Gonadal function and response to human chorionic and menopausal gonadotrophin therapy in male patients with idiopathic hypogonadotrophic hypogonadism

Efficacy of Gonadotropin Treatment for Induction of Spermatogenesis in Men With Pathologic Gonadotropin Deficiency: A Meta-Analysis

INTRODUCTION

Hypogonadotropic hypogonadism (HH) is a treatable cause of nonobstructive azoospermic male infertility. Gonadotropin treatment can successfully induce spermatogenesis in most patients, although comprehensive quantitative summary data on spermatogenic outcomes like those required to induce pregnancy is lacking in the literature.

MATERIALS AND METHODS

Systematic review and meta-analysis of outcomes related to male reproductive function following gonadotropin treatment.

RESULTS

Our search strategy identified 41 studies encompassing 1673 patients with a mean age of 25 (± 5) years. Average sperm concentration achieved after a median of 18 months of gonadotropin treatment was 11.6 M/mL of ejaculate (95% CI 8.4-14.9). Sperm concentrations > 0, > 1, > 5, > 10 and > 20 M/mL were achieved by 78%, 55%, 36%, 24% and 15% of patients, respectively. Mean sperm output and the proportion of patients achieving all sperm thresholds were significantly greater following combined hCG/FSH treatment compared with hCG monotherapy. When compared by diagnosis, patients with congenital HH (CHH) had significantly lower mean sperm output compared with patients with hypopituitarism or mixed patient cohorts that did not differentiate between CHH and hypopituitarism. Treatment-related increases in testosterone and testicular volume (TV) were not different between hCG and combined hCG/FSH treated patients, although increases in TV were lower in men with CHH compared with those with hypopituitarism.

CONCLUSIONS

Gonadotropin treatment successfully induced spermatogenesis in most men with pathological gonadotropin deficiency. Sperm outputs more consistent with those typically needed to induce a natural pregnancy were less commonly achieved. Despite similar effects on serum testosterone and TV, combined hCG/FSH appeared more efficacious than hCG alone at inducing spermatogenesis.

Gonadotropins for pubertal induction in males with hypogonadotropic hypogonadism: systematic review and meta-analysis

OBJECTIVE

Hypogonadotropic hypogonadism is characterized by inadequate secretion of pituitary gonadotropins, leading to absent, partial, or arrested puberty. In males, classical treatment with testosterone promotes virilization but not testicular growth or spermatogenesis. To quantify treatment practices and efficacy, we systematically reviewed all studies investigating gonadotropins for the achievement of pubertal outcomes in males with hypogonadotropic hypogonadism.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of Medline, Embase, Global Health, and PsycINFO databases in December 2022. Risk of Bias 2.0/Risk Of Bias In Non-randomized Studies of Interventions/National Heart, Lung, and Blood Institute tools for quality appraisal. Protocol registered on PROSPERO (CRD42022381713).

RESULTS

After screening 3925 abstracts, 103 studies were identified including 5328 patients from 21 countries. The average age of participants was <25 years in 45.6% (n = 47) of studies. Studies utilized human chorionic gonadotropin (hCG) (n = 93, 90.3% of studies), human menopausal gonadotropin (n = 42, 40.8%), follicle-stimulating hormone (FSH) (n = 37, 35.9%), and gonadotropin-releasing hormone (28.2% n = 29). The median reported duration of treatment/follow-up was 18 months (interquartile range 10.5-24 months). Gonadotropins induced significant increases in testicular volume, penile size, and testosterone in over 98% of analyses. Spermatogenesis rates were higher with hCG + FSH (86%, 95% confidence interval [CI] 82%-91%) as compared with hCG alone (40%, 95% CI 25%-56%). However, study heterogeneity and treatment variability were high.

CONCLUSIONS

This systematic review provides convincing evidence of the efficacy of gonadotropins for pubertal induction. However, there remains substantial heterogeneity in treatment choice, dose, duration, and outcomes assessed. Formal guidelines and randomized studies are needed.

The use of hormone stimulation in male infertility

Infertility affects 15% of couples worldwide and in approximately 50% of cases the cause is secondary to an abnormality of the sperm. However, treatment options for male infertility are limited and empirical use of hormone stimulation has been utilised. We review the contemporary data regarding the application of hormone stimulation to treat male infertility. There is strong evidence supporting the use of hormone stimulation in hypogonadotropic hypogonadism but there is inadequate evidence for all other indications.

Current concepts surrounding neonatal hormone therapy for boys with congenital hypogonadotropic hypogonadism

INTRODUCTION

Congenital hypogonadotropic hypogonadism (CHH) is a genetic disorder of reproduction and development, characterized by deficient gonadotropin-releasing hormone (GnRH) secretion or action, affecting 1-in-4,000-15,000 males. Micropenis and undescended testes are cardinal features of antenatal GnRH deficiency and could indicate absent minipuberty in the first postnatal months. In this review, we outline the pathophysiology and clinical consequences of absent minipuberty and its implications for optimal approaches to the endocrine management of affected boys.

AREAS COVERED

Deficient GnRH activity during fetal development and neonatal-infancy phase of minipuberty accounts for the diminished mass of Sertoli cells and seminiferous tubules among CHH males, enduring impairment of reproductive function even during gonadotropin replacement in adult life. In overcoming this obstacle, several clinical studies of neonatal gonadotropin replacement have consistently shown positive results in inducing testicular development and correcting cryptorchidism.

EXPERT OPINION

A high index of clinical suspicion, combined with hormonal testing undertaken in the postnatal period of 1-4 months, can reliably confirm or refute the diagnosis of CHH. Timely identification of CHH in affected male infants (having characteristic "red flag' developmental anomalies) opens up the possibility for gonadotropin replacement as a targeted therapy to restore the normal hormonal milieu of minipuberty. Further work is necessary in formulating optimal gonadotropin treatment regimens to be more widely adopted in clinical practice.

Hormonal therapy is effective and safe for cryptorchidism caused by idiopathic hypogonadotropic hypogonadism in adult males

BACKGROUND

Hormonal therapy is a reasonable treatment for cryptorchidism caused by idiopathic hypogonadotropic hypogonadism (IHH). However, the clinical evidence on whether it is effective and safe for the treatment of cryptorchidism caused by IHH is lacking.

AIM

To evaluate the effect of hormonal therapy in testicular descent, puberty development, and spermatogenesis in adult males with cryptorchidism caused by IHH.

METHODS

This retrospective study included 51 patients with cryptorchidism caused by IHH from the Andrology Clinic of University affiliated teaching hospital. Patients were divided into two groups: group A patients received hormonal therapy; group B patients received surgical treatment for cryptorchidism followed by hormonal therapy.

RESULTS

The rate of successful testicular descent following hormonal therapy (19/32 in group A) or surgical treatment (11/19 in group B) shows no statistically significant difference. There was also no statistically significant difference in penile length, Tanner stage of pubic hair, testicular volume, and success rate of spermatogenesis between the two groups. Testicular atrophy was seen in a single patient in group B.

CONCLUSIONS

Hormone therapy in adult males with cryptorchidism caused by IHH is effective and safe regarding testicular descent, puberty development, and spermatogenesis. This study provides new insight into the treatment of cryptorchidism caused by IHH and highlights that hormonal therapy could be an effective, safe, and economic treatment option for cryptorchidism in males caused by IHH.

Comparison of Clinical Characteristics and Spermatogenesis in CHH Patients Caused by PROKR2 and FGFR1 Mutations

A retrospective study was conducted to investigate the effect of gonadotropin or pulsatile gonadotropin-releasing hormone (GnRH) therapy on spermatogenesis in congenital hypogonadotropic hypogonadism (CHH) patients with PROKR2 (prokineticin receptor 2) or FGFR1 (fibroblast growth factor receptor 1) mutations. Clinical features, gonadotropin levels, testicular volume (TV), and sperm concentration in response to gonadotropin and pulsatile GnRH therapy were compared between groups with PROKR2 and FGFR1 mutations. Twelve patients with PROKR2 gene mutation and fourteen patients with FGFR1 gene mutation were included. The incidence of cryptorchidism in PROKR2 and FGFR1 groups was 16.7% and 50%, respectively (p = 0.110). The baseline TV in the PROKR2 group was larger than that in FGFR1 group (2.0 vs. 1.63, p = 0.047). The initial LH, FSH, and testosterone levels were similar between the two groups. Based on the analysis of achieving spermatogenesis using Kaplan-Meier and log-rank tests, the PROKR2 group demonstrated shorter period of seminal spermatozoa appearance than the FGFR1 group (χ² = 8.297, p = 0.004); the median duration of achieving spermatogenesis in the PROKR2 and FGFR1 groups was 9 and 16 months, respectively. The PROKR2 mutation group exhibited shorter required time to achieve different sperm concentration thresholds (5, 10, and 15 million/mL) than the FGFR1 mutation group (p = 0.012, 0.024, and 0.040). In conclusion, the PROKR2 group achieved spermatogenesis easily than the FGFR1 group, possibly due to the lower prevalence of cryptorchidism and larger baseline testicular volume in the PROKR2 group.

Gonadotropin Therapy Once a Week for Spermatogenesis in Hypogonadotropic Hypogonadism

OBJECTIVE

Hypogonadotropic hypogonadism (HH) can be caused by congenital HH (CHH), pituitary stalk interruption syndrome (PSIS), and pituitary injury (acquired HH). Gonadotropin therapy, typically administrated every other day or twice a week, is a common method for spermatogenesis. The aim of this retrospective study was to evaluate the efficacy of once a week gonadotropin therapy on spermatogenesis in patients with HH (n=160).

METHODS

Their diagnoses were Kallmann syndrome (KS) (n=61), normosmic CHH (nCHH) (n=34), PSIS (n=48), and acquired HH (n=17). The rate of successful spermatogenesis and median time to achieve spermatogenesis among these four subgroups were compared, as well as between a once weekly group (n=95) and a twice weekly group (n=223) of CHH patients.

RESULTS

Once a week gonadotropin therapy resulted in 74% of HH patients (119/160) who achieved spermatogenesis with significantly increased testicular volume and total testosterone levels (p<0.001). The median period of spermatogenesis was 13 (11.4, 14.6) months. Larger basal testicular volume (p=0.0056) was an independent predictor for earlier sperm appearance. Six spontaneous pregnancies occurred. Compared with the twice weekly regimen for spermatogenesis, the once a week injection group had a similar median time of sperm appearance (14 [11.6, 16.4] vs. 15 [13.5, 16.5] months), similar success rate (78% [74/95] vs. 64% [143/223]), sperm concentration (20.9 [5.0,46.3] vs. 11.7 [2.1, 24.4] million/mL), and progressive sperm motility (40.8±27.3% vs. 36.9%±20.2%).

CONCLUSION

Once a week gonadotropin therapy is effective in inducing spermatogenesis, similar to that of twice weekly therapy. Larger basal testicular size was a favorable indicator for earlier spermatogenesis.

Testosterone versus hCG in Hypogonadotropic Hypogonadism – Comparing Clinical Effects and Evaluating Current Practice

Background. Gonadotropin therapy is not typically used for pubertal induction in hypogonadotropic hypogonadism (HH), however, represents a promising alternative to testosterone. It can potentially lead to the maintenance of future fertility in addition to testicular growth. We compared the pubertal effects of human chorionic gonadotropin (hCG) versus testosterone in adolescent males with HH. We evaluated the current practice, among pediatric endocrinologists, to identify barriers against gonadotropin use. Methods. In this retrospective review, we compared the effect of testosterone versus hCG therapy on mean testicular volume (MTV), penile length, growth velocity, and testosterone levels. We surveyed pediatric endocrinologists at our center, using RedCap. Results. Outcomes were assessed in 52 male patients with HH (hCG, n = 4; T, n = 48) after a mean treatment duration of 13.4 (testosterone) and 13.8 months (hCG; P = .79). Final MTV was higher with hCG (8.25 mL) than testosterone (3.4 mL; P < .001). The groups did not differ in penile length, growth velocity, or testosterone levels. Survey results showed that more than half the providers were aware of the benefits of gonadotropins, however, 91% were uncomfortable prescribing hCG. Commonly reported barriers to prescribing hCG were lack of experience (62%) and insurance coverage concerns (52%). Conclusions. Larger testicular volume predicts faster induction of spermatogenesis. Since hCG promoted better testicular growth, compared to testosterone, it may potentially improve future fertility outcomes in HH patients. Our results identify an opportunity to improve current practice among pediatric endocrinologists worldwide and reduce barriers to prescribing gonadotropins in the adolescent population.

Clinical Characteristics and Spermatogenesis in Patients with Congenital Hypogonadotropic Hypogonadism Caused by FGFR1 Mutations

OBJECTIVE

The aim of this study was to investigate the clinical characteristics of patients diagnosed with congenital hypogonadotropic hypogonadism (CHH) caused by FGFR1 (fibroblast growth factor receptor 1) gene mutations and to evaluate the effect of gonadotropin or pulsatile gonadotropin-releasing hormone (GnRH) therapy on spermatogenesis.

METHODS

A retrospective study was conducted on CHH patients admitted to Peking Union Medical College Hospital from January 2012 to March 2020. Clinical features and laboratory results were recorded. Testicular volume and sperm count responding to gonadotropin and pulsatile GnRH therapy were compared between the FGFR1 mutation group and the mutation-negative group.

RESULTS

(1) FGFR1 mutation group included 14 patients who received sperm-induction therapy, and the mutation-negative group enrolled 25 CHH patients. (2) The incidence of cryptorchidism was 50.0% (7/14) and 12.0% (3/25) in the FGFR1 group and the mutation-negative group, respectively (p=0.019). The baseline testicular volume of the FGFR1 mutation group was smaller than that of the mutation-negative group, 1.6 (0.5-2.0) mL vs. 2 (1.75-4) mL (p=0.033). The baseline luteinizing hormone (LH), Follicle-stimulating hormone (FSH), and testosterone levels were similar between the two groups. (3) Using the Kaplan-Meier and log-rank tests for the analysis of spermatogenesis, it was found that there was no significant difference in the first sperm appearance between the FGFR1 mutation group and the mutation-negative group (χ ² = 1.974, p=0.160). The median time of spermatogenesis in the FGFR1 mutation group was longer than that in the mutation-negative group, 16 months vs. 10 months, respectively. The cumulative spermatogenesis success rate at 12 months in the FGFR1 mutation group (35.71%) was lower than that in the mutation-negative group (68.75%) (p=0.047). The sperm concentration in the mutation-negative group was more easily achieved for different thresholds compared with that in the FGFR1 mutation group, but no significant difference was observed (p > 0.05) between the two groups. The last follow-up examination showed that the testicular volume was 7.00 (4.75-12.00) mL and 10.56 ± 4.82 mL (p=0.098), the ejaculate volume of sperm was 2.20 (1.40-2.26) mL and 3.06 ± 1.42 mL (p=0.175), and the sperm concentration was 7.19 (1.00-9.91) million/mL and 18.80 (4.58-53.62) million/mL (p=0.038) in the FGFR1 mutation and mutation-negative groups, respectively, while the sperm motility (A%, A + B%, and A + B + C%) was similar for the two groups (p=0.839, 0.909, and 0.759, respectively). The testosterone level during treatment was 366.02 ± 167.03 ng/dL and 362.27 ± 212.86 ng/dL in the FGFR1 mutation and mutation-negative groups, respectively (p=0.956).

CONCLUSION

Patients with FGFR1 mutations have a higher prevalence of cryptorchidism and smaller testicular volume. Although patients with FGFR1 mutations have a similar rate of success for spermatogenesis compared to that of the mutation-negative patients, a longer treatment period was required and a lower sperm concentration was achieved.

Clinical Management of Congenital Hypogonadotropic Hypogonadism

The initiation and maintenance of reproductive capacity in humans is dependent on pulsatile secretion of the hypothalamic hormone GnRH. Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder that results from the failure of the normal episodic GnRH secretion, leading to delayed puberty and infertility. CHH can be associated with an absent sense of smell, also termed Kallmann syndrome, or with other anomalies. CHH is characterized by rich genetic heterogeneity, with mutations in >30 genes identified to date acting either alone or in combination. CHH can be challenging to diagnose, particularly in early adolescence where the clinical picture mirrors that of constitutional delay of growth and puberty. Timely diagnosis and treatment will induce puberty, leading to improved sexual, bone, metabolic, and psychological health. In most cases, patients require lifelong treatment, yet a notable portion of male patients (∼10% to 20%) exhibit a spontaneous recovery of their reproductive function. Finally, fertility can be induced with pulsatile GnRH treatment or gonadotropin regimens in most patients. In summary, this review is a comprehensive synthesis of the current literature available regarding the diagnosis, patient management, and genetic foundations of CHH relative to normal reproductive development.

Congenital Hypogonadotrophic Hypogonadism: Minipuberty and the Case for Neonatal Diagnosis

Congenital hypogonadotrophic hypogonadism (CHH) is a rare but important etiology of pubertal failure and infertility, resulting from impaired gonadotrophin-releasing hormone secretion or action. Despite the availability of effective hormonal therapies, the majority of men with CHH experience unsatisfactory outcomes, including chronic psychosocial and reproductive sequelae. Early detection and timely interventions are crucial to address the gaps in medical care and improve the outlook for these patients. In this paper, we review the clinical implications of missing minipuberty in CHH and therapeutic strategies that can modify the course of disease, as well as explore a targeted approach to identifying affected male infants by integrating clinical and biochemical data in the early postnatal months.

Gonadotropin-Induced Spermatogenesis in CHH Patients with Cryptorchidism

Congenital hypogonadotropic hypogonadism (CHH) patients with cryptorchidism history usually have poor spermatogenesis outcome, while researches focusing on this population are rare. This study retrospectively evaluated gonadotropin-induced spermatogenesis outcome in CHH patients with cryptorchidism (n = 40). One hundred and eighty-three CHH patients without cryptorchidism were served as control. All patients received combined gonadotropins therapy (HCG and HMG) and were followed up for at least 6 months. The median follow-up period was 24 (15, 33) months (totally 960 person-months). Sperm (>0/ml) initially appeared in semen at a median of estimated 24 months (95% confidence interval (CI) 17.8-30.2). Twenty (20/40, 50%) patients succeeded in producing sperms, and the average time to produce first sperm was 19 ± 8 months. Five pregnancies were achieved in 9 (5/9, 56%) couples who desired for children. Compared with CHH patients without cryptorchidism (n = 183), cryptorchid patients had longer median time for sperm appearance in semen (24 months vs. 15 months, P < 0.001), lower rate of spermatogenesis (50% vs. 67%, P=0.032), and lower mean sperm concentration (1.9 (0.5, 8.6) million/ml vs. 11.1(1.0, 25.0) million/ml, P=0.006) at the last visit. In conclusion, CHH patients with cryptorchidism require a longer period for gonadotropin-induced spermatogenesis. The successful rate and sperm concentration were lower than patients without cryptorchidism.

Testicular growth and spermatogenesis: new goals for pubertal hormone replacement in boys with hypogonadotropic hypogonadism? -a multicentre prospective study of hCG/rFSH treatment outcomes during adolescence

CONTEXT/OBJECTIVE

Testosterone treatment for pubertal induction in boys with hypogonadotropic hypogonadism (HH) provides virilization, but does not induce testicular growth or fertility. Larger studies evaluating the outcomes of gonadotropin replacement during adolescence have not been reported to date; whether previous testosterone substitution affects testicular responses is unresolved. We aimed to assess the effects of human chorionic gonadotropin (hCG) and recombinant FSH (rFSH) in boys and adolescents with HH with respect to a) testicular growth, b) spermatogenesis, c) quality of life (QoL) and to identify factors influencing therapeutic success.

DESIGN/SETTING

A prospective case study was conducted in 26 paediatric endocrine centres PATIENTS/INTERVENTIONS: HCG and rFSH were administered until cessation of testicular growth and plateauing of spermatogenesis to (1) prepubertal HH boys with absent or early arrested puberty (group A) and to (2) HH adolescents who had previously received full testosterone replacement (group B).

OUTCOME MEASURES

Bi-testicular volumes (BTVs), sperm concentrations and QoL.

RESULTS

Sixty (34 A/26 B) HH patients aged 14-22 years were enrolled. BTVs rose from 5 ± 5 to 34 ± 3 ml in group A vs 5 ± 3 to 32 ± 3 ml in group B, with normal final BTVs (≥24 ml) attained in 74%/70% after 25/23 months in A/B, respectively. Sperm in the ejaculate were found in 21/23(91%)/18/19(95%), with plateauing concentrations after 31/30 months of hCG and 25/25 months of combined treatment in A/B. Sperm concentrations were normal (≥15 mill/ml) in 61%/32%, with mean concentrations of 40 ± 73 vs 19 ± 38 mill/ml in A/B (n.s.). Outcomes were better in patients without bilateral cryptorchidism, with non-congenital HH causes, higher baseline BTVs, and higher baseline inhibin B and AMH levels. QoL increased in both groups.

CONCLUSIONS

HCG/rFSH replacement during adolescence successfully induces testicular growth and spermatogenesis, irrespective of previous testosterone replacement, and enhances QoL.

Factors affecting post-pubertal penile size in patients with hypospadias

Objectives

To evaluate actual post-pubertal penile size and factors affecting it in hypospadias patients, we retrospectively reviewed medical charts.

Patients and methods

Hypospadias patients whose external genitalia were categorized into Tanner stage 5, and whose stretched penile length was evaluated at 15 years old or older from April 2008 to April 2015, were enrolled in the present study. Stretched penile length was measured by a single examiner. Actual post-pubertal stretched penile length and factors affecting the post-pubertal stretched penile length were estimated. Statistical analysis was performed using Mann–Whitney U test and univariate and multivariate linear regression models for the determination of independent factors.

Results

Thirty patients met the inclusion criteria. Median age at evaluation was 17.2 years. Thirteen and 17 had mild and severe hypospadias, respectively. Endocrinological abnormality was identified in 5. Multivariate analysis showed that the severity of hypospadias and endocrinological abnormality were significant factors affecting stretched penile length. Stretched penile length in 25 patients without endocrinological abnormality was significantly longer than that in those with endocrinological abnormality (p = 0.036). Among patients without endocrinological abnormality, stretched penile length in 13 with severe hypospadias was significantly shorter than that in 12 with mild hypospadias (p = 0.004).

Conclusions

While the severity of hypospadias and endocrinological abnormality at post-pubertal evaluation were factors affecting post-pubertal penile size, stretched penile length in patients with severe hypospadias was shorter even in cases without endocrinological abnormality. These results suggest that severe hypospadias is not only a disorder of urethral development, but also a disorder of penile development.

Expert consensus document: European Consensus Statement on congenital hypogonadotropic hypogonadism--pathogenesis, diagnosis and treatment

Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder caused by the deficient production, secretion or action of gonadotropin-releasing hormone (GnRH), which is the master hormone regulating the reproductive axis. CHH is clinically and genetically heterogeneous, with >25 different causal genes identified to date. Clinically, the disorder is characterized by an absence of puberty and infertility. The association of CHH with a defective sense of smell (anosmia or hyposmia), which is found in ∼50% of patients with CHH is termed Kallmann syndrome and results from incomplete embryonic migration of GnRH-synthesizing neurons. CHH can be challenging to diagnose, particularly when attempting to differentiate it from constitutional delay of puberty. A timely diagnosis and treatment to induce puberty can be beneficial for sexual, bone and metabolic health, and might help minimize some of the psychological effects of CHH. In most cases, fertility can be induced using specialized treatment regimens and several predictors of outcome have been identified. Patients typically require lifelong treatment, yet ∼10-20% of patients exhibit a spontaneous recovery of reproductive function. This Consensus Statement summarizes approaches for the diagnosis and treatment of CHH and discusses important unanswered questions in the field.

Gonadotrophin replacement for induction of fertility in hypogonadal men

Congenital hypogonadotrophic hypogonadism (CHH) is a rare form of infertility caused by deficient secretion or action of gonadotrophin-releasing hormone. There is no consensus regarding the optimal approach to fertility treatment in CHH men. In most cases, appropriate hormonal treatment with human chorionic gonadotrophin with or without follicle stimulating hormone will induce testicular development, spermatogenesis and fertility. Recent studies have examined sequential treatment with FSH pre-treatment to optimize fertility outcomes in severely affected CHH patients. This paper reviews historical and recent literature to summarize the current evidence on therapeutic approaches for CHH men seeking fertility.

Factors affecting spermatogenesis upon gonadotropin-replacement therapy: a meta-analytic study

A meta-analysis was performed to systematically analyse the results of gonadotropin and GnRH therapy in inducing spermatogenesis in subjects with hypogonadotropic hypogonadism (HHG) and azoospermia. An extensive Medline and Embase search was performed including the following words: 'gonadotropins' or 'GnRH', 'infertility', 'hypogonadotropic', 'hypogonadism' and limited to studies in male humans. Overall, 44 and 16 studies were retrieved for gonadotropin and GnRH therapy, respectively. Of those, 43 and 16 considered the appearance of at least one spermatozoa in semen, whereas 26 and 10 considered sperm concentration upon gonadotropin and GnRH, respectively. The combination of the study results showed an overall success rate of 75% (69-81) and 75% (60-85) in achieving spermatogenesis, with a mean sperm concentration obtained of 5.92 (4.72-7.13) and 4.27 (1.80-6.74) million/mL for gonadotropin and GnRH therapy, respectively. The results upon gonadotropin were significantly worse in studies involving only subjects with a pre-pubertal onset HHG, as compared with studies involving a mixed population of pre- and post-pubertal onset [68% (58-77) vs. 84% (76-89), p = 0.011 and 3.37 (2.25-4.49) vs. 12.94 (8.00-17.88) million/mL, p < 0.0001; for dichotomous and continuous data, respectively]. A similar effect was observed also upon GnRH. No difference in terms of successful achievement of spermatogenesis and sperm concentration was found for different FSH preparations. Previous use of testosterone replacement therapy (TRT) did not affect the results obtained with gonadotropins. Finally, a higher success rate was found for subjects with lower levels of gonadotropins at the baseline and for those using both human chorionic gonadotropin and FSH. Gonadotropin therapy, even with urinary derivatives, is a suitable option in inducing/restoring fertility in azoospermic HHG subjects. Gonadotropins appear to be more efficacious in subjects with a pure secondary nature (low gonadotropins) and a post-pubertal onset of the disorder, whereas previous TRT does not affect outcome.

Effects of three different medications on metabolic parameters and testicular volume in patients with hypogonadotropic hypogonadism: 3-year experience

INTRODUCTION

The aim of this study was to demonstrate the influences of three different treatment strategies on biochemical parameters and testicular volume (TV) in patients with idiopathic hypogonadotropic hypogonadism (IHH).

SUBJECTS DESIGN AND METHODS

Seventy-seven never-treated patients with IHH and age and body mass index (BMI)-matched 42 healthy controls were analysed in a retrospective design. Twenty-eight patients were treated with testosterone esters (TE), 25 patients were treated with human chorionic gonadotropin (hCG) and 24 patients were treated with testosterone gel (TG). Biochemical parameters, tanner stages (TS) and TV were evaluated before and after 6 months of treatment.

RESULTS

Pretreatment TV, TS and biochemical test results were similar among the three treatment subgroup. In the TE-treated group, BMI, haemoglobin, haematocrit, creatinine, triglyceride, total testosterone (TT), TS and TV increased, but HDL-cholesterol (C) and urea level decreased significantly. In the hCG-treated group, triglyceride level decreased, and luteinizing hormone level, TS and TV increased significantly. BMI, TT, TS and TV increased, and leucocyte count, total-C, HDL-C levels decreased significantly in the TG-treated patients. No treatment type resulted in any changes in insulin resistance markers.

CONCLUSION

hCG treatment resulted in favourable effects particularly on TV and lipid parameters. When TV improvement is considered less important, TG treatment may be a better option for older patients with IHH because of its easy use, neutral effects on triglyceride, haemoglobin and haematocrit, and its beneficial effects on total cholesterol level.

Neonatal gonadotropin therapy in male congenital hypogonadotropic hypogonadism

Congenital hypogonadotropic hypogonadism (CHH) causes pubertal failure and infertility in both women and men due to partial or total secretory failure of the two pituitary gonadotropins lutropin (LH) and follitropin (FSH) during periods of physiological activation of the gonadotropic axis. Men and women with CHH frequently seek treatment for infertility after hypogonadism therapy. Some etiologies, such as autosomal dominant or X-linked Kallmann syndrome, raise the question of hereditary transmission, leading to increasing demands for genetic counseling and monitoring of medically assisted pregnancies. Diagnosis and treatment of newborn boys is, therefore, becoming an increasingly important issue. In male individuals with complete forms of CHH, the antenatal and neonatal gonadotropin deficit leads to formation of a micropenis and cryptorchidism, which could undermine future sexual and reproductive functions. Standard treatments, usually started after the age of puberty, often only partially correct the genital abnormalities and spermatogenesis. The aim of this Review is to examine the possible additional benefits of neonatal gonadotropin therapy in male patients with CHH. Encouraging results of neonatal therapy, together with a few reports of prepubertal treatment, support the use of this novel therapeutic strategy aimed at improving sexual and reproductive functions in adulthood.

Penile growth in response to human chorionic gonadotropin (HCG) treatment in patients with idiopathic hypogonadotrophic hypogonadism

Penile growth is under androgenic control. Human chorionic gonadotropin (hCG) has a stimulatory effect on testicular steroidogenesis and penile growth. The purpose of this study was to evaluate the effect of hCG treatment on the gonadal response and penile growth in male idiopathic hypogonadotrophic hypogonadism (IHH) presenting with micropenis. A total of 20 IHH patients who met the criteria for micropenis were included in this study. hCG (1,500-2,000 IU) was administrated intramuscularly, 3 times per week, for 8 weeks. Basic laboratory and hormonal indexes (including serum testosterone and LH levels), penis length (flaccid and stretched), and testicular volume were measured before and 24 weeks after hCG treatment. The patients' mean age was 18.9 years (range, 12 to 24 years). The mean serum testosterone level was significantly increased after hCG treatment (baseline, 2, 4, 12, and 24 weeks: 0.90±1.35 ng/ml, 1.77±1.31 ng/ml, 3.74±2.24 ng/ml, 5.49±1.70 ng/ml, and 5.58±1.75 ng/ml, respectively; p<0.05). Mean penile length also increased significantly 24 weeks after treatment (flaccid length: from 3.39±1.03 cm to 5.14±1.39 cm; stretched length: from 5.41±1.43 cm to 7.45±1.70 cm; p<0.001). Mean testicular volumes increased significantly as well (left: from 5.45 cc to 6.83 cc; right: from 5.53 cc to 7.03 cc). There were no remarkable adverse effects of the hCG treatment. The hCG treatment increased the serum testosterone level, penile length, and testicular volume in IHH patients. Our results suggest that hCG treatment has a beneficial effect on gonadal function and penile growth in patients with IHH presenting with micropenis.

Efficacy of recombinant human follicle stimulating hormone at low doses in inducing spermatogenesis and fertility in hypogonadotropic hypogonadism

BACKGROUND

Recombinant-FSH (rFSH) added to hCG at dose of 450 IU weekly is effective in inducing spermatogenesis in patients with hypogonadotropic hypogonadism (HH), but there are no data on the use of lower doses.

AIM

This observational retrospective study evaluated whether 150-225 IU of rFSH weekly were able to induce spermatogenesis in HH men who failed to start it with hCG alone.

SUBJECTS AND METHODS

Thirty-four patients with pre-pubertal onset HH (20-44 yr old) without adverse fertility factors were considered for this study. After hCG pre-treatment they received also either rFSH (Group 1) or highly purified urinary FSH (hpFSH) (Group 2) 75 IU sc 2 or 3 times weekly. Semen analysis was performed every 3 months during pre-treatment and the 1st yr of combined therapy. Patients were also invited to refer pregnancies in their partners during the subsequent 12 months.

RESULTS

Total sperm count/ejaculate did not show significant difference between 2 groups, while a significantly higher forward motility was observed in Group 1 (p<0.05). The median times to achieve sperm output thresholds (first sperm appearance, sperm concentration >1.5 or >5 mil/ml) were significantly lower in Group 1 (p<0.04, 0.03, and 0.001, respectively). A tendency to a shorter time to pregnancy was shown in partners of Group 1.

CONCLUSIONS

Our data indicate that lower rFSH week dose than that so far used was able to induce potentially fertilizing sperm output in HH men previously treated with hCG. The rFSH effects are comparable to those of hpFSH but with a trend to a faster outcome achievement.

Induction of spermatogenesis by recombinant follicle-stimulating hormone (puregon) in hypogonadotropic azoospermic men who failed to respond to human chorionic gonadotropin alone

A multicenter, open-label, randomized efficacy and safety study was performed with combined human chorionic gonadotropin (hCG) and recombinant follicle-stimulating hormone (recFSH) (Puregon(R)) treatment to induce spermatogenesis in hypogonadotropic hypogonadal male patients. Patients were pretreated for 16 weeks with hCG to normalize testosterone levels. A total of 30 of 49 (61%) subjects had normalized testosterone levels but were still azoospermic after the hCG-alone phase. These patients were randomized into 2 treatment schemes with recFSH (2 x 225 IU recFSH per week [group A] or 3 x 150 IU recFSH per week [group B]), in combination with hCG for a period of 48 weeks. Total testosterone increased during the hCG-alone period from 1.08 and 1.22 ng/mL to 6.26 and 4.52 ng/mL for groups A and B, respectively. Combined gonadotropin treatment was effective in inducing spermatogenesis (sperm count >/=1 x 10(6)/mL) in 14 of 30 subjects (47%) and this was achieved after a median duration of treatment of approximately 5.5 months. Treatment time necessary for first sperm cells to appear in the ejaculate was related to the initial testicular volume. Subjects with a history of maldescended testes (11 of 30 subjects, 37%) showed a lower mean response to treatment as indicated by the relatively lower number of subjects reaching levels of at least 1 x 10(6) sperm cells per milliliter. Combined testicular volume increased during combined gonadotropin treatment from 11.4 to 24.0 mL. Although subjects with a history of maldescended testes had a lower starting testicular volume, subjects with and without a history of maldescended testes showed approximately the same relative increase in testicular volume. Total testosterone levels showed only a minor further increase during the combined gonadotropin treatment period. In conclusion, a weekly dose of 450 IU (3 x 150 IU or 2 x 225 IU) recFSH, in addition to hCG, was able to induce spermatogenesis in many hypogonadotropic azoospermic men who failed to respond to treatment with hCG alone.

Predicting pregnancy and spermatogenesis by survival analysis during gonadotrophin treatment of gonadotrophin-deficient infertile men

BACKGROUND

Predictors of fertility or spermatogenesis during gonadotrophin therapy of gonadotrophin-deficient men remain poorly defined.

METHODS AND RESULTS

In order to evaluate potential predictors, this study evaluated 29 consecutive gonadotrophin-deficient men all desiring paternity who received 43 courses of therapy in one centre between 1982 and 1998. The Kaplan-Meier survival analysis estimates of median (SE) time to a sperm concentration of >0, >5 and >20 x 10(6)/ml were 5.5 (1.1), 12.4 (2.3) and 29.1 (1.9) months respectively. Conception occurred in 22/43 cycles (with eight men achieving two pregnancies) with a median (SE) Kaplan-Meier estimate of 20.5 (4.7) months. The median sperm concentration at conception was 5.0 (SE 2.0; range 0.0-59.5) x 10(6)/ml. Multivariate correlated Cox proportional hazards models predicting these same sperm thresholds and conception were developed by forward stepwise variable selection with verification of the model by backward stepping. Larger testicular volume, prior gonadotrophin therapy, completion of puberty, older age, the absence of adverse fertility factors and the absence of multiple pituitary hormone deficiency predicted a favourable response. Multivariate modelling suggests that the two most important predictors of sperm output are testicular volume and pubertal status. The most important potentially modifiable predictor was prior gonadotrophin therapy. The efficacy of recombinant and urinary FSH were similar. Prior androgen therapy and partner's age did not appear to be significant.

CONCLUSIONS

Since prolonged treatment may be required to induce spermatogenesis, attention to these predictors may allow appropriate early use of advanced reproductive technologies.

The endocrine control of spermatogenesis

The hormonal regulation of spermatogenesis involves a complex interplay within the hypothalamo-pituitary-testicular axis, which commences before birth with male sexual development and continues through puberty and into adulthood. Hypothalamic gonadotrophin-releasing hormone drives these events by inducing pituitary gonadotrophin secretion, thereby stimulating testicular androgen secretion (providing virility) and spermatogenesis (providing fertility). Evidence from both animal models and man supports a need for both follicle-stimulating hormone and testosterone in achieving full spermatogenic potential, but a species difference in their relative roles exists. Clinical endocrine disorders can arise from a deficiency of hypothalamic gonadotrophin-releasing hormone and/or pituitary gonadotrophins, which results in hypogonadotrophic hypogonadism, featuring delayed/absent puberty and infertility. Physiologically-based and effective treatment with pulsatile gonadotrophin-releasing hormone or gonadotrophins can often restore fertility. Clinical conditions can also be caused by rare genetic disorders of the gonadotrophin molecules or the receptors for androgens and gonadotrophins, which result in a range of phenotypes (from male pseudohermaphroditism through to infertility); these disorders provide a unique insight into the physiology of sexual development and spermatogenesis.

Absence of effect of recombinant growth hormone to classic gonadotropin treatment on spermatogenesis of patients with severe hypogonadotropic hypogonadism

Encouraging clinical results have suggested a complimentary or permissive role of growth hormone (GH) to gonadotropin in inducing spermatogenesis in patients with hypogonadotropic hypogonadism, who did not respond to gonadotropin therapy alone. This study evaluates the effects of GH on spermatogenesis in four azoospermic hypogonadic hypogonadotropic (HH) men, treated initially for 6 months with gonadotropins (GN) alone (phase I), followed by a 6 months cotreatment of GH with GN (phase II). Plasma testosterone (T), IGF-1 levels, testicular volume, and spermiogram were evaluated under basal conditions and every 3 months during treatment. GN treatment alone induced a significant increase of T levels and semen volume, whereas testicular volume increased very little; all patients remained azoospermic. The combined GN-GH treatment induced, as expected, an increase in IGF-1 levels and an increase of T levels to values in the normal male range as well as a further, moderate, increase in testicular volume; azoospermia persisted, however, in all patients. The data do not confirm the beneficial effects of combined GN-GH treatment in hypogonadotropic hypogonadal males reported in the literature.

Efficacy and safety of recombinant human follicle stimulating hormone (Gonal-F) with urinary human chorionic gonadotrophin for induction of spermatogenesis and fertility in gonadotrophin-deficient men

In order to evaluate the efficacy and safety of recombinant human follicle stimulating hormone (r-hFSH) in combination with urinary human chorionic gonadotrophin (HCG) to induce spermatogenesis and fertility in gonadotrophin-deficient men, we conducted a prospective, open, non-comparative multicentre study in two Australian academic medical centres. Ten men with gonadotrophin deficiency requiring induction of spermatogenesis and fertility were treated with HCG for 3-6 months followed by the s.c. self-administration of injections of r-hFSH in combination with HCG for 18 months. Among the eight men who commenced r-hFSH treatment, seven demonstrated sperm output at a median of 6 months and five achieved the target sperm output of 1. 5x10(6) per ml at a median of 9 months of FSH treatment. Mean testicular volume increased by 4.2 ml during FSH treatment. Three men produced pregnancies in their partners, two of which resulted in the birth of healthy babies and a third patient's partner had a miscarriage. We conclude that r-hFSH is well tolerated and effective in inducing testis growth, spermatogenesis and fertility in gonadotrophin-deficient men. The efficacy of r-hFSH seems comparable with urinary FSH at restoring normal fertility in gonadotrophin-deficient men.

Congenital hypogonadotropic hypogonadism and micropenis: effect of testosterone treatment on adult penile size why sex reversal is not indicated

Micropenis is commonly due to fetal testosterone deficiency. The clinical management of this form of micropenis has been contentious, with disagreement about the capacity of testosterone treatment to induce a functionally adequate adult penis. As a consequence, some clinicians recommend sex reversal of affected male infants. We studied 8 male subjects with micropenis secondary to congenital pituitary gonadotropin deficiency from infancy or childhood to maturity (ages 18 to 27 years). Four patients were treated with testosterone before 2 years of age (group I) and four between age 6 and 13 years (group II). At presentation, the mean penile length in group I was 1.1 cm (-4 SD; range, 0.5 to 1.5 cm) and in group II it was 2.7 cm (-3.4 SD; range, 1.5 to 3.5 cm). All patients received one or more courses of 3 intramuscular injections of testosterone enanthate (25 or 50 mg) at 4-week intervals in infancy or childhood. At the age of puberty the dose was gradually increased to 200 mg monthly and later to an adult replacement regimen. As adults, both group I and II had attained a mean final penile length of 10.3 cm 2.7 cm with a range of 8 to 14 cm (mean adult stretched penile length for Caucasians is 12.4 2.7 cm). Six of 8 men were sexually active, and all reported normal male gender identity and psychosocial behavior. We conclude that 1 or 2 short courses of testosterone therapy in infancy and childhood augment penile size into the normal range for age in boys with micropenis secondary to fetal testosterone deficiency; replacement therapy at the age of puberty results in an adult size penis within 2 SD of the mean. We found no clinical, psychologic, or physiologic indications to support conversion of affected male infants to girls. Further, the results of this study do not support the notion, derived from data in the rat, that testosterone treatment in infancy or childhood impairs penile growth in adolescence and compromises adult penile length.

Induction of puberty with human chorionic gonadotropin and follicle-stimulating hormone in adolescent males with hypogonadotropic hypogonadism

OBJECTIVE

To evaluate the clinical and hormonal responses of adolescent males with hypogonadotropic hypogonadism (HH) in response to gonadotropin replacement with the use of long-term combined hCG and FSH therapy.

DESIGN

Prospective clinical study.

SETTING

Clinical pediatric department providing tertiary care.

PATIENT(S)

Seven prepubertal males with isolated HH with a mean (+/-SD) age of 15.44+/-1.97 years and seven prepubertal males with panhypopituitarism-associated HH with a mean (+/-SD) age of 18.1+/-3.24 years were studied.

INTERVENTION(S)

Human chorionic gonadotropin (1,000-1,500 IU IM) and FSH (75-100 IU SC) were administered every alternate day of the week until the total induction of puberty and spermatogenesis was achieved.

MAIN OUTCOME MEASURE(S)

Serum testosterone levels, testicular volume, penis length, and sperm count were evaluated after the administration of hCG and FSH.

RESULT(S)

All patients achieved normal sexual maturation and normal or nearly normal adult male levels of testosterone. The increase in testicular size was significant in both groups. Positive sperm production was assessed in four of five patients with isolated HH and in three of three patients with panhypopituitarism-associated HH.

CONCLUSION(S)

Long-term combined hCG and FSH therapy is effective in inducing puberty, increasing testicular volume, and stimulating spermatogenesis in adolescent males with isolated HH and panhypopituitarism-associated HH.

Clinical evaluation in isolated hypogonadotrophic hypogonadism (Kallmann syndrome)

OBJECTIVE

To describe the clinical features, laboratory investigation and treatment of Kallmann syndrome.

DESIGN

A retrospective study of patients treated in the Endocrine Clinic of the Royal Children's Hospital and St Vincent's Hospital, Melbourne, between 1984 and 1996.

RESULTS

Eleven males and 5 females with Kallmann syndrome are described. Their ages at presentation ranged from one week to 21 years. Presenting symptoms were micropenis, small testes, anosmia and delayed puberty. Fifty-six percent (9/16) had a family history of either anosmia or infertility. The features of Kallmann syndrome are variable. We have described unilateral renal aplasia, coloboma of iris, deafness, midline anomalies, oculomotor apraxia and Moebius anomalad as features that were associated with Kallmann syndrome in our group of subjects. One patient diagnosed as having X-linked Kallmann syndrome has previously been shown to have a specific mutation in an intronic sequence adjacent to exon 6. Most patients showed low serum levels of basal gonadotrophins, testosterone or oestrogen, and had a poor response to LHRH stimulation, but two patients showed a pubertal response to LHRH stimulation, and may have a variant form of Kallmann syndrome. Treatment given to these patients included exogenous testosterone or oestrogen for induction of puberty, with appropriate pubertal progress occurring in each patient.

CONCLUSION

The manifestations of Kallmann syndrome vary, depending upon the degree of LHRH deficiency. Therapy should combine exogenous sex hormone replacement and psychological support, with long-term follow-up to ensure maintenance of normal sexual function, normal bone mass and psychosocial outcome, with fertility induction when indicated.

Efficacy and safety of highly purified urinary follicle-stimulating hormone with human chorionic gonadotropin for treating men with isolated hypogonadotropic hypogonadism. European Metrodin HP Study Group

OBJECTIVE

To assess the efficacy and safety of highly purified urinary FSH in combination with hCG in inducing spermatogenesis in men with primary, complete isolated hypogonadotropic hypogonadism.

DESIGN

Prospective, open, noncomparative, multicenter study.

SETTING

Eight European clinical centers.

PATIENT(S)

Twenty-eight men with primary, complete isolated hypogonadotropic hypogonadism.

INTERVENTION(S)

The administration of hCG for 3-6 months followed by the administration of SC highly purified urinary FSH in combination with hCG for 18 months.

MAIN OUTCOME MEASURE(S)

The primary efficacy end point was a sperm density of at least 1.5 x 10(6) mL. Secondary efficacy end points included mean testicular volume, serum inhibin concentration, semen analysis, and pregnancy in the female partner for couples who desired fertility. Safety was assessed by monitoring adverse events and performing routine laboratory tests.

RESULT(S)

Twenty-five (89.3%) patients achieved spermatogenesis; 18 (64.3%) achieved a density of >1.5 x 10(6)/mL. All secondary end points were improved. No serious study drug-related adverse events were recorded.

CONCLUSION(S)

Highly purified urinary FSH in combination with hCG was successful in inducing and maintaining spermatogenesis in men with primary, complete isolated hypogonadotropic hypogonadism. Highly purified urinary FSH administered SC was well tolerated during the treatment period.

The use of the hCG stimulation test in the endocrine evaluation of cryptorchidism

OBJECTIVE

To review retrospectively the value of the human chorionic gonadotrophin (hCG) test in the evaluation of prepubertal boys with bilateral impalpable testes.

SUBJECTS AND METHODS

The study comprised 31 boys investigated between 1974 and 1990 at the Hospital for Sick Children, London. All boys had an hCG test consisting of three intramuscular injections of hCG on successive days at a daily dose dependent on their age (< 1 year old, 500 units; 1-10 years, 1000 units; > 10 years, 1500 units). Blood samples were taken before the first dose and 24 h after the last dose and the level of plasma testosterone assessed and expressed as a pre/post ratio.

RESULTS

Eight boys had no response to hCG, due to anorchia. One boy had no response to hCG but had bilateral atrophic intra-abdominal testes. Twenty-two boys responded to hCG and had testes whose size was related to the degree of testosterone elevation after this stimulatory test. The hCG test therefore had a positive predictive value of 89% and a negative predictive value of 100%. There was a quantitative difference in testosterone response between 14 boys who had bilateral intra-abdominal testes of 'normal' volume (median pre/post ratio, 11.4) and nine boys who had an otherwise reduced volume of testes (dysplastic or unilateral intra-abdominal) (median pre/post ratio of 4; P = 0.02).

CONCLUSION

The hCG test is a valid indicator of the presence of functioning testicular tissue. It is predictive of anorchia and a good response to hCG suggests the presence of testes sufficiently large for orchidopexy.