common medications used by RUs were clomiphene (100%), anastrozole (85.7%), and hCG/LH (82.1%). Non-RUs used these less frequently. Overall, 24.4% of the urologists reported that they would use T to treat male infertility: 14.4% (n = 4) of RUs and 24.4% (n = 30) of non-RUs. Conclusion(s) A total of 65.9% of urologists would treat male infertility with the use of EMT and surgery. The most common EMTs were clomiphene, anastrozole, and hCG/LH. Of concern, 24.4% of urologists considered T to treat male infertility, a medication with known contraceptive potential. This is unchanged from the 2010 survey, and confirms the need for reproductive medicine guidelines that include the topic of EMT use in infertile men.
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Affiliation(s)
- Hatim Thaker
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edmund Y Ko
- Department of Urology, Loma Linda University, Loma Linda, California
| | | | | | - Joseph P Alukal
- Department of Urology, Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Mary K Samplaski
- Institute of Urology, University of Southern California, Los Angeles, California
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Krzastek SC, Smith RP. Non-testosterone management of male hypogonadism: an examination of the existing literature. Transl Androl Urol 2020; 9:S160-S170. [PMID: 32257856 PMCID: PMC7108991 DOI: 10.21037/tau.2019.11.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Testosterone deficiency is defined as a total testosterone level <300 ng/dL confirmed on two early morning lab draws. Testosterone therapy has historically been offered to men with symptomatic testosterone deficiency in the form of injections, gels, or pellets. However, these treatments are invasive or have undesirable effects including the risk of drug transference. Additionally, testosterone therapy has been associated with increases in hematocrit and controversy remains regarding the risk of cardiovascular and thromboembolic events while on testosterone therapy. As such, much interest has recently been focused on alternative treatment options for testosterone deficiency in the form of orally-administered medications with more favorable side effect profiles. Lifestyle modifications and varicocelectomy have been shown to raise endogenous testosterone production. Similarly, SERMs and aromatase inhibitors (AIs) have been shown to raise testosterone levels safely and effectively. Human chorionic gonadotropin (hCG) remains the only FDA-approved non-testosterone treatment option for testosterone deficiency in men. However, this medication is expensive and requires patient-administered injections. Over the counter herbal supplements and designer steroids remain available though they are poorly studied and are associated with the potential for abuse as well as increased hepatic and cardiovascular risks. This review aims to discuss the existing treatment alternatives to traditional testosterone therapy, including efficacy, safety, and side effects of these options. The authors suggest that the SERM clomiphene citrate (CC) holds the greatest promise as a non-testosterone treatment option for testosterone deficiency.
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Affiliation(s)
- Sarah C Krzastek
- Department of Urology, University of Virginia, Charlottesville, VA, USA
| | - Ryan P Smith
- Department of Urology, University of Virginia, Charlottesville, VA, USA
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8
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Keihani S, Alder NJ, Cheng PJ, Stoddard GJ, Pastuszak AW, Hotaling JM. Obesity and Baseline Estradiol Levels Are Independent Predictors for Initiation of Anastrozole in Hypogonadal Men on Clomiphene Citrate. World J Mens Health 2020; 38:582-590. [PMID: 32202084 PMCID: PMC7502320 DOI: 10.5534/wjmh.190160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/02/2020] [Accepted: 01/29/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To assess the conversion rate from clomiphene citrate (CC) monotherapy to combination CC+anastrozole (AZ) therapy in hypogonadal men and the predictors associated with the initiation of AZ. MATERIALS AND METHODS A retrospective review of records from hypogonadal men treated with CC in a single fertility center was performed from 2013 to 2018. Patient age, body mass index (BMI), blood pressure, and reproductive hormones were obtained at baseline. Obesity was defined as BMI≥30 kg/m². Cox proportional hazards models were used to identify predictors of switching to combination CC+AZ therapy. RESULTS A total of 318 men on CC were included. Median (interquartile range) age was 34 years (30-39 years) and patients were followed for a median of 9 months (4-17 months). Of these, 97 (30.5%) were started on CC+AZ therapy. These patients had higher baseline BMI and estradiol, which in multivariable regression were significant predictors for switching to CC+AZ therapy. A threshold of 18.5 pg/mL for baseline estradiol provided the highest accuracy for predicting the addition of AZ after adjusting for baseline BMI and total testosterone levels. CONCLUSIONS In our practice, following CC monotherapy, 30% of men were initiated on CC+AZ. Obesity (BMI≥30 kg/m²) and baseline estradiol ≥18.5 pg/mL can predict the conversion to combination therapy with addition of AZ. This information can be used to counsel patients and also help to identify patients who can be started on combination therapy upfront.
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Affiliation(s)
- Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Nathan J Alder
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Philip J Cheng
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Alexander W Pastuszak
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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9
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Giagulli VA, Silvestrini A, Bruno C, Triggiani V, Mordente A, Mancini A. Is There Room for SERMs or SARMs as Alternative Therapies for Adult Male Hypogonadism? Int J Endocrinol 2020; 2020:9649838. [PMID: 32411230 PMCID: PMC7201459 DOI: 10.1155/2020/9649838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 01/09/2023] Open
Abstract
Hypogonadotropic hypogonadism (HH) can be sustained by organic or functional alterations of the hypothalamic-pituitary-testicular axis. Functional HH is related to systemic alterations, such as obesity or chronic inflammatory diseases, but could contribute to a negative course of the illness. For such situation, according to results obtained in infertile women, the administration of selective estrogen receptor modulators (SERMs) has been proposed in males too, with positive results on both metabolic and sexual function. This class of medications increases gonadotropin levels via antagonism to the estrogenic receptor; similar biological effects are also exerted by aromatase inhibitors (AIs), despite different mechanism of action. After a brief review of trials regarding SERMs and AIs use in male HH, we describe the structure and function of the androgen receptor (AR) as a basis for clinical research about compounds able to bind to AR, in order to obtain specific effects (SARMs). The tissue selectivity and different metabolic fate in comparison to testosterone can potentiate anabolic versus androgenic effects; therefore, they might be a valid alternative to testosterone replacement therapy avoiding the negative effects of testosterone (i.e., on prostate, liver, and hematopoiesis). Trials are still at an early phase of investigation and, at the moment, the application seems to be more useful for chronic disease with catabolic status while the validation as replacement for hypogonadism requires further studies.
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Affiliation(s)
- Vito A. Giagulli
- Internal Medicine, Geriatrics, Endocrinology and Rare Disease, Interdisciplinary Department of Medicine, University of Bari, School of Medicine, Policlinico, Bari, Italy
| | - Andrea Silvestrini
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Carmine Bruno
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Vincenzo Triggiani
- Internal Medicine, Geriatrics, Endocrinology and Rare Disease, Interdisciplinary Department of Medicine, University of Bari, School of Medicine, Policlinico, Bari, Italy
| | - Alvaro Mordente
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Antonio Mancini
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
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10
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Obesity and Hypogonadism-A Narrative Review Highlighting the Need for High-Quality Data in Adolescents. CHILDREN-BASEL 2019; 6:children6050063. [PMID: 31052376 PMCID: PMC6560454 DOI: 10.3390/children6050063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/26/2019] [Accepted: 04/28/2019] [Indexed: 12/30/2022]
Abstract
The prevalence of obesity continues to rise in adult and pediatric populations throughout the world. Obesity has a direct impact on all organ systems, including the reproductive system. This review summarizes current knowledge about the effects of obesity on the male reproductive system across age, highlighting the need for more data in children and adolescents. Male hypogonadism is commonly seen in patients with obesity and affects the onset, duration, and progression of puberty. Different pathophysiologic mechanisms include increased peripheral conversion of testosterone to estrone and increased inflammation due to increased fat, both of which lead to suppression of the hypothalamic-pituitary-gonadotropin (HPG) axis and delayed development of secondary sexual characteristics in adolescent males. Evaluation of the HPG axis in obesity includes a thorough history to exclude other causes of hypogonadism and syndromic associations. Evaluation should also include investigating the complications of low testosterone, including increased visceral fat, decreased bone density, cardiovascular disease risk, and impaired mood and cognition, among others. The mainstay of treatment is weight reduction, but medications such as testosterone and clomiphene citrate used in adults, remain scarcely used in adolescents. Male hypogonadism associated with obesity is common and providers who care for adolescents and young adults with obesity should be aware of its impact and management.
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Francisco R, Jaroudi S, Murtaza Ali M, Frost J, Chemitiganti R, Peiris AN. Clomiphene for hypogonadism complicated by polycythemia. Proc (Bayl Univ Med Cent) 2019; 32:75-77. [PMID: 30956589 DOI: 10.1080/08998280.2018.1526570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 10/27/2022] Open
Abstract
Male hypogonadism is associated with poor sexual function. Testosterone therapy via the intramuscular route is the preferred treatment but is associated with secondary polycythemia. We report a patient in whom clomiphene citrate improved hypogonadal symptoms and restored normal free testosterone levels. Clomiphene is inexpensive and can be given orally in secondary hypogonadism. Clomiphene citrate is a promising alternative in patients who develop secondary polycythemia with testosterone.
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Affiliation(s)
- Roshirl Francisco
- Texas Tech University Health Sciences Center School of MedicineLubbock Texas
| | - Sarah Jaroudi
- Texas Tech University Health Sciences Center School of MedicineLubbock Texas
| | - Mariam Murtaza Ali
- Department of Internal Medicine, Texas Tech University Health Sciences Center School of Medicine at Permian BasinTexas
| | - Jill Frost
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of PharmacyAmarillo Texas
| | - Rama Chemitiganti
- Department of Internal Medicine, Texas Tech University Health Sciences Center School of Medicine at Permian BasinTexas
| | - Alan N Peiris
- Texas Tech University Health Sciences Center School of MedicineLubbock Texas.,Department of Internal Medicine, Texas Tech University Health Sciences Center Clinical Research InstituteLubbock Texas
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Wheeler KM, Sharma D, Kavoussi PK, Smith RP, Costabile R. Clomiphene Citrate for the Treatment of Hypogonadism. Sex Med Rev 2019; 7:272-276. [DOI: 10.1016/j.sxmr.2018.10.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 01/07/2023]
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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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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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Cangiano B, Cacciatore C, Persani L, Bonomi M. Switch to restoration therapy in a testosterone treated central hypogonadism with erythrocytosis. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170055. [PMID: 28721216 PMCID: PMC5510393 DOI: 10.1530/edm-17-0055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/07/2017] [Indexed: 11/30/2022] Open
Abstract
We describe a case of severe erythrocytosis caused by testosterone replacement therapy in a 66-year-old man affected with hypogonadotropic hypogonadism (HH) determining osteoporosis, resolved by switching to restoration therapy with clomiphene citrate. The patient complained fatigue, loss of libido and defective erections and a spontaneous vertebral fracture despite bisphosphonate therapy and vitamin D supplementation. The examinations proved isolated HH and he was therefore treated with testosterone gel with regression of specific manifestations but elevated hemoglobin and hematocrit values. Therefore, it was decided to switch to a restoration therapy with clomiphene citrate 25 mg/die, which resulted in the resolution of symptoms without evident side effects. In a couple of months, the patient showed normalization of testosterone levels and increment of testicular volume. Since secondary hypogonadism is the consequence of an insufficient stimulation of the gonads by hypothalamic–pituitary axis, therapeutic approaches aimed to restore endogenous testosterone production should be considered in alternative to testosterone replacement, particularly if side effects intervene. Among these strategies, clomiphene citrate seems to have a high efficacy and safety profile also in the elderly with isolated HH and no evident pituitary lesion.
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Affiliation(s)
- B Cangiano
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, MilanItaly.,Department of Clinical Sciences and Community Health, University of Milan, MilanItaly
| | - C Cacciatore
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, MilanItaly.,Department of Clinical Sciences and Community Health, University of Milan, MilanItaly
| | - L Persani
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, MilanItaly.,Department of Clinical Sciences and Community Health, University of Milan, MilanItaly
| | - M Bonomi
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, MilanItaly.,Department of Clinical Sciences and Community Health, University of Milan, MilanItaly
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