The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval

Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

Hypopituitarism

Hypopituitarism refers to deficiency of one or more hormones produced by the anterior pituitary or released from the posterior pituitary. Hypopituitarism is associated with excess mortality, a key risk factor being cortisol deficiency due to adrenocorticotropic hormone (ACTH) deficiency. Onset can be acute or insidious, and the most common cause in adulthood is a pituitary adenoma, or treatment with pituitary surgery or radiotherapy. Hypopituitarism is diagnosed based on baseline blood sampling for thyroid stimulating hormone, gonadotropin, and prolactin deficiencies, whereas for ACTH, growth hormone, and antidiuretic hormone deficiency dynamic stimulation tests are usually needed. Repeated pituitary function assessment at regular intervals is needed for diagnosis of the predictable but slowly evolving forms of hypopituitarism. Replacement treatment exists in the form of thyroxine, hydrocortisone, sex steroids, growth hormone, and desmopressin. If onset is acute, cortisol deficiency should be replaced first. Modifications in replacement treatment are needed during the transition from paediatric to adult endocrine care, and during pregnancy.

Luteal phase support with progesterone in intrauterine insemination: a prospective randomized study

OBJECTIVE

To determine the effect of vaginal progesterone as luteal support on pregnancy outcomes in infertile patients who undergo ovulation induction with gonadotropins and intrauterine insemination (IUI).

DESIGN

Prospective randomized trial.

SETTING

Tertiary referral center.

PATIENT(S)

About 398 patients with primary infertility were treated during 893 ovarian stimulation and IUI cycles from February 2010 to September 2012.

METHODS

All patients underwent ovarian stimulation with gonadotropins combined with IUI. Patients in the supported group received vaginal micronized progesterone capsules 200 mg once daily from the day after insemination until next menstruation or continuing for up to 8 weeks of pregnancy. Women allocated in the control group did not receive luteal phase support.

MAIN OUTCOME MEASURE(S)

Livebirth rate, clinical pregnancy rate and early miscarriage rate per cycle.

RESULT(S)

Of the 893 cycles, a total of 111 clinical pregnancies occurred. There were no significant differences between supported with progesterone and unsupported cycle in terms of livebirth rate (10.2% versus 8.3%, respectively, with a p value = 0.874) and clinical pregnancy rate (13.8% compared with 11.0% in unsupported cycle with a p value = 0.248). An early miscarriage rate of 3.6% was observed in the supported cycles and 2.7% in the unsupported cycles, with no significant differences between the groups (p value = 0.874).

CONCLUSION(S)

In infertile patients treated with mildly ovarian stimulation with recombinant gonadotropins and IUI, luteal phase support with vaginal progesterone is not associated with higher livebirth rate or clinical pregnancy rate compared with patients who did not receive any luteal phase support.

Outcome from consecutive ICSI cycles in patients treated with recombinant human LH and those supplemented with urinary hCG-based LH activity during controlled ovarian stimulation in the long GnRH-agonist protocol

Clinical results were compared in a well-established, assisted reproduction program during the cross-over from highly purified (HP)-human menopausal gonadotropin (hMG) to rhFSH/rhLH. We included the last 33 patients treated with HP-hMG and the first 33 patients receiving rhFSH/rhLH for ovarian stimulation in their first intracytoplasmic sperm injection cycle. Patient baseline characteristics were almost identical in the two groups. Ovarian stimulation characteristics (days of stimulation, total amount of FSH administered using a modest initial loading dose of 150 IU/d, patients with oocyte retrieval) were similar for the two groups. However, the number of total and leading follicles and E2 serum levels on the human chorionic gonadotropin injection day were significantly higher in the rhFSH/rhLH group. The oocyte yield was significantly higher in the rhFSH/rhLH group as well as the number of metaphase II oocytes, difference almost reaching the statistical significance. The number of oocytes fertilized was also higher in patients receiving rhFSH/rhLH treatment. Implantation and clinical pregnancy rates were similar in both the study groups. It is concluded that in women undergoing controlled ovarian hyperstimulation under pituitary suppression for ART, the recombinant combined product containing FSH and LH in a fixed 2:1 ratio is more effective than HP-hMG in terms of follicle development, oocyte yield and quality, and fertilization rates.

[Pituitary down-regulation and ovulation stimulation with gradually increased gonadotropin in controlled ovarian hyperstimulation]

OBJECTIVE

To evaluate the efficacy of ovulation stimulation protocol with gradual increment of gonadotropin in women with high ovarian response.

METHODS

A retrospective study was conducted between june 2005 and April 2006 in 70 women undergoing controlled ovarian hyperstimulation. The clinical outcomes of the women using gradual increment protocol were compared with those of women receiving other ovulation-stimulating protocols.

RESULTS

The mean number of large follicles (>or=14 mm) and retrieved oocytes on the day of retrival was significantly lower, but the duration of stimulation was significantly longer in the gradual increment group than in the control group. The rate of follicular puncture was also higher in the former group. The clinical pregnancy rate, total gonadotropin dosage, cancellation rate and incidence of ovarian hyperstimulation syndrome were similar for the two groups.

CONCLUSION

Ovulation stimulation protocol with gradually increased gonadotropin may provide a promising alternative for controlled ovarian hyperstimulation in women with a strong ovarian response.

The effect of withholding gonadotropin (a coasting period) on the outcome of in vitro fertilization cycles

OBJECTIVE

The purpose of this study was to evaluate the effects of coasting (withdrawing gonadotropin administration) on the cycle outcomes, including total number and quality of oocytes and embryos and pregnancy rate in patients undergoing in vitro fertilization.

STUDY DESIGN

Sixty-seven patients undergoing coasting were evaluated in a retrospective study at the Royan Institute between May 2002 and June 2003. All patients underwent standard long protocol with gonadotropin-releasing hormone (GnRH) analogue and human menopausal gonadotropin (HMG) and then in vitro fertilization and embryo transfer (IVF-ET). Coasting was considered when the estradiol level was more than 3000 pg/ml and the number of follicles >10 in each ovary. HCG was administered whenever estradiol reached < or =3000 pg/ml and then the (IVF-ET) program was carried out. According to coasting periods, patients were divided into two groups: coasting period < or =3 days and coasting period >3 days. Statistical comparisons were performed using Student's t test and Fisher's exact test.

RESULTS

There were no significant differences between the two groups with regard to mean age, body mass index (BMI), number of polycystic ovary syndrome (PCOS) patients, number of HMG ampoules and stimulation duration. The total number of retrieved oocytes decreased significantly in patients with more than 3 days of coasting (P=0.04). The number of high quality oocytes also decreased in this group; however, this did not reach significant levels. There were no significant differences between the two groups with regard to fertilization and pregnancy rate. None of the patients developed severe ovarian hyperstimulation syndrome (OHSS).

CONCLUSION

This study reveals that a long coasting period (>3 days) has a negative effect on the number of oocytes, although the fertilization and pregnancy rates are not affected. Prospective randomized studies with larger sample sizes are needed to compare coasting with other procedures.

Ovarian response to repeated administration of alternating exogenous gonadotropin regimens in the ocelot (Leopardus pardalis) and tigrinus (Leopardus tigrinus)

Exogenous gonadotropins are used to stimulate ovarian follicular growth and ovulation in mammalian species, including wild cats. However, successes in application of assisted reproduction techniques in nondomestic felids have been sparse. Our objectives were to assess the effectiveness of alternating gonadotropin regimens on ovarian responses. Five adult female ocelots and four adult female tigrinus were treated four to six times, using alternating eCG/hCG and pFSH/pLH at 4-month intervals. Laparoscopies were done to assess follicular development and to collect oocytes from matures follicles. The average number of follicles and corpus luteum (CL) per stimulation was higher in ocelots (7.0 +/- 0.8; mean +/- S.E.M.) than in tigrinus (2.5 +/- 0.4; P < 0.05), but the percentage of mature oocytes did not differ between the two species (mean range, 54-55%). Within species, both gonadotropin regimens were equally effective in inducing follicular growth and oocyte maturation. The total number of ovarian structures and oocyte maturation percentages did not decrease in either species with sequential stimulations. In summary, female ocelots and tigrinus continued to respond to repeated alternating ovarian stimulation protocols. In conclusion, the use of alternating gonadotropin regimens may permit more intensive reproductive management in these endangered cats.

Pregnancy outcomes in in vitro fertilization cycles with serum estradiol drop prior to human chorionic gonadotropin

OBJECTIVE

To study the effect of an unpredictable drop in serum estradiol prior to hCG administration on pregnancy outcomes in in vitro fertilization cycles.

METHODS

3653 consecutive IVF cycles from January 1, 1998 to December 31, 2000 at Brigham and Women's Hospital were reviewed, and 65 cycles in which oocyte retrieval (ER) was performed following a drop in serum estradiol (E(2)) not associated with intentional withdrawal of gonadotropins were identified. Daily gonadotropin dose was decreased at some time in 25 of these cycles, while the remaining 40 cycles did not have a reduction in gonadotropin dose. A retrospective case-control study of the respective live birth rates and pregnancy loss rates of patients with unpredictable E(2) drops in the 65 study cycles were compared to 65 age matched controls.

RESULTS

Live birth rates (32% vs. 35%, p=0.72) and pregnancy loss rates (28% vs. 30%, p=0.76) were similar for all study and control groups respectively. There were no differences in live birth and pregnancy loss rates in cycles undergoing gonadotropin dose reduction (40% vs. 44%, p=0.78 and 29% vs. 39%, p=0.70) and cycles without gonadotropin dose reduction (28% vs. 30%, p=0.81 and 27% vs. 20%, p=0.72).

CONCLUSIONS

In the absence of coasting, a drop in serum estradiol levels during GnRH-agonist downregulated controlled ovarian hyperstimulation for IVF prior to hCG is not associated with a decrease in live birth rates or pregnancy loss rates.

Short- and long-term effects of ovulation induction

Ovulation induction using clomiphene citrate, gonadotropins, and gonadotropin-releasing hormone is reviewed. The short- and long-term consequences of these therapies are discussed in detail.

Follicular fluid hormone concentrations after ovarian stimulation using gonadotropin preparations with different FSH/LH ratios. II. Comparison of hMG and recombinant FSH

OBJECTIVE

A small amount of LH is necessary for 17 beta-estradiol production in the ovarian follicle. Human menopausal gonadotropin (hMG) contains equal amounts of FSH and LH activity, whereas recombinant FSH is a gonadotropin preparation without LH. The aim of the present randomized study was to investigate whether ovarian stimulation treatment with recombinant FSH or hMG resulted in different steroidal composition of follicular fluid.

METHODS

Antral fluid from mature follicles was collected in in vitro fertilization cycles and concentrations of testosterone, androstenedione, estrone, estradiol, progesterone, FSH, and LH were determined. Seven patients (27 samples) were treated with hMG, 6 patients (22 samples) with recombinant FSH.

RESULTS

Androgen, estrogen, progesterone, and FSH concentrations in follicular fluid tended to be lower in the group treated with recombinant FSH, but the variation was large and differences were statistically not significant.

CONCLUSION

Treatment with a gonadotropin preparation containing no LH resulted in adequate androgen and estrogen levels in antral fluid of the ovarian follicle in women with normal endocrine profiles, even during pituitary suppression by a GnRH agonist. Apparently, the amount of endogenous LH was sufficient for steroid production within the follicle.

Follicular fluid hormone concentrations during controlled ovarian hyperstimulation using gonadotropin preparations with different FSH/LH ratios. I. Comparison of an FSH-dominant and a purified FSH preparation

OBJECTIVE

The aim of the present randomized study was to investigate whether ovarian stimulation treatment with gonadotropin preparations containing different amounts of LH activity resulted in variations of steroidal composition of follicular fluid. A different endocrine milieu within the follicle might influence oocyte quality.

METHODS

Antral fluid from mature follicles was collected in in vitro fertilization cycles and concentrations of testosterone, androstenedione, estrone, estradiol, progesterone, FSH, and LH were determined. A comparison was made between treatment with a purified FSH preparation (nine patients, 35 follicular fluid samples) and a FSH-dominant human menopausal gonadotropin (hMG) preparation (nine patients, 34 samples).

RESULTS

No differences in any of the hormone levels could be detected between the two groups.

CONCLUSION

Treatment with gonadotropin preparations containing different FSH/LH ratios did not result in different androgen, estrogen and progesterone levels in follicular fluid.

Sexual behavior of men with isolated hypogonadotropic hypogonadism or prepubertal anterior panhypopituitarism

Sexual behavior of men with secondary hypogonadism was studied. Seven of the thirteen subjects presented with hypogonadism secondary to isolated gonadotropin (Gn) deficit, whereas the other six had idiopathic prepubertal anterior panhypopituitarism. Testosterone (T) levels were low and did not differ between the two groups. All subjects were evaluated both during replacement therapy (Gn in the first group; Gn plus cortisone and thyroxine in the second group) and 2 months after withdrawal of Gn therapy. During and after withdrawal of Gn administration, men with isolated deficit of Gn retained sexual activity and nocturnal penile tumescence, although they were partially compromised compared with a control group; on the other hand, panhypopituitarics reported compromised sexual function during Gn treatment and no sexual function when Gn therapy was not given. We conclude that different lesions of the hypothalamus-pituitary axis were accompanied by varying degrees of sexual impairment in the two groups of men presenting both secondary hypogonadism and very low T levels.

Serum inhibin concentrations before and during gonadotropin treatment in men with hypogonadotropic hypogonadism: physiological and clinical implications

We measured by RIA the inhibin concentrations in the sera of 20 men with hypogonadotropic hypogonadism before and during treatment with gonadotropins in order to determine the role of gonadotropins in the control of inhibin secretion and the utility of the serum inhibin concentration in assessing the spermatogenic response to gonadotropin treatment in these patients. Before treatment the mean serum inhibin concentration in the 20 hypogonadotropic men as a group (391 +/- 49 U/L) was significantly lower (P less than 0.001) than that in 27 normal men (741 +/- 52 U/L). In the 7 men whose hypogonadism was of postpubertal onset, the mean serum inhibin concentration (559 +/- 69 U/L) was not significantly lower than that in normal men. In the 13 men whose hypogonadism was of prepubertal onset, the serum inhibin level was significantly lower [381 +/- 74 U/L (P less than 0.01) in the 7 without a history of cryptorchidism and 207 +/- 46 U/L (P less than 0.01) in the 6 with a history of cryptorchidism]. All 20 patients were azoospermic or severely oligospermic and had distinctly subnormal serum testosterone concentrations, even those whose serum inhibin values were normal. In the 7 patients with postpubertal hypogonadism, treatment with hCG alone for 6 months increased the serum testosterone concentration and maximum sperm count to normal, even though the previously normal inhibin concentration was not increased further. In the 13 patients with prepubertal hypogonadism, treatment with hCG alone increased the serum inhibin concentration, and combined treatment with hCG and human menopausal gonadotropin (hMG) increased inhibin further, to well within the normal range (742 +/- 143 U/L) in the patients without a history of cryptorchidism and to just within the normal range (487 +/- 96 U/L) in those with such a history. In the 7 patients with prepubertal hypogonadism but no history of cryptorchidism, treatment with hCG and hMG increased the maximum sperm count to normal in 5. In the 6 patients with prepubertal hypogonadism who did have a history of cryptorchidism, hCG and hMG treatment produced a normal sperm count in only 1. Of 12 patients whose serum inhibin level was more than 300 U/L before treatment, 11 developed a normal maximum sperm count in response to treatment, but of 8 patients whose inhibin concentration was less than 300 U/L before treatment, only 2 developed a normal sperm count in response to treatment (P less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Gonadotropin therapy of female infertility

Anovulatory infertility in 134 women was treated with gonadotropins for a total of 318 cycles. The patients were classified into WHO group I, hypothalamic-pituitary failure (72 patients), and WHO group II, hypothalamic-pituitary dysfunction (62 patients). All patients in this group had failed to achieve pregnancy with clomiphene citrate therapy in repeated cycles. The pregnancy rate in group I was 72.2% vs 17.7% in group II. The 'take home' baby rate was 57.1% in group I vs 13.1% in group II. The rate of miscarriages was 14.3% without any significant difference between the groups. Multiple pregnancies occurred only in group I patients (19.2%). The conception rate was highest in the first four cycles, whereas no patient became pregnant after the sixth treatment cycle. Ovarian hyperstimulation syndrome occurred most frequently in group II patients, however, overall only 2.2% of the patients needed hospitalization because of hyperstimulation. Gonadotropin therapy must be considered an efficient and successful treatment of infertility in patients with hypothalamic-pituitary failure, whereas the success rate is rather poor in patients with hypothalamic-pituitary dysfunction.

[Treatment in male infertile clinic of Kaizuka Municipal Hospital]

The results of treatment of 68 idiopathic male infertile cases are reported. The follow up period was 3 years and 8 months from the time the Department of Urology, Kaizuka Municipal Hospital had opened. The main treatments were human mammary gonadotropin-human chorionic gonadotropin (HMG-HCG) therapy and high ligation of left testicular vein in the cases accompanied with varicocele. Adjuvant therapy was administration of vitamin B12, herb medicine and antibiotic agents for prostatovesiculitis. Some cases were administered clomiphene citrate. The results in 43 cases at over 10 weeks after treatment was followed. Mean sperm count and mean sperm activity rate in 11 cases accompanied with no varicocele and whose sperm count was 2 approximately 45 x 10(6)/ml were raised from 11.0 +/- 8.0 SD x 10(6)/ml and 19.1 +/- 11.4 SD% to 22.7 +/- 16.8 SD x 10(6)/ml and 26.9 +/- 18.5 SD%, respectively after 20 weeks of HMG-HCG therapy. Efficacy was 7 out of 11 (63.6%) in sperm count and 6 out of 11 (54.5%) in sperm activity rate. Pregnancy was obtained in 3 cases. Effect of HMG-HCG therapy was not observed in 8 cases accompanied with varicocele and whose sperm count was 2 approximately 45 x 10(6)/ml. High ligation of left testicular vein was effective in all of the 4 cases accompanied with varicocele and whose sperm count was 2 approximately 45 x 10(6)/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of ovulation with human pituitary gonadotrophin. Twelve years' experience

Twelve years' experience in the therapeutic use of human pituitary gonadotrophins in 74 patients with anovulation is reviewed. Of these 74 patients, 54 conceived on at least one occasion. A new development, the use of radioimmunoassays for oestrone-3-glucuronide and pregnanediol-3-glucuronide to monitor responses, has been shown to be as effective as the more laborious chemical methods which were previously used. The adoption of radioimmunoassay monitoring allows the simultaneous treatment of up to five patients, and will markedly reduce existing waiting lists for this treatment.

Estrogen excretion patterns in induced ovulation

Observation of response to gonadotropins in the treatment of anovulation has allowed us to define the estrogen excretion pattern which leads to a successful single pregnancy. The typical pattern shows a low pretreatment urinary total estrogen excretion; treatment with gonadotropins, of human pituitary origin, is continued for about 14 days. There is a predictable rate of rise of preovulatory estrogen excretion (30 microgram/24 hr2). Human choronic gonadotropin--about 4000 IU--should be given when an estrogen excretion of 75-100 microgram/24 hr has been obtained. The use of this pattern of ovarian response is put forward as a useful guide in the planning of gonadotropin therapy.

Studies of the coagulation and fibrinolytic systems in hyperstimulation syndrome after administration of human gonadotropins

Coagulation and fibrinolytic profiles have been studied in two groups of sterility patients receiving low dosage regimens of human gonadotropins for ovarian stimulation. This investigation was prompted by a report of two patients with severe episodes of intravascular coagulation associated with periods of "hyperstimulation" from these drugs. No statistically significant changes were found as a result of administration of one ampoule of human menopausal (HMG) or pituitary gonadotropins (HPG) for 8 days followed by 9000 units of human chorionic gonadotrophin (HCG). A course of 2-3 ampoules HMG on alternate days for longer periods of time prior to administration of HCG also failed to produce significant alterations of the coagulation or fibrinolytic mechanisms. In two patients with severe hyperstimulation there were elevated levels of factor V, platelets, fibrinogen, profibrinolysin, and fibrinolytic inhibitors. Generation of thromboplastin was also increased when plasma was diluted one to fifty in the thromboplastin generation test. These results suggest a possibly increased coagulation potential in patients with "hyperstimulation syndrome" but not in those receiving the low dosage regimens of human gonadotropins more commonly used for ovarian stimulation at the present time.

An improved in vitro bioassay method for measuring luteinizing hormone (LH) activity using mouse Leydig cell preparations

An improved in vitro bioassay method for the measurement of LH activity is presented. The method is based on the assay of testosterone produced by "Leydig cell" preparations from mouse testes in the presence of added gonadotrophin. The method is significantly improved in terms of sensitivity, precision and practicability when compared to the previously described bioassay method employing decapsulated testes from adult mice. The sensitivity of the improved method is 15 μIU for HCG and 50 μIU for HMG. The useful range of the method is 15–260 μIU for HCG and 50–900 μIU for HMG. Using a 3 + 3 point assay design with each dose in quadruplicate, a mean index of precision (λ̅) of 0.044 was obtained in 19 assays.

Human FSH, TSH, ACTH, LTH, STH, oxytocin, vasopressin and LHRH preparations did not influence the bioassay method at levels likely to be found in biological samples. A good correlation was found between estimates obtained by the "Leydig cell" method and by the method using decapsulated testes when various HCG and HMG preparations were used. With the proposed method at least 30 samples can be assayed each week by 2 persons, with a marked reduction in cost.

Sialic acid content and sperm receptivity of cervical mucus in relation to oestrogen excretion following administration of FSH

The cervical mucus was studied with regard to changes in sialic acid content and sperm receptivity. The data were correlated with the urinary total oestrogen excretion in anovulatory women treated with human pituitary gonadotrophins (HPG). With increasing total oestrogen excretion the sialic acid content decreased and the sperm receptivity increased. At a total oestrogen level of about 60 μg/24 h the respective patterns of the curves were reversed and higher values for total oestrogen were actually associated with a decrease in sperm receptivity and an increase in sialic acid content. The possible significance of these observations is discussed.