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Dwyer AA, McDonald IR, Quinton R. Current landscape of fertility induction in males with congenital hypogonadotropic hypogonadism. Ann N Y Acad Sci 2024. [PMID: 39190467 DOI: 10.1111/nyas.15214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
Congenital hypogonadotropic hypogonadism (CHH) is a rare reproductive disorder caused by deficient secretion or action of gonadotropin-releasing hormone (GnRH) and is a hormonally treatable form of male infertility. Both pulsatile GnRH treatment and combined gonadotropin therapy effectively induce spermatogenesis in 75%-80% of males with CHH, albeit the ejaculate does not usually approach normal semen parameters by WHO criteria. This is in some contrast to the cumulative fertility outcomes in females with CHH on gonadotropin treatment that are indistinguishable from those of reproductively normal females. Emerging data provide insights into early life determinants of male fertility (i.e., minipuberty), and research has identified key predictors of outcomes for fertility-inducing treatment in men with CHH. Such developments provide mounting evidence for tailoring approaches to maximize fertility potential in CHH, although there is no clear consensus to date on the optimal approach to fertility-inducing treatment. This review provides an up-to-date review on the current evidence underpinning therapeutic approaches for inducing spermatogenesis in males with CHH. In the absence of evidence-based clinical guidelines, this synthesis of current evidence provides guidance for clinicians working with males with CHH seeking fertility.
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Affiliation(s)
- Andrew A Dwyer
- P50 Massachusetts General Hospital-Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Isabella R McDonald
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Richard Quinton
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Northern Regional Gender Dysphoria Service, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle, UK
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2
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De Silva NL, Papanikolaou N, Grossmann M, Antonio L, Quinton R, Anawalt BD, Jayasena CN. Male hypogonadism: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2024:S2213-8587(24)00199-2. [PMID: 39159641 DOI: 10.1016/s2213-8587(24)00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 08/21/2024]
Abstract
Organic male hypogonadism due to irreversible hypothalamic-pituitary-testicular (HPT) pathology is easily diagnosed and treated with testosterone-replacement therapy. However, controversy surrounds the global practice of prescribing testosterone to symptomatic men with low testosterone and non-gonadal factors reducing health status, such as obesity, type 2 diabetes, and ageing (ie, functional hypogonadism), but without identifiable HPT axis pathology. Health optimisation remains the gold-standard management strategy. Nevertheless, in the last decade large clinical trials and an individual patient data meta-analysis of smaller clinical trials confirmed that testosterone therapy induces modest, yet statistically significant, improvements in sexual function without increasing short-term to medium-term cardiovascular or prostate cancer risks in men with functional hypogonadism. Although testosterone improves bone mineral density and insulin sensitivity in these men, trials from the last decade suggest insufficient evidence to determine the safety and effectiveness of use of this hormone for the prevention of fractures or type 2 diabetes. This Review discusses the pathogenesis and diagnosis of male hypogonadism and appraises the evidence underpinning the management of this condition.
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Affiliation(s)
- Nipun Lakshitha De Silva
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Nikoleta Papanikolaou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Mathis Grossmann
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Leen Antonio
- Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium; Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Northern Regional Gender Dysphoria Service, Cumbria Northumberland Tyne & Wear NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Bradley David Anawalt
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
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3
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De Silva N, Howard SR, O'Sullivan J, Russell J, Lee A, Duffy L, Cheetham T, Mamoojee Y, Quinton R. Gonadotropin treatment of cryptorchidism in congenital hypogonadotropic hypogonadism-Age is no limit? Clin Endocrinol (Oxf) 2024. [PMID: 39023306 DOI: 10.1111/cen.15117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/07/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Neomal De Silva
- Department of Endocrinology & Metabolism, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Paediatric Endocrinology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
| | - Jacquelin O'Sullivan
- Department of Paediatric Endocrinology, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Julia Russell
- Department of Paediatric Endocrinology, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Annette Lee
- Department of Endocrinology & Metabolism, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Louise Duffy
- Department of Endocrinology & Metabolism, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Timothy Cheetham
- Department of Paediatric Endocrinology, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle Upon Tyne, UK
- Translational & Clinical Research Institute, University of Newcastle-Upon-Tyne, Newcastle Upon Tyne, UK
| | - Yaasir Mamoojee
- Department of Endocrinology & Metabolism, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Richard Quinton
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Northern Gender Dysphoria Service, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, Benfield House, Walkergate Park Hospital, Newcastle Upon Tyne, UK
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4
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Rohayem J, Alexander EC, Heger S, Nordenström A, Howard SR. Mini-Puberty, Physiological and Disordered: Consequences, and Potential for Therapeutic Replacement. Endocr Rev 2024; 45:460-492. [PMID: 38436980 PMCID: PMC11244267 DOI: 10.1210/endrev/bnae003] [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: 07/21/2023] [Indexed: 03/05/2024]
Abstract
There are 3 physiological waves of central hypothalamic-pituitary-gonadal (HPG) axis activity over the lifetime. The first occurs during fetal life, the second-termed "mini-puberty"-in the first months after birth, and the third at puberty. After adolescence, the axis remains active all through adulthood. Congenital hypogonadotropic hypogonadism (CHH) is a rare genetic disorder characterized by a deficiency in hypothalamic gonadotropin-releasing hormone (GnRH) secretion or action. In cases of severe CHH, all 3 waves of GnRH pulsatility are absent. The absence of fetal HPG axis activation manifests in around 50% of male newborns with micropenis and/or undescended testes (cryptorchidism). In these boys, the lack of the mini-puberty phase accentuates testicular immaturity. This is characterized by a low number of Sertoli cells, which are important for future reproductive capacity. Thus, absent mini-puberty will have detrimental effects on later fertility in these males. The diagnosis of CHH is often missed in infants, and even if recognized, there is no consensus on optimal therapeutic management. Here we review physiological mini-puberty and consequences of central HPG axis disorders; provide a diagnostic approach to allow for early identification of these conditions; and review current treatment options for replacement of mini-puberty in male infants with CHH. There is evidence from small case series that replacement with gonadotropins to mimic "mini-puberty" in males could have beneficial outcomes not only regarding testis descent, but also normalization of testis and penile sizes. Moreover, such therapeutic replacement regimens in disordered mini-puberty could address both reproductive and nonreproductive implications.
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Affiliation(s)
- Julia Rohayem
- Department of Pediatric Endocrinology and Diabetology, Children's Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland
- University of Muenster, 48149 Muenster, Germany
| | - Emma C Alexander
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Sabine Heger
- Department of Pediatric Endocrinology, Children's Hospital Auf der Bult, 30173 Hannover, Germany
| | - Anna Nordenström
- Pediatric Endocrinology, Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
- Department of Paediatric Endocrinology, Royal London Children's Hospital, Barts Health NHS Trust, London E1 1FR, UK
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Svingen T, Andersson AM, Angelova J, Axelstad M, Bakker J, Baumann L, Beronius A, Bouftas N, Chalmel F, Christiansen S, Cornil C, Damdimopoulou P, Deepika D, Dollé MET, Draskau MK, Fischer MB, Hagen CP, Hessel E, Holmer ML, Hughes S, Jensen G, Johansson HKL, Juul A, Kumar V, Kumar S, Lardenois A, Main KM, Mazaud-Guittot S, Moe SJ, Mola G, Parent AS, Pineda R, Rolland A, Rosenmai AK, Song Y, Suglia A, Tena-Sempere M, Wehrli L, Zilliacus J, van Duursen M. Enhanced identification of endocrine disruptors through integration of science-based regulatory practices and innovative methodologies: The MERLON Project. OPEN RESEARCH EUROPE 2024; 4:68. [PMID: 38883262 PMCID: PMC11179054 DOI: 10.12688/openreseurope.17319.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 06/18/2024]
Abstract
The prevalence of hormone-related health issues caused by exposure to endocrine disrupting chemicals (EDCs) is a significant, and increasing, societal challenge. Declining fertility rates together with rising incidence rates of reproductive disorders and other endocrine-related diseases underscores the urgency in taking more action. Addressing the growing threat of EDCs in our environment demands robust and reliable test methods to assess a broad variety of endpoints relevant for endocrine disruption. EDCs also require effective regulatory frameworks, especially as the current move towards greater reliance on non-animal methods in chemical testing puts to test the current paradigm for EDC identification, which requires that an adverse effect is observed in an intact organism. Although great advances have been made in the field of predictive toxicology, disruption to the endocrine system and subsequent adverse health effects may prove particularly difficult to predict without traditional animal models. The MERLON project seeks to expedite progress by integrating multispecies molecular research, new approach methodologies (NAMs), human clinical epidemiology, and systems biology to furnish mechanistic insights and explore ways forward for NAM-based identification of EDCs. The focus is on sexual development and function, from foetal sex differentiation of the reproductive system through mini-puberty and puberty to sexual maturity. The project aims are geared towards closing existing knowledge gaps in understanding the effects of EDCs on human health to ultimately support effective regulation of EDCs in the European Union and beyond.
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Affiliation(s)
- Terje Svingen
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - Anna-Maria Andersson
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | | | - Marta Axelstad
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - Julie Bakker
- Neuroendocrinology Laboratory, GIGA-Neurosciences, University of Liege, Liege, Belgium
| | - Lisa Baumann
- Environmental Health and Toxicology, Amsterdam Institute for Life and Environment, Vrije Universiteit Amsterdam, Amsterdam, North Holland, 2800, The Netherlands
| | - Anna Beronius
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, 17177, Sweden
| | - Nora Bouftas
- Environmental Health and Toxicology, Amsterdam Institute for Life and Environment, Vrije Universiteit Amsterdam, Amsterdam, North Holland, 2800, The Netherlands
| | - Frederic Chalmel
- Univ Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), Rennes, F-25000, France
| | - Sofie Christiansen
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - Charlotte Cornil
- Neuroendocrinology Laboratory, GIGA-Neurosciences, University of Liege, Liege, Belgium
| | - Pauliina Damdimopoulou
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, 14186, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska Institutet, Huddinge, 14186, Sweden
| | - Deepika Deepika
- IISPV, Departament d' Enginyeria Quimica, Universitat Rovira i Virgili, Tarragona, Catalonia, 43007, Spain
| | - Martijn E T Dollé
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Monica Kam Draskau
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - Margit Bistrup Fischer
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Casper P Hagen
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Ellen Hessel
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marie Louise Holmer
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - Samantha Hughes
- Environmental Health and Toxicology, Amsterdam Institute for Life and Environment, Vrije Universiteit Amsterdam, Amsterdam, North Holland, 2800, The Netherlands
| | - Genon Jensen
- Health and Environment Alliance (HEAL), Brussels, Belgium
| | | | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Vikas Kumar
- IISPV, Departament d' Enginyeria Quimica, Universitat Rovira i Virgili, Tarragona, Catalonia, 43007, Spain
| | - Saurav Kumar
- IISPV, Departament d' Enginyeria Quimica, Universitat Rovira i Virgili, Tarragona, Catalonia, 43007, Spain
| | - Aurélie Lardenois
- Univ Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), Rennes, F-25000, France
| | - Katharina M Main
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Severine Mazaud-Guittot
- Univ Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), Rennes, F-25000, France
| | - S Jannicke Moe
- Norwegian Institute for Water Research (NIVA), Oslo, 0579, Norway
| | - Gylli Mola
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Anne-Simone Parent
- Neuroendocrinology Laboratory, GIGA-Neurosciences, University of Liege, Liege, Belgium
| | - Rafael Pineda
- Department of Cell Biology, Physiology and Immunology / IMIBIC., University of Cordoba, Cordoba, 14012, Spain
| | - Antoine Rolland
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, 17177, Sweden
| | - Anna Kjerstine Rosenmai
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Region Hovedstaden, 2800, Denmark
| | - You Song
- Norwegian Institute for Water Research (NIVA), Oslo, 0579, Norway
| | - Antonio Suglia
- Univ Rennes, Inserm, Irset (Institut de recherche en santé, environnement et travail), Rennes, F-25000, France
| | - Manuel Tena-Sempere
- Department of Cell Biology, Physiology and Immunology / IMIBIC., University of Cordoba, Cordoba, 14012, Spain
| | - Lydia Wehrli
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, 14186, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska Institutet, Huddinge, 14186, Sweden
| | - Johanna Zilliacus
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, 17177, Sweden
| | - Majorie van Duursen
- Environmental Health and Toxicology, Amsterdam Institute for Life and Environment, Vrije Universiteit Amsterdam, Amsterdam, North Holland, 2800, The Netherlands
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Kumar L, Solanki S, Jain A, Botts M, Gupta R, Rajput S, Roti Roti E. MAPKs signaling is obligatory for male reproductive function in a development-specific manner. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1330161. [PMID: 38406668 PMCID: PMC10885697 DOI: 10.3389/frph.2024.1330161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/17/2024] [Indexed: 02/27/2024] Open
Abstract
Mitogen-activated protein kinases (MAPKs) represent widely expressed and evolutionarily conserved proteins crucial for governing signaling pathways and playing essential roles in mammalian male reproductive processes. These proteins facilitate the transmission of signals through phosphorylation cascades, regulating diverse intracellular functions encompassing germ cell development in testis, physiological maturation of spermatozoa within the epididymis, and motility regulation at ejaculation in the female reproductive tract. The conservation of these mechanisms appears prevalent across species, including humans, mice, and, to a limited extent, livestock species such as bovines. In Sertoli cells (SCs), MAPK signaling not only regulates the proliferation of immature SCs but also determines the appropriate number of SCs in the testes at puberty, thereby maintaining male fertility by ensuring the capacity for sperm cell production. In germ cells, MAPKs play a crucial role in dynamically regulating testicular cell-cell junctions, supporting germ cell proliferation and differentiation. Throughout spermatogenesis, MAPK signaling ensures the appropriate Sertoli-to-germ cell ratio by regulating apoptosis, controlling the metabolism of developing germ cells, and facilitating the maturation of spermatozoa within the cauda epididymis. During ejaculation in the female reproductive tract, MAPKs regulate two pivotal events-capacitation and the acrosome reaction essential for maintaining the fertility potential of sperm cells. Any disruptions in MAPK pathway signaling possibly may disturb the testicular microenvironment homeostasis, sperm physiology in the male body before ejaculation and in the female reproductive tract during fertilization, ultimately compromising male fertility. Despite decades of research, the physiological function of MAPK pathways in male reproductive health remains inadequately understood. The current review attempts to combine recent findings to elucidate the impact of MAPK signaling on male fertility and proposes future directions to enhance our understanding of male reproductive functions.
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Affiliation(s)
- Lokesh Kumar
- Genus Breeding India Pvt Ltd., Pune, India
- GenusPlc, ABS Global, Windsor, WI, United States
| | - Subhash Solanki
- Genus Breeding India Pvt Ltd., Pune, India
- GenusPlc, ABS Global, Windsor, WI, United States
| | - Ashish Jain
- Department of Microbiology, Smt. CHM College, University of Mumbai, Ulhasnagar, India
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Alexander EC, Faruqi D, Farquhar R, Unadkat A, Ng Yin K, Hoskyns R, Varughese R, Howard SR. Gonadotropins for pubertal induction in males with hypogonadotropic hypogonadism: systematic review and meta-analysis. Eur J Endocrinol 2024; 190:S1-S11. [PMID: 38128110 PMCID: PMC10773669 DOI: 10.1093/ejendo/lvad166] [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: 07/10/2023] [Revised: 10/28/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Emma C Alexander
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Duaa Faruqi
- Faculty of Life Sciences and Medicine, King’s College London, Guy’s Campus, London SE1 1UL, United Kingdom
| | - Robert Farquhar
- Faculty of Life Sciences and Medicine, King’s College London, Guy’s Campus, London SE1 1UL, United Kingdom
| | - Ayesha Unadkat
- Faculty of Life Sciences and Medicine, King’s College London, Guy’s Campus, London SE1 1UL, United Kingdom
| | - Kyla Ng Yin
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Rebecca Hoskyns
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Rachel Varughese
- Department of Paediatric Endocrinology, Great Ormond Street Hospital NHS Trust, London WC1N 3JH, United Kingdom
| | - Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
- Department of Paediatric Endocrinology, Royal London Children’s Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
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8
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Virtanen HE, Rodprasert W, Toppari J. Deteriorating Semen Quality: The Role of the Environment. Semin Reprod Med 2023; 41:226-240. [PMID: 38499038 DOI: 10.1055/s-0044-1782151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Since the end of the last century, several reports have suggested that semen quality is declining, especially in Western countries. Furthermore, cross-sectional studies using similar protocols have suggested regional differences in semen quality of young and fertile men. Reasons for these regional differences and local adverse trends in semen quality are unknown, but environmental factors are suspected to have a role. Besides adulthood environmental exposures, those occurring during testicular development may also affect semen quality. Longitudinal follow-up studies and mixture risk analyses are needed to study the effect of fetal, childhood, and adult life environment on semen quality.
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Affiliation(s)
- Helena E Virtanen
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Wiwat Rodprasert
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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9
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Stuckey BGA, Nolan JD, Hurley DM, Martin GB. Congenital hypogonadotrophic hypogonadism, induction of minipuberty, and future fertility. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0038. [PMID: 37458575 PMCID: PMC10388679 DOI: 10.1530/edm-23-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/29/2023] [Indexed: 08/02/2023] Open
Abstract
Summary A 33-year-old man with Kallmann syndrome had received pulsatile GnRH as an infant for the treatment of cryptorchidism. As an adult, his treatment for fertility with gonadotrophins was unusually rapid compared with expectations, with a total sperm count of 25 million after only 12 months of gonadotrophin therapy. We propose that pulsatile GnRH treatment as an infant induced minipuberty and facilitated his successful, rapid response to therapy. We also propose that identification of the absence of minipuberty in infants with clinical signs suggesting congenital hypogonadotrophic hypogonadism (CHH) is an opportunity for intervention with pulsatile GnRH yielding benefits for fertility decades later. Learning points Absence of minipuberty in males with CHH results in low Sertoli cell numbers and delayed response to induction of spermatogenesis in adulthood. Presentation with 'red flags' for androgen deficiency including cryptorchidism at birth, with or without micropenis, should prompt screening for CHH and minipuberty by measurement of gonadotrophins and testosterone in the first 2 months after birth. Pulsatile GnRH therapy in patients with CHH, given prior to age of attainment of Sertoli cell maturation, can replicate the normal physiology of minipuberty, thereby priming the testis for future fertility.
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Affiliation(s)
- Bronwyn G A Stuckey
- Keogh Institute for Medical Research, Nedlands, Western Australia, Australia
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Nedlands, Western Australia, Australia
| | - James D Nolan
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David M Hurley
- Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Graeme B Martin
- School of Agriculture and Environment, University of Western Australia, Nedlands, Western Australia, Australia
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10
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Lærkeholm Müller M, Busch AS, Ljubicic ML, Upners EN, Fischer MB, Hagen CP, Albrethsen J, Frederiksen H, Juul A, Andersson AM. Urinary concentration of phthalates and bisphenol A during minipuberty is associated with reproductive hormone concentrations in infant boys. Int J Hyg Environ Health 2023; 250:114166. [PMID: 37058994 DOI: 10.1016/j.ijheh.2023.114166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND The transient postnatal activation of the hypothalamic-pituitary-gonadal hormone axis is termed minipuberty and considered an important developmental period, which is highly sensitive to endocrine disruption. Here, we explore exposure-outcome associations during minipuberty between concentrations of potentially endocrine disrupting chemicals (EDCs) in urine of infant boys and their serum reproductive hormone concentrations. METHODS In total, 36 boys participating in the COPENHAGEN Minipuberty Study had data available for both urine biomarkers of target endocrine disrupting chemicals and reproductive hormones in serum from samples collected on the same day. Serum concentrations of reproductive hormones were measured by immunoassays or by LC-MS/MS. Urinary concentrations of metabolites of 39 non-persisting chemicals, including phthalates and phenolic compounds, were measured by LC-MS/MS. Nineteen chemicals had concentrations above the limit of detection in ≥50% of children and were included in data analysis. Associations of urinary phthalate metabolite and phenol concentrations (in tertiles) with hormone outcomes (age- and sex-specific SD-scores) were analysed by linear regression. Primarily, we focused on the EU regulated phthalates; butylbenzyl phthalate (BBzP), di-iso-butyl phthalate (DiBP), di-n-butyl phthalate (DnBP), and di-(2-ethylhexyl) phthalate (DEHP) as well as bisphenol A (BPA). Urinary metabolites of DiBP, DnBP and DEHP were summed and expressed as ∑DiBPm, ∑DnBPm and ∑DEHPm. RESULTS Compared to boys in the lowest ∑DnBPm tertile, urinary concentration of ∑DnBPm was associated with concurrent higher luteinizing hormone (LH) and anti-Müllerian hormone (AMH) SD-scores as well as lower testosterone/LH ratio in boys in the middle ∑DnBPm tertile (estimates (CI 95%) 0.79 (0.04; 1.54), 0.91 (0.13; 1.68), and -0.88 (-1.58;-0.19), respectively). Further, higher insulin-like peptide 3 (INSL3) SD-scores and lower DHEAS SD-score in boys in the highest ∑DnBPm tertile (0.91 (0.12; 1.70) and -0.85 (-1.51;-0.18), respectively) were observed. In addition, boys in the middle and highest ∑DEHPm tertile had higher LH (1.07 (0.35; 1.79) and 0.71 (-0.01; 1.43), respectively) and in the highest ∑DEHPm tertile also higher AMH (0.85 (0.10; 1.61)) concentration SD-scores, respectively. Boys in the highest BPA tertile had significantly higher AMH and lower DHEAS concentration compared to boys in the lowest BPA tertile (1.28 (0.54; 2.02) and -0.73 (-1.45; -0.01)), respectively. DISCUSSION Our findings indicate that exposure to chemicals with known or suspected endocrine disrupting potential, especially the EU-regulated DnBP, DEHP and BPA, may modify male reproductive hormone concentrations in infant boys suggesting that minipuberty is a critical window sensitive to endocrine disruption.
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Affiliation(s)
- Matilde Lærkeholm Müller
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Alexander Siegfried Busch
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; University of Münster, Department of General Pediatrics, Münster, Germany
| | - Marie Lindhardt Ljubicic
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emmie N Upners
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Margit B Fischer
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper P Hagen
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jakob Albrethsen
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Hanne Frederiksen
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anna-Maria Andersson
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
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11
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Dwyer AA, Stamou M, McDonald IR, Anghel E, Cox KH, Salnikov KB, Plummer L, Seminara SB, Balasubramanian R. Reversible hypogonadotropic hypogonadism in men with the fertile eunuch/Pasqualini syndrome: A single-center natural history study. Front Endocrinol (Lausanne) 2022; 13:1054447. [PMID: 36407308 PMCID: PMC9666691 DOI: 10.3389/fendo.2022.1054447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 11/07/2022] Open
Abstract
Congenital hypogonadotropic hypogonadism (HH) is a heterogeneous genetic disorder characterized by disrupted puberty and infertility. In most cases, HH is abiding yet 10-15% undergo reversal. Men with HH and absent and partial puberty (i.e., testicular volume <4mL and >4mL respectively) have been well-studied, but the rare fertile eunuch (FE) variant remains poorly characterized. This natural history study of 240 men with HH delineates the clinical presentation, neuroendocrine profile, rate of reversal and genetics of the FE variant. We compared three HH groups: FE (n=38), absent puberty (n=139), and partial puberty (n=63). The FE group had no history of micropenis and 2/38 (5%) had cryptorchidism (p<0.0001 vs. other groups). The FE group exhibited higher rates of detectable gonadotropins, higher mean LH/FSH levels, and higher serum inhibin B levels (all p<0.0001). Neuroendocrine profiling showed pulsatile LH secretion in 30/38 (79%) of FE men (p<0.0001) and 16/36 (44%) FE men underwent spontaneous reversal of HH (p<0.001). The FE group was enriched for protein-truncating variants (PTVs) in GNRHR and FGFR1 and 4/30 (13%) exhibited oligogenic PTVs. Findings suggest men with the FE variant exhibit the mildest neuroendocrine defects of HH men and the FE sub-type represents the first identified phenotypic predictor for reversible HH.
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Affiliation(s)
- Andrew A. Dwyer
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, United States
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Stamou
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Isabella R. McDonald
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Ella Anghel
- Boston College Lynch School of Education and Human Development, Department of Measurement, Evaluation, Statistics and Assessment, Chestnut Hill, MA, United States
| | - Kimberly H. Cox
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Kathryn B. Salnikov
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Lacey Plummer
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Stephanie B. Seminara
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Ravikumar Balasubramanian
- Massachusetts General Hospital – Harvard Center for Reproductive Medicine, Massachusetts General Hospital, Boston, MA, United States
- Reproductive Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
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12
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Koskenniemi JJ, Toppari J. The Beauty of Age-dependent Standardization in Pediatric Endocrine Research and Practice. J Clin Endocrinol Metab 2022; 107:e3528-e3529. [PMID: 35436333 PMCID: PMC9282242 DOI: 10.1210/clinem/dgac243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Jaakko J Koskenniemi
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, and Centre for Population Health Research, University of Turku, 20520 Turku, Finland
- Department of Pediatrics, Turku University Hospital, 20520 Turku, Finland
| | - Jorma Toppari
- Correspondence: Jorma Toppari, MD, PhD, Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, and Centre for Population Health Research, Department of Pediatrics, University of Turku, 20520 Turku, Finland. E-mail:
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13
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Holmboe SA, Scheutz Henriksen L, Frederiksen H, Andersson AM, Priskorn L, Jørgensen N, Juul A, Toppari J, Skakkebæk NE, Main KM. Prenatal exposure to phenols and benzophenones in relation to markers of male reproductive function in adulthood. Front Endocrinol (Lausanne) 2022; 13:1071761. [PMID: 36568115 PMCID: PMC9780366 DOI: 10.3389/fendo.2022.1071761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Environmental exposure during fetal life may disrupt testicular development. In humans, a limited number of studies have investigated whether these adverse effects persist into adulthood. Using data from a prospective, population-based birth cohort study, The Copenhagen Mother-Child cohort, the objective was to assess if there is an association between fetal exposure to selected phenols and benzophenones and markers of testicular function in adult men. METHODS Pregnant women were recruited in 1997-2001. Their sons were examined clinically at 18-20 years of age, with focus on adult markers of reproductive function (anogenital distance (AGD), semen quality and reproductive hormones). In total, 101 18-20-year-old men were included, whose mothers during pregnancy had a serum sample drawn and analyzed for bisphenol A (BPA) and seven other simple phenols, as well as six benzophenones. To investigate the association between chemical levels (in tertiles, T1-T3) in relation to markers of reproductive function, univariate and multiple linear regression analyses were performed. RESULTS In fully adjusted analyses, increased levels of luteinizing hormone (LH) were observed with higher fetal exposure to BPA (percentage difference (95%CI)) (T2: 12% (-8%,36%) and T3: 33% (10%,62%), compared to T1) and benzophenone-3 (BP-3) (T2: 21% (-2%,49%), T3: 18% (-4%,45%)), while no clear association was seen to total testosterone (TT). Higher levels of BPA and BP-3 were associated with a lower TT/LH ratio, although only significant for BPA (p-trend=0.01). No associations were seen to AGD or markers of semen quality. CONCLUSION In conclusion, high exposure to BPA and BP-3 was associated with a compensated reduced Leydig cell function but no other changes in markers of reproductive health. As maternal levels of BPA and BP-3 were not correlated, separate effects may be at play. Larger studies on long-term reproductive consequences of prenatal exposures are warranted to validate our findings.
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Affiliation(s)
- Stine A. Holmboe
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- *Correspondence: Stine A. Holmboe,
| | - Louise Scheutz Henriksen
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Hanne Frederiksen
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anna-Maria Andersson
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lærke Priskorn
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Niels Jørgensen
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
- Department of Paediatrics, Turku University Hospital, Turku, Finland
| | - Niels E. Skakkebæk
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Katharina M. Main
- Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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