Treatment of cryptorchidism with human chorionic gonadotropin or gonadotropin releasing hormone. A double-blind controlled study of 243 boys

European Paediatric Surgeons' Association Survey on the Adherence to EAU/ESPU Guidelines in the Management of Undescended Testes

INTRODUCTION

 The aim of this study was to assess the adherence to the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU) 2016 guidelines in the management of undescended testes (UDT).

MATERIALS AND METHODS

 An online questionnaire was sent in 2023 to members of the European Paediatric Surgeons' Association (EUPSA).

RESULTS

 Among 157 members, 46 and 44% perform orchidopexy before 12 and 18 months, respectively. In total, 92% recommend conservative management of retractile testes and 58% offer close follow-up. In case of nonpalpable testes, 78% favor laparoscopy and 18% ultrasonography. If a peeping testicle is identified at laparoscopy, 76% perform a single-stage orchidopexy. In case of a high testicle, a staged procedure is preferred (84%). Management of blind-ending spermatic vessel is heterogenous with a majority ending the operation, followed by exploration of the inguinal canal and removal of the testicular nubbin with optional fixation of the contralateral testis. Only a minority recommends hormonal therapy to improve fertility potential in bilateral UDT. A majority (59%) discuss testis removal in UDT in postpubertal boys. In addition, 77% declare following the EAU/ESPU guidelines. Unawareness of guidelines was the most common reason cited for nonadherence. International guidelines were found to have the greatest influence on clinical practice; however, personal experience and institutional practice seem to play an important role.

CONCLUSION

 Most recommendations of the EAU/ESPU guidelines are being followed by EUPSA members; however, personal and institutional practice impact decision making. Hormonal therapy in bilateral UDT, management of vanishing testes, and UDT in postpubertal boys could be improved.

Hormone Therapy During Infancy or Early Childhood for Patients with Hypogonadotropic Hypogonadism, Klinefelter or Turner Syndrome: Has the Time Come?

Managing patients unable to produce sex steroids using gonadotropins to mimic minipuberty in hypogonadotropic hypogonadism, or sex steroids in patients with Klinefelter or Turner syndrome, is promising. There is a need to pursue research in this area, with large prospective cohorts and long-term data before these treatments can be routinely considered.

A history of cryptorchidism is associated with impaired testicular function in early adulthood: a cross-sectional study of 6376 men from the general population

STUDY QUESTION

Is there a difference in testicular function in early adulthood between men born with cryptorchidism and men born with normally descended testes?

SUMMARY ANSWER

In men from the general population, a history of cryptorchidism was associated with lower total testis volume and impaired semen quality as well as altered serum levels of reproductive hormones.

WHAT IS KNOWN ALREADY

The association between cryptorchidism and testicular function is well documented in studies based on sub-fertile or infertile men recruited from a clinical setting. However, the association has not previously been investigated in men from the general population, who were unselected regarding fertility status.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional population-based study of 6376 young Danish men examined from 1996 to 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study is based on young men from the greater Copenhagen area, Denmark (median age of 19 years) who were unselected regarding fertility status and semen quality. The young men delivered a semen sample, had a blood sample drawn and underwent a physical examination including assessment of testis volume. Participants completed a questionnaire regarding cryptorchidism at birth, current lifestyle and their mother’s pregnancy, after consulting their mother. The differences in markers of testicular function, including testis volume, semen parameters and reproductive hormones between men with and without a history of cryptorchidism were investigated with multiple linear regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The participation rate was 24% for the entire study period. Overall, a history of cryptorchidism was associated with reduced testicular function. In the adjusted models, a history of cryptorchidism was associated with a 3.5 ml lower total testis volume, determined by orchidometer (P < 0.001), 28% lower sperm concentration (95% CI: −37 to −20) and 26% lower inhibin B/FSH ratio (95% CI: −50 to −22) compared to men without a history of cryptorchidism, suggesting a reduced spermatogenetic capacity. Men with a history of cryptorchidism also had a slightly reduced Leydig cell function expressed as a 6% lower testosterone/LH ratio (95% CI: −12 to −0.7). The significant effect sizes and different markers of testicular function pointing in the same direction across the different models based on a large sample size support that the results are not chance findings.

LIMITATIONS, REASONS FOR CAUTION

Information on cryptorchidism at birth and treatment modus was obtained by retrospective self-report, and each participant only delivered one semen sample.

WIDER IMPLICATIONS OF THE FINDINGS

The results suggest that men with a history of cryptorchidism could be at increased risk of experiencing fertility problems. However, among these men there is a wide variation in semen quality and further research is needed in order to identify the subgroup of boys born with cryptorchidism who are at the greatest risk of impaired semen quality when reaching adulthood.

STUDY FUNDING/COMPETING INTEREST(S)

The study received financial support from the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603. FP7/2007-2013, DEER Grant agreement no. 212844); the Danish Ministry of Health; the Danish Environmental Protection Agency; A.P. Møller and wife Chastine McKinney Møllers Foundation; and Svend Andersens Foundation. None of the founders had any role in the study design, collection, analysis or interpretation of data, writing of the paper or publication decisions. The authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

[German guideline on undescended testis-what is relevant in daily routine?]

With an incidence of 0.7-3% in male infants, undescended testicles is one of the most common congenital anomalies. In the first 6 months of life, the testicles may spontaneously descend in up to 70% of individuals. If the testicle is not in a scrotal position afterwards, fertility can gradually be reduced and the risk of a testicular tumor increases. Therefore, the current German guideline for undescended testis recommends that therapy should be take place between 6 and 12 months of life. After extensive information on the advantages and disadvantages, hormone therapy with the aim of a descensus or in those with bilateral anomaly with the aim of improving the germ cell pool can be offered. After the first year of life, hormone therapy is obsolete. Otherwise, surgical intervention is the treatment of choice. In the case of gliding or deep inguinal testis via scrotal or inguinal access, in the case of nonpalpable and sonographically undetectable testis, laparoscopy is carried out for diagnosis and simultaneous therapy. In the first postoperative year, adequate follow-up should be done to detect a re-ascensus and/or insufficient growth. Regular self-examinations from the age of 15 serve for the early detection of a testicular tumor that occurs only very rarely (approximately 0.003%).

["Uncomplicated" inguinal testis : How practicable are the guidelines?]

It has been known for more than 20 years that early treatment of maldescended testicles can have a positive effect on fertility and a negative effect on the development of tumors. In certain circumstances, hormone therapy is still recommended in German-speaking countries. However, its benefit is still controversially discussed. Therapy is usually initiated by the pediatrician, who is usually the first to detect undescended testicles. Since therapy may involve early hormone therapy as well as surgery, acceptance among pediatricians and also the parents may be reduced. The question also arises as to how far the implementation is practicable. In patients with nonpalpable testis, there are many controversies concerning the value of ultrasound investigations. In the following two case studies, the treatment decisions for undescended testes in infancy are exemplified. Furthermore, the available evidence from the literature and guidelines is presented to provide assistance for daily routine care and to critically discuss potential fields of application and limitations of existing guidelines.

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.

Efficacy and safety of human chorionic gonadotropin for treatment of cryptorchidism: A meta-analysis of randomised controlled trials

AIM

Although human chorionic gonadotropin (hCG) has long been employed in the management of cryptorchidism, its safety and efficacy is still controversial. Hence, in the present study, we conducted a meta-analysis of the treatment of cryptorchidism using hCG.

METHODS

We searched the Medline, Embase, CINAHL, EBSCO, The Cochrane Library, China National Knowledge Infrastructure and WanFang databases. Data were extracted by two reviewers using the designed extraction form. Data up to July 2015 were obtained using the terms 'cryptorchidism', 'chorionic gonadotropin' and 'randomised controlled trials'. All the publications were downloaded, and the respective authors were contacted for any further details and clarifications, if deemed necessary. The data analysis included randomised controlled trials that compared hCG with other hormone treatments offered to prepubescent males presenting with cryptorchidism. Testicular descent rate was used as the final positive outcome of the treatments offered. The software Review Manager (RevMan 5.3, The Cochrane Collaboration, London, UK) was used to review the management and data analysis. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled with a fixed effect model if no heterogeneity was present.

RESULTS

A total of seven trials satisfied the selection criteria. The overall quality of the studies downloaded from various databases was low. Data from these seven studies were divided into three subgroups depending on the design of the trials: Two studies compared hCG with a placebo, and three studies compared hCG with gonadotropin-releasing hormone (GnRH) in unilateral cryptorchidism, whereas two other studies compared hCG with GnRH in bilateral cryptorchidism. Analysis of these trials revealed no significant differences between the effectiveness of hCG treatment and GnRH treatment in bilateral (RR 0.05, 95% CI (-0.29-0.40), two trials, n = 104, P = 0.76) as well as unilateral cryptorchidism (RR 0.04, 95% CI (-0.12, 0.21), three trials, n = 81, P = 0.61). A meta-analysis of these studies showed that hCG treatment is not superior to placebo (RR 7.74, 95% CI (0.14-425.72), two trials, n = 31, P = 0.32).

CONCLUSION

A meta-analysis of the seven studies led us to conclude that hCG treatment is no more effective than placebo, and there were no significant differences in the effectiveness of hCG versus GnRH treatment.

Canadian Urological Association-Pediatric Urologists of Canada (CUA-PUC) guideline for the diagnosis, management, and followup of cryptorchidism

Cryptorchidism is one of the most common congenital anomalies in males, characterized by inability to palpate the testicle in the expected normal anatomical position (i.e., within its respective hemi-scrotum). It represents an abnormality of testicular descent and development associated with long-term concerns, including infertility, hypogonadism, and development of neoplasms.

Growth and descent of the testes in infants with hypogonadotropic hypogonadism receiving subcutaneous gonadotropin infusion

Background

One third of infants with congenital hypogonadotropic hypogonadism (CHH) are said to have micropenis and/or bilateral or unilateral cryptorchidism leading many of them to orchiopexy. Our previous study in two patients suggests that prolonged subcutaneous infusion of large doses of gonadotropins might normalize testicular function and growth.

Case presentation

To confirm the effects of early and prolonged subcutaneous infusion of large doses of gonadotropins on growth and descent of the testes. Eight boys with CHH, aged 0.25–11 months. Testes were non-palpable in 5 or in high scrotal position in 3. CHH was isolated in 5 infants and part of a syndrome of combined pituitary hormonal deficits in the 3 others. In response to gonadotropin infusion, mean levels of testicular hormones were normalized. Complete testis descent occurred in 6 patients. Partial descent occurred in 2. Testes re-ascended in 1 patient. Testes and penis gained normal dimensions in all cases.

Conclusion

Subcutaneous gonadotropin infusion seems able to induce testis descent in a large proportion of infants with CHH. If confirmed, this may allow patients to avoid testes surgery but studies in larger series are needed to evaluate the benefits of this treatment versus traditional orchiopexy.

Electronic supplementary material

The online version of this article (doi:10.1186/s13633-016-0031-9) contains supplementary material, which is available to authorized users.

Hormone replacement in disorders of sex development: Current thinking

Congenital disruptions of sex hormone production lead to wide-ranging developmental and physiological effects in individuals who have atypical chromosomal, gonadal or anatomic sex. Aberrant developmental sex hormone exposure causes disorders of genital anatomy, attainment of secondary sexual characteristics and has long-term effects on metabolism, fertility and psychological functioning. Principles in the management of disorders of sex development (DSD) aim to improve physiological health and long-term outcome, as well as development of male or female sexual anatomy. Concerns raised by DSD patient advocacy groups about beneficence and autonomy with respect to prescribed hormone treatments and avoidance of unnecessary genital and gonadal surgery have demanded greater informed consent and attention to long-term outcome. Hormone treatment is influenced by underlying clinical diagnosis and by factors such as sex of rearing and gender identity of the affected individual. We describe diagnostic criteria for different DSDs, clinical considerations in management protocols, together with current concepts and detailed practical hormone treatments for male and female individuals with DSD. Gender identity issues requiring multidisciplinary consensus, ethical consideration and informed consent or assent from the young person are also addressed.

Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review

BACKGROUND AND OBJECTIVE

Controversy remains concerning the optimal treatment approach for cryptorchidism. The objective of this study was to assess effectiveness of hormone therapy or surgery for cryptorchidism.

METHODS

We searched Medline and other databases from 1980 to February 2012. Two reviewers independently assessed studies against predetermined criteria. Two reviewers independently extracted data and assigned overall quality and strength of evidence ratings using predetermined criteria.

RESULTS

Fourteen studies addressed effectiveness of hormonal treatments, and 26 studies addressed surgical intervention outcomes. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by >10%. Surgical treatment is associated with success rates of testicular descent ranging from 33% to 100%, depending on surgery. Weighted success averages were 78.7% for 1-stage Fowler-Stephens (FS), 86% for 2-stage FS, and 96.4% for primary orchiopexy. Descent rates were similar among studies comparing laparoscopic and open surgeries. Reported harms of hormonal treatments were mild and transient. Adverse effects specifically associated with surgical repair were rare.

CONCLUSIONS

The body of the reviewed literature comprises primarily fair- and poor-quality studies, limiting our ability to draw definitive conclusions. Hormonal treatment is marginally effective relative to placebo but is successful in some children and with minimal harms, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for FS procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

Long-term outcomes of retractile testis

Purpose

Retractile testis is considered to be a variant of normal testis in prepubertal boys. There is no agreed-upon management of retractile testis. The aim of this study was to provide data on the long-term outcomes of patients with retractile testis.

Materials and Methods

This study retrospectively reviewed the medical record of 43 boys who were referred for suspected undescended or retractile testis and were finally diagnosed with retractile testis between January 2001 and December 2008. All boys were biannually examined by a pediatric urologist to evaluate the presence of retractile, descended, or undescended testis and testicular volume.

Results

Of 43 boys, there were 22 boys with unilateral retractile testis (51.1%) and 21 boys with bilateral retractile testis (48.9%). Their mean age was 3.0±2.7 years and the follow-up duration was 4.4±1.7 years. Of 64 retractile testes, 29 (45.3%) succeeded in descending, 26 (40.6%) remained retractile, and 9 (14.1%) became undescended testis or of a decreased size requiring orchiopexy. The mean initial diagnostic age of the patients who underwent orchiopexy was 1.3±0.9 years; meanwhile, the mean initial diagnostic age of those who went on to have normal testis was 4.3±3.3 years (p=0.009). The mean follow-up duration was 3.6±1.5 years in the orchiopexy group, 4.0±1.4 years in the descended testis group, and 5.1±1.8 years in group with remaining retractile testis.

Conclusions

Retractile testis has a risk of requiring orchiopexy. The risk is higher in the population diagnosed at a younger age. Boys with retractile testis should be observed periodically until the testis is descended in the normal position.

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.

Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes

PURPOSE

We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis.

MATERIALS AND METHODS

Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent.

RESULTS

A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p <0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter.

CONCLUSIONS

HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.

The effect of electromagnetic field on undescended testis after orchiopexy

Undescended testis is a common problem leading to infertility. After orchiopexy some studies support the necessity of hormonal therapy. Electromagnetic field stimulation on living tissues increase cell proliferation, protein and DNA synthesis. Sixteen prepubertal rats was objected to the fixation of left testes to the anterior abdominal wall for 30 days, right testes were removed. Another group of sixteen rats objected only to the right orchiectomy and a manipulation simulating study group without fixation. After orchiopexy, animals were divided into two groups. Both groups had eight rats. Electromagnetic field (EMF) stimulation group had the stimulation for two hours every day for ten days, while the second group did not. The sham group also divided into two groups. The first one applied EMF and name as Group CEM, the second one was sham. Weight of removed testes were measured and fixed in 10% formaldehyde for histopathological evaluation. At the creating of undescended testis and right orchiectomies a blood sample was obtained for testosterone level of prepubertal rats. After finishing EMF stimulation the rats were mated with females for 17 days. After fertility study a blood sample was obtained for testosterone assay and body weight were measured and fixed in formaline for histopathologic evaluation. All the rats were killed with overdose ether anesthesia and number of fetuses were recorded. Histopathological evaluation was based on Johnsen criteria and seminiferous tubule diameter measurements. We conclude that EMF stimulation resulted in Leydig cell proliferation, increase in testosterone level, testis weight, but decrease in germ cell population.

Effect of a combined GnRH/hCG therapy in boys with undescended testicles: evaluated in relation to testicular localization within the first week after birth

Among 509 boys referred with undescended testicles, 112 had true undescended testicles unilaterally and 62 bilaterally. Patients with true undescended testicles were offered hormonal treatment unless the condition was associated with hernia or previous operations. Boys less than 5 years old were primarily treated with gonadotrophin releasing hormone (GnRH), while boys more than 5 years old were primarily treated with human chorionic gonadotrophin (hCG). If the effect of the primary treatment was insufficient the other hormone was given. Testicular descent was obtained for 64% (23/36) of the intraabdominally located testicles in boys with bilaterally undescended testicles versus only 14% (3/21) in boys with unilaterally undescended testicles (p < .001). Treating 1 to 4 years old boys with GnRH resulted in descent in 16 of 95 testicles and secondary treatment with hCG yielded an additional 34, whereas secondary treatment of 5 to 13 years old boys with GnRH added only 10 descended testicles to 51 of 101 testicles. Reading the maternity records of 272 of the boys support other studies showing that testicles may reascend. Boys with endocrinological or "surgical" causes of incomplete testicular descent were relatively more likely to have had one or two undescended testicles during the first postnatal week compared with boys found to have only retractile testicles (p < .001). Treatment with hormones resulted in descent in 56% of boys whose testicles were both descended within one week after birth. Conversely, only 1 of 20 boys with unilateral testicular undescent postnatally was sufficiently treated with hormones (p < .001). The hormonal effect in boys with bilaterally undescended testicles at delivery did not differ significantly from boys with either one or none undescended testicle postnatally. In 35 of 51 boys (69%) in whom the hormonal effect was insufficient, operation revealed a "surgical cause" of the incomplete testicular descent.

Cryptorchidism: treatment with human chorionic gonadotropin--a Venezuelan experience

The study comprised 323 cryptorchidic boys, between 6 months and 14 years of age (mean age 5.68 years) with 440 maldescended testes. Testicular position was graded as inguinal low or prescrotal (I), inguinal middle (II), inguinal high (III), and abdominal testes (IV). Boys before 4 years of age received human chorionic gonadotropin (hCG) as intramuscular injections (I.M.), 500 IU twice a week for 5 weeks; and boys 4 or more years of age received hCG (IM), 1000 IU twice a week for 5 weeks. The objectives of this study were to evaluate the response of maldescended testes to treatment with hCG, and to investigate possible associations between the patients' ages and position of the testes with the response to hCG. Out of the 440 maldescended testes, 329 were in an inguinal location (75%) and 111 were abdominally located (25%). The overall response to hCG was 40%, and the inguinal testes response was 49%, with the highest success rates (72%) for the prescrotal testes. A positive correlation was found (p < .0001) between the rate of success and the testicular position. There was no association between the hCG response and the age at which treatment was initiated.

Does treatment with human chorionic gonadotropin induce reversible changes in undescended testes in boys?

Between May 1993 and November 1995, 71 cryptorchid boys were treated with human chorionic gonadotropin (hCG); 42 were operated upon following unsuccessful hCG treatment. A routine orchiopexy was performed in each case. In 10 cases a testicular biopsy was made during orchipexy within 3 days following hCG treatment; in another 10 biopsies were taken 6 to 9 months after treatment. Testicular biopsies were taken at the time of orchiopexy in 5 cryptorchid boys who were not treated with hCG as a control group. A mild, inflammation-like reaction was found in the cryptorchid testes in the period immediately following the last hCG injections, but those studied 6 to 9 months after the last injection there were no apparent such reactions. In contrast to the inflammation-like reaction, the volume density of blood vessels, interstitial bleeding, and diameter of the seminiferous tubules had not regressed. The numbers of spermatogonia per tubular transverse section and the percentage of tubular transverse sections containing spermatogonia (the fertility index) were increased.

Primary gonadotropin releasing hormone and adjunctive human chorionic gonadotropin treatment in cryptorchidism: a clinical trial

OBJECTIVES

The effect of intranasal gonadotropin-releasing hormone (GnRH) and intramuscular human chorionic gonadotropin (hCG) in the treatment of cryptorchidism was investigated in 48 prepubertal boys.

METHODS

Forty-eight prepubertal boys with 70 undescended testes were enrolled into a prospective study between November 1989 and November 1991. GnRH was applied as nasal spray at a dose of 1.2 mg/day for 4 weeks. The patients with partial descent were subsequently treated with 1500 IU hCG weekly for 3 weeks.

RESULTS

Complete descent was observed in 53% (37 of 70) of testes; 58% (15 of 26) in unilateral and 50% (22 of 44) in bilateral undescended testes. One abdominally located testicle did not respond to therapy. Of 37 testes located in the inguinal canal, seven (19%) descended. On the other hand, descensus rates were 100% for the testes located at the external inguinal ring and at a high scrotal level. Six primarily descended testes (16%) showed relapse during the follow-up. Surgery was performed in 12 patients (14 testes), revealing associated hernia in nine testes and epididymal anomalies in four.

CONCLUSIONS

We believe that the GnRH and hCG combination is an effective therapy for undescended testes located at and beyond the external inguinal ring and should be the first treatment choice because of its noninvasiveness. Both unilateral and bilateral undescended testes responded with similar success rate to hormonal therapy. Surgery should be considered for proximal cryptorchidism.

The influence of patency of the vaginal process on the efficacy of hormonal treatment of cryptorchidism

To investigate the effects of patency of the vaginal process (processus vaginalis testis) on the efficacy of hormonal treatment of cryptorchidism, we carried out a blind, controlled, prospective study in which all patients underwent inguinal herniography. The sample comprised 310 boys with true cryptorchidism (244 unilateral, 66 bilateral) and without symptomatic hernia/ hydrocele or other pathologies. Patients age ranged from 8 months to 11 years 5 months. All patients were treated with human chorionic gonadotropin (twice-weekly intramuscular injections for 5 weeks; total dose 2500 IU for patients less than 1-year-old, 5000 IU for 1- to 6-year-olds, 10000 IU for 6- to 11-year-olds). Following treatment, 37% (139/376) of the testes descended. The incidence of descent was highest for testes initially in caudal positions. Considering only non patent (i.e., normal) vaginal processes, the incidence of testis descent was 49.5% (139/281); none of the 95 testes associated with a patent vaginal process descended in response to hormone treatment.

CONCLUSION

Prior detection of patent vaginal process by inguinal herniography permits identification of a significant subset of patients for whom hormone treatment will be ineffective. Our data suggest that this predictive procedure is 100% reliable.

Cryptorchidism and testicular torsion

The cause of cryptorchidism remains obscure. Hormonal therapy is ineffective for most patients and initial response may be temporary. Surgery remains the most effective treatment for cryptorchidism. Testicular torsion is a surgical emergency in the postnatal infant and the pubertal male. Controversy surrounds the management of prenatal torsion.

LHRH and cryptorchidism

This paper is a historic review of two studies of the treatment of cryptorchidism. One was concluded 20 years ago with native LHRH, while the other took place 14 years ago and involved one of the potent LHRH analogues. The first study was initiated at the end of 1971-at a time when the different modes of action of the decapeptide were by far not evaluated to the full extent they are now-and included ten prepubertal boys with undescended testes aged five to ten years. The treatment consisted of intramuscular application of 20 micrograms LHRH once daily for three weeks. Additionally, three boys, five, seven and nine years of age, also presenting undescended testes underwent an LHRH test with intravenous bolus application of 200 micrograms. In all three subjects, a 2.5-fold increase in plasma testosterone was observed 20 min after the bolus. The treatment group showed neither a rise in LH nor in testosterone at the end of therapy. Testicular descent was achieved in six out of six boys with bilateral and in 2/4 with unilateral undescended testes. These good results might be based on the fact that six boys had retractile rather than actually undescended testes. In the second study started in 1978, 18 boys, three to 12 years of age with either unilateral or bilateral cryptorchidism, were treated with a synthetic LHRH analogue ("D-Leu 6, Des-Gly-10 LHRH ethylamide") applied intranasally. The peptide prepared in an aqueous solution was administered in the form of nose drops.(ABSTRACT TRUNCATED AT 250 WORDS)

The behavior of epididymis, processus vaginalis and testicular descent in cryptorchid boys treated with buserelin

This randomized double-blind, placebo-controlled study was initiated to analyze the behavior of epididymis, processus vaginalis and testicular descent in cryptorchid boys treated with a low dose (20 micrograms) of a luteinizing hormone-releasing hormone analogue (Buserelin), administered daily, as a nasal spray, for a short period (28 days). Fifty-nine true cryptorchid boys were randomly assigned to 3 groups: buserelin treatment [22], surgical treatment [18] or placebo control group [19]. The 3 groups of patients were similar before treatment in regard to testicular position, chronological and bone age, height and weight, luteinizing hormone, follicle-stimulating hormone, testosterone, penile size and the volume of the contralateral descended testis. None of the patients had retractile testes. Buserelin significantly induced testicular descent compared to the boys treated with a placebo (P < 0.01). A normal epididymis was found more often in boys with successful descent (P < 0.003). A closed processus vaginalis was also more frequently observed in the group treated with buserelin than in surgically treated one (P < 0.05). In conclusion, buserelin was capable of inducing testicular descent besides provoking further development of the epididymis and closing the processus vaginalis.

Management of cryptorchidism

The forces guiding testicular descent have not been completely elucidated. Both testosterone and anti-Müllerian hormone might play a role. Available evidence suggests that malfunction of the testes of some sort usually precedes maldescent. The proper management of cryptorchidism has long been a controversial issue. In unilateral cryptorchidism, hormonal function and fertility are generally normal. To maximize fertility in patients with bilateral cryptorchidism, surgical treatment should be completed ideally by the first birthday. GnRH is unlikely to be of much help in initiating testicular descent. Cryptorchidism is associated with a three- to tenfold increase in testicular cancer. Twenty percent of tumors in unilateral cryptorchidism are in the normally descended testes. The condition of all boys and men with a history of cryptorchidism should be followed by physicians their entire lives, and these boys and men must become proficient in self-examination.

Buserelin treatment of cryptorchidism: a randomized, double-blind, placebo-controlled study

The objectives of the study were to determine whether a low dose of a luteinizing hormone-releasing hormone analogue (buserelin) has an effect on testicular descent, if buserelin affects germ cell maturation and epididymal development, the incidence of retractile testes in the controlled trials, and if the subsequent administration of human chorionic gonadotropin has any effect on the groups treated. The study was double blind, placebo controlled in which patients with cryptorchidism were assigned randomly into 3 groups: buserelin treatment (22), surgical treatment (18) or placebo control group (19). The 3 groups of patients were similar before treatment in regard to testicular position, chronological and bone age, height and weight, luteinizing hormone, follicle-stimulating hormone, testosterone, penile size and the volume of the contralateral testis. Buserelin (20 micrograms). administered daily in a nasal spray significantly induced testicular descent compared to the group treated with a placebo (p less than 0.01). A normal epididymis was found more often in boys with successful descent (p less than 0.003). Boys treated with buserelin had the highest number and the best maturation index of the germ cells; human chorionic gonadotropin influenced the descent in both groups but it was more efficacious when it was administered after treatment with buserelin, although it had no additional effect on germ cell maturation. None of the boys had retractile testes. Buserelin was capable of inducing testicular descent in addition to increasing simultaneously the number of germ cells and provoking further development of the epididymis.

Hormonal treatment of cryptorchidism--hCG or GnRH--a multicentre study

In a modified, double-blind controlled study, 163 prepubertal boys (aged 1.8-13.0 years) with bilateral and 94 (aged 1.5-13.1 years) with unilateral cryptorchidism were allocated to treatment with either human chorionic gonadotrophin (im), gonadotrophin releasing hormone (intranasally) or placebo (intranasally). In individuals with the bilateral condition treatment with human chorionic gonadotrophin resulted in complete descent of both testes in 23% of patients. Treatment with human chorionic gonadotrophin in unilateral cryptorchidism resulted in complete descent in 19% of patients; all results were significantly better than those obtained with gonadotrophin releasing hormone or placebo. Linear and logistic regression analysis of the results obtained by treatment of bilateral disease showed that all treatments were more successful the younger the age of the boys. The data indicated that bilateral and unilateral cryptorchidism respond differently to hormonal treatment. We suggest that human chorionic gonadotrophin should be the first choice of treatment for prepubertal boys older than one year.

Management of the non-descended testis: doubtful value of luteinizing-hormone-releasing-hormone (LHRH). A double-blind, placebo-controlled multicentre study

In a double-blind, placebo-controlled multicentre study, the effect of luteinizing-hormone-releasing-hormone (LHRH) in 141 boys was analysed after 4-week treatment period with 0.4 mg LHRH nasal spray or placebo nasal spray three times daily. Data from 123 boys was analysed, with 62 boys in the treatment group and 61 in the placebo group. Full response i.e. the testis at the bottom of the scrotum on both sides in boys with bilaterally undescended testes, was found in six patients, one of them in the placebo group [Therapeutic gain of LHRH with 95% CI: 8.1% (0.1-16.6%, P = 0.12)]. Only in these boys could surgery be avoided. Considering the number of testes (and not the number of boys) a significant effect was found on at least one testis in 25% of boys with bilaterally undescended testes [Therapeutic gain with 95% CI: 24.0% (13.2-34.8%, P = 0.001)]. In unilateral undescended testes, the LHRH treatment showed no effect (P = 1.00). The inclusion of retractile testes did not affect our results. In our opinion LHRH has a limited place in treatment of the non-descended testis.