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Tang L, Chen M, Li J, Xu X, Pu X. Association of testosterone with myocardial infarction and severity of coronary artery disease among male patients. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200281. [PMID: 38779505 PMCID: PMC11109021 DOI: 10.1016/j.ijcrp.2024.200281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/22/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Background Coronary heart disease (CHD) remains a leading cause of morbidity and mortality, particularly in aging populations. Men typically exhibit higher rates of CHD compared to women, with testosterone levels inversely associated with cardiovascular risk. This study investigates the relationship between testosterone levels and angiographically confirmed CHD, disease severity, and myocardial infarction (MI) among CHD cases. Methods A cohort of 1724 male patients undergoing diagnostic or interventional coronary angiography was examined. Demographic, clinical, and biochemical data were collected, including serum total testosterone levels. The severity of CHD was assessed using the Gensini score, and MI cases were diagnosed according to World Health Organization criteria. Results Results revealed significant differences in testosterone levels among CHD subtypes, particularly between MI and unstable angina/stable angina groups (p < 0.001). Testosterone levels were inversely correlated with CHD severity, as evidenced by the Gensini score (Pearson coefficient = -0.062, P = 0.004). Cross-validation random forest analysis demonstrated the significant contribution of testosterone to CHD severity discrimination (p < 0.05). Conclusions There is an association between testosterone and a predisposition to severe CAD indicated by Gensini score and myocardial infarction.
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Affiliation(s)
- Lujing Tang
- Department of Gastroenterology, The Children's Hospital Zhejiang University School of Medicine, China
| | - Mengsha Chen
- School of Public Health, Zhejiang University School of Medicine, China
| | - Jiahao Li
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Xiaodong Xu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, China
| | - Xiangyuan Pu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, China
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Morin-Grandmont A, Walsh-Wilkinson É, Labbé EA, Thibodeau SÈ, Dupont É, Boudreau DK, Arsenault M, Bossé Y, Couet J. Biological sex, sex steroids and sex chromosomes contribute to mouse cardiac aging. Aging (Albany NY) 2024; 16:7553-7577. [PMID: 38742935 PMCID: PMC11131996 DOI: 10.18632/aging.205822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/15/2024] [Indexed: 05/16/2024]
Abstract
After menopause, the incidence of cardiovascular disease rapidly rises in women. The disappearing protection provided by sex steroids is a consequence of the development of many risk factors. Preclinical studies are necessary to understand better the effects of ovarian hormones loss cardiac aging. To mimic menopause in mice and study its consequences, we delayed ovariectomy at 12 months and followed animals for 12 months. Using RNA sequencing, we investigated changes in the myocardial exome with aging. In addition, with four-core genotypes (FCG) transgenic mice, we studied sex chromosome effects on cardiac aging. Heart weight increased from 3 to 24 months (males + 35%, females + 29%). In males, 75% of this increase had occurred at 12 months; in females, only 30%. Gonadectomy of mice at 12 months blocked cardiac hypertrophy in both sexes during the second year of life. The dosage of the X chromosomes did not influence cardiac growth in young and older mice. We performed an RNA sequencing study in young and old mice. We identified new highly expressed genes modulated during aging (Bdh, Myot, Cpxm2, and Slc38a1). The myocardial exome in older animals displayed few differences related to the animal's sex or the presence or absence of sex steroids for a year. We show that the morphological evolution of the heart depends on the biological sex via gonadal sex hormone actions. The myocardial exome of old male and female mice is relatively similar. Our study emphasizes the need to consider sex steroid effects in studying cardiac aging.
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Affiliation(s)
- Audrey Morin-Grandmont
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Élisabeth Walsh-Wilkinson
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Emylie-Ann Labbé
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Sara-Ève Thibodeau
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Élizabeth Dupont
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Dominique K. Boudreau
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marie Arsenault
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Yohan Bossé
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Jacques Couet
- Groupe de Recherche sur les Valvulopathies, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
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Li Z, Zhu C, Yin C, Li H, Liu Y, Li J. Multi-omics reveals the testosterone promotion effect mechanism of Cordyceps Sobolifera on Leydig cells. JOURNAL OF ETHNOPHARMACOLOGY 2024; 325:117817. [PMID: 38316217 DOI: 10.1016/j.jep.2024.117817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Cordyceps sobolifera (CS) has been traditionally utilized as an ethnic remedy for various health conditions, including chronic kidney diseases, anti-fatigue interventions, and management of chronic inflammation. Notably, CS is recognized for its substantial content of bioactive compounds, among which nucleosides prominently feature as constituents with diverse therapeutic advantages. AIM OF THE STUDY This study aims to investigate the effects of CS on testosterone secretion in Leydig cells and explore the underlying mechanism. MATERIALS AND METHODS Leydig cells were isolated from rat testes to establish a primary rat Leydig cells model. Cell proliferation and testosterone secretion were assessed via the methyl-piperidino-pyrazole (MTT) assay and enzyme-linked immunosorbent assay (ELISA), respectively. Samples earmarked for RNA sequencing (RNA-Seq) analysis facilitated the identification of significantly differentially expressed genes (DEGs), and we conducted Gene Ontology (GO)/Kyoto Encyclopedia of Genes and Genomes (KEGG) functional annotation and enrichment analyses. The veracity of our findings was validated through quantitative real time polymerase chain reaction (qRT-PCR) and western blotting. RESULTS The results showed that CS and guanosine could promote Leydig cell proliferation and bolster testosterone secretion. Our integrative analysis of metabolomics and transcriptomics has unveiled the potential mechanisms governing testosterone synthesis. Specifically, metabolomics has illuminated striking correlations within cholesterol metabolism, and bile secretion. Concurrently, transcriptomics has underscored the pivotal roles played by the cyclic adenosine monophosphate (cAMP) signaling pathway and steroid hormone biosynthesis. Furthermore, our investigation has demonstrated CS's aptitude in elevating the expression of proteins and genes. Notably, our findings have elucidated that these effects can be mitigated by protein kinase A (PKA) and adenylate cyclase (AC) specific inhibitors. CONCLUSION This study delineates the cAMP-PKA pathways as plausible mechanisms underpinning the testosterone-enhancing properties of CS, with guanosine emerging as a fundamental bioactive constituent.
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Affiliation(s)
- Zihan Li
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Hubei Shizhen Laboratory, Wuhan 430061 China
| | - Chengshan Zhu
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Hubei Shizhen Laboratory, Wuhan 430061 China
| | - Cong Yin
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Hubei Shizhen Laboratory, Wuhan 430061 China
| | - Heyu Li
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Tianjin Ubasio Technology Group Co., Ltd., Tianjin 300457, China
| | - Yimei Liu
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Hubei Shizhen Laboratory, Wuhan 430061 China
| | - Juan Li
- Hubei Province Key Laboratory of Traditional Chinese Medicine Resource and Chemistry, College of Pharmacy, Hubei University of Chinese Medicine, Huang-Jia-Hu West Road 16(#), Hongshan District, Wuhan, Hubei 430065, China; Hubei Shizhen Laboratory, Wuhan 430061 China.
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Lim J, Hashemian M, Blechter B, Roger VL, Wong JY. Pre-diagnostic free androgen and estradiol levels influence heart failure risk in both women and men: A prospective cohort study in the UK Biobank. Eur J Heart Fail 2024; 26:540-550. [PMID: 38528787 PMCID: PMC11096034 DOI: 10.1002/ejhf.3189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 03/27/2024] Open
Abstract
AIMS Serum sex hormones have been linked to cardiovascular disease risk. However, their roles in the pathogenesis of heart failure (HF) in both men and women are unclear. We investigated the associations between free androgen, testosterone, and estradiol, and future risk of HF. METHODS AND RESULTS This prospective cohort study evaluated UK Biobank participants free of prevalent cardiovascular disease and HF at baseline. Unitless free androgen, testosterone, and estradiol indices were generated using serum concentrations of total testosterone (nmol/L), estradiol (pmol/L), sex hormone binding globulin (SHBG, nmol/L), and albumin (g/L) in blood collected at enrolment. Multivariable Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HF in relation to quartiles (Q) of free androgen (FAI), testosterone (FTI), estradiol (FEI) indices, and potential confounders. There were 180 712 men (including 5585 HF cases with FAI and 571 HF cases with FEI), and 177 324 women (including 2858 HF cases with FAI and 314 HF cases with FEI) with complete data. Increased FAI was associated with decreased HF risk in both men (HRQ4 vs. Q1: 0.86, 95% CI 0.79-0.94, p-trendcontinuous < 0.0001) and post-menopausal women (HRQ4 vs. Q1: 0.83, 95% CI 0.73-0.95). Similar inverse associations were observed for FTI only in men (HRQ4 vs. Q1: 0.91, 95% CI 0.83-0.98). Higher FEI was significantly associated with decreased HF risk among men (HRQ4 vs. Q1: 0.76, 95% CI 0.59-0.98), but was positively associated among pre-menopausal women (HRQ4 vs. Q1: 2.16, 95% CI 1.11-4.18). CONCLUSIONS Sex hormones potentially influence HF pathogenesis and may offer pathways for interventions.
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Affiliation(s)
- Jungeun Lim
- Epidemiology and Community Health Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Maryam Hashemian
- Epidemiology and Community Health Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Batel Blechter
- Occupational and Environmental Health Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Véronique L. Roger
- Epidemiology and Community Health Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Jason Y.Y. Wong
- Epidemiology and Community Health Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
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Zhan X, Liu Y, Chen T, Wan H, Xiong S, Li S, Deng X, Chen L, Fu B. The association between serum testosterone level and congestive heart failure in US male adults: data from National Health and Nutrition Examination Survey (NHANES) 2011-2016. Reprod Biol Endocrinol 2024; 22:4. [PMID: 38169409 PMCID: PMC10759552 DOI: 10.1186/s12958-023-01171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND This study aimed to investigate the relationship between serum testosterone levels and the risk of congestive heart failure (CHF) in adult males. Previous research has suggested a potential link between serum testosterone and cardiovascular health, but the findings have been inconclusive. METHODS This study was cross-sectional, and the data were obtained from the 2011-2016 cycle of the National Health and Nutrition Examination Survey (NHANES), which included a sample of 6,841 male participants. Serum testosterone levels were measured using a standardized assay, and CHF status was assessed through self-reporting. Covariates such as age, ethnicity, lifestyle factors, and health conditions were considered in the analysis. RESULTS Among the participants, 242 individuals had a documented history of CHF. We observed a linear correlation between serum testosterone levels and CHF occurrence, with higher serum testosterone levels associated with a decreased risk of CHF (Q4 vs. Q1, OR = 0.29, 95% CI: 0.19-0.47, P < 0.001). After adjusting for confounding variables, multivariate analysis revealed that high serum testosterone levels remained significantly associated with a lower risk of CHF (OR: 0.47, 95% CI: 0.27-0.80, P = 0.01). Subgroup analysis indicated a significant association between high serum testosterone levels and reduced CHF risk in individuals over 50 years old. CONCLUSION Our findings suggest that the serum testosterone level was positively associated with CHF in adult males. This study highlights the potential role of serum testosterone in cardiovascular health, particularly in older individuals. Further research is needed to elucidate the underlying mechanisms and explore the clinical implications of these findings.
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Affiliation(s)
- Xiangpeng Zhan
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Yang Liu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Tao Chen
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Hao Wan
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Situ Xiong
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Sheng Li
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
| | - Xinxi Deng
- Department of Urology, Jiu Jiang first People's Hospital, Jiujiang, Jiangxi Province, China.
| | - Luyao Chen
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China.
| | - Bin Fu
- Department of Urology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China.
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Blackwell K, Blackwell M, Blackwell T. Testosterone Replacement Therapy and Cardiovascular Disease: Balancing Safety and Risks in Hypogonadal Men. Curr Cardiol Rep 2023; 25:1157-1163. [PMID: 37733143 DOI: 10.1007/s11886-023-01935-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW: The purpose of this review is to analyze the link between testosterone replacement therapy (TRT) and adverse cardiovascular (CV) events. RECENT FINDINGS: A few published studies suggest a link between TRT and CV events. These studies contained flaws, and many other studies reveal a reduction in CV events. Hypogonadism is associated with increased mortality in men with CVD. TRT in hypogonadal men can improve many CVD risk factors, reduce QT interval prolongation, lead to better outcomes in heart failure patients, and slow the progression of atherosclerosis. The use of TRT to achieve physiologic testosterone concentrations in men does not pose a threat to CV health and has demonstrated a cardioprotective effect.
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Affiliation(s)
- Kelli Blackwell
- UTMB 301 University Blvd, Rebecca Sealy Bldg 5.138, Galveston, TX, 77554, USA
| | - Michele Blackwell
- UTMB 301 University Blvd, Rebecca Sealy Bldg 5.138, Galveston, TX, 77554, USA
| | - Thomas Blackwell
- UTMB 301 University Blvd, Rebecca Sealy Bldg 5.138, Galveston, TX, 77554, USA.
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Clasen SC, Fung C, Sesso HD, Travis LB. Cardiovascular Risks in Testicular Cancer: Assessment, Prevention, and Treatment. Curr Oncol Rep 2023; 25:445-454. [PMID: 36867377 DOI: 10.1007/s11912-023-01375-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW Testicular cancer (TC) is the leading cancer in men between 18 and 39 years of age. Current treatment involves tumor resection followed by surveillance and/or one or more lines of cisplatin-based chemotherapy (CBCT) and/or bone marrow transplant (BMT). Ten years after treatment, CBCT has been associated with significant atherosclerotic cardiovascular disease (CVD) including myocardial infarction (MI), stroke, and heightened rates of hypertension, dyslipidemia, diabetes mellitus, and metabolic syndrome (MetS). Additionally, low testosterone levels and hypogonadism contribute to MetS and may further drive CVD. RECENT FINDINGS CVD in TCS has been associated with worse physical functioning accompanied by role limitations, decreased energy, and decreased overall health. Exercise may play a role in ameliorating these effects. Systematic CVD screening practices are needed at TC diagnosis and in survivorship. We encourage a multidisciplinary partnership between primary care physicians, cardiologists, cardio-oncologists, medical oncologists, and survivorship providers to address these needs.
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Affiliation(s)
- Suparna C Clasen
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indiana University, 1800 N. Capitol Ave., E308, Indianapolis, IN, 46202, USA.
| | - Chunkit Fung
- Division of Hematology and Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, James P. Wilmot Cancer Institute, Rochester, NY, USA
| | - Howard D Sesso
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lois B Travis
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Epidemiology, Fairbanks School of Public Health, Indianapolis, IN, USA
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Caretta N, Facondo P, Mereu S, Delbarba A, Crepaldi MC, Vedovato M, Avogaro A, Ferlin A. Cardiometabolic indices predict hypogonadism in male patients with type 2 diabetes. J Endocrinol Invest 2023; 46:599-608. [PMID: 36282472 PMCID: PMC9938038 DOI: 10.1007/s40618-022-01941-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate in men with type 2 diabetes the association of cardiometabolic indices [Visceral Adiposity Index (VAI), Triglyceride Glucose Index (TyG), and lipid accumulation product (LAP)] with total testosterone (TT) levels, and their predictive cut-off values in identifying hypogonadism. METHODS 265 consecutive men aged 40-70 years with type 2 diabetes performed an andrological evaluation; metabolic parameters and TT were determined. Receiver operating characteristic (ROC) curves were used to identify cut-off values of cardiometabolic indices in predicting low testosterone (TT < 12 nmol/l). RESULTS VAI, TyG, and LAP were negatively associated with TT levels. The prevalence of hypogonadism in men in the fourth quartiles of VAI, TyG, and LAP was ~ 70.0-75.0% compared to ~ 10.0-17.0% in men in the first quartiles (p < 0.001). The sensitivity and specificity of the three cardiometabolic indices in predicting TT < 12 nmol/l were significantly higher concerning BMI, waist circumference, lipid profile and HbA1c. Cut off values of VAI ≥ 3.985, TyG ≥ 4.925, and LAP ≥ 51.645 predict hypogonadism with good sensitivity and specificity. CONCLUSION This is the first study evaluating the association of VAI, TyG, and LAP with hypogonadism in men with type 2 diabetes. Alterations in these indices should direct the patients to andrological evaluation.
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Affiliation(s)
- N Caretta
- Unit of Andrology and Reproductive Medicine, University Hospital of Padova, Padua, Italy
| | - P Facondo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - S Mereu
- Department of Medicine, University of Padova, Padua, Italy
| | - A Delbarba
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy
| | - M C Crepaldi
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Padua, Italy
| | - M Vedovato
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Padua, Italy
| | - A Avogaro
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Padua, Italy
| | - A Ferlin
- Department of Medicine, Unit of Andrology and Reproductive Medicine, University of Padova, Padua, Italy.
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