The correlation between highly sensitive C-reactive protein levels and erectile function among men with late-onset hypogonadism

We investigated the correlation between highly sensitive C-reactive protein (hs-CRP) levels and erectile function, and assessed the clinical role of hs-CRP levels in men with late-onset hypogonadism (LOH) syndrome. For 77 participants, we assessed Sexual Health Inventory for men (SHIM) score, Aging Male Symptoms (AMS) score and International Prostate Symptom Score (IPSS). We also evaluated free testosterone (FT), hs-CRP, total cholesterol, triglyceride levels, high density lipoprotein cholesterol, hemoglobin A1c, body mass index, waist size and blood pressure. We attempted to identify parameters correlated with SHIM score and to determine the factors affecting cardiovascular risk based on hs-CRP levels. A Spearman rank correlation test revealed that age, AMS score, IPSS and hs-CRP levels were significantly correlated with SHIM score. Age-adjusted analysis revealed that hs-CRP and IPSS were the independent factors affecting SHIM score (r= -0.304 and -0.322, respectively). Seventeen patients belonged to the moderate to high risk group for cardiovascular disease, whereas the remaining 60 belonged to the low risk group. Age, FT value and SHIM score showed significant differences between the two groups. A multivariate regression analysis demonstrated that SHIM score was an independent factor affecting cardiovascular risk (OR: 0.796; 95%CI: 0.637-0.995).

RigiScan data under long-term testosterone therapy: improving long-term blood circulation of penile arteries, penile length and girth, erectile function, and nocturnal penile tumescence and duration

BACKGROUND

Late-onset hypogonadism (LOH) presents with low serum testosterone (TT) levels and sexual and nonsexual symptoms. Erectile dysfunction affects a man's self-esteem and as a result partner relationship and quality of life.

OBJECTIVES

To investigate the andrological clinical profile outcomes of testosterone therapy (TTh) in men (n = 88) with symptomatic LOH complaints and symptoms.

MAIN OUTCOME MEASURES

Erectile function was assessed using the International Index of Erectile Function-5 questionnaire at baseline and at 6 and 12 months of TTh. In addition, penile length was measured at baseline and 12 months. We also evaluated nocturnal penile tumescence (NPT, using RigiScan) and blood flow of cavernous arteries (penile Doppler ultrasonography) at baseline and 12 months of TT.

MATERIALS AND METHODS

Eighty-eight LOH men (M_age 51.1 years) with erectile dysfunction, all with serum TT <10.4 nmol/L before TTh. Patients received intramuscular long-acting testosterone undecanoate for 12 months.

RESULTS

Following TTh, in all patients, serum TT levels were restored within 3 months to normal levels. Compared with baseline values, erectile function significantly improved at 6 (mean score increase 1.95) and 12 months (mean score increase 2.16). No significant changes in penile length were observed. NPT significantly improved at 12 months in terms of both the frequency (mean increase 1.27 times) and duration of rigidity (mean increase 5.12 min). As regards the blood flow of the cavernous arteries, we observed a significant improvement (decrease of 1.16 cm/s) and end diastolic velocity of the penile arteries.

CONCLUSION

TTh in men with LOH resulted in improvement of the erectile function, NPT, and to some extent the blood flow of the cavernous arteries.

Fertile eunuch syndrome with the mutations (Trp8Arg and Ile15Thr) in the beta subunit of luteinizing hormone

Fertile eunuch syndrome is caused by isolated LH deficiency, but its pathophysiology still remains controversial. We report a case of fertile eunuch syndrome with homozygous Trp8Arg and Ile15Thr mutations in the LH beta subunit gene. An 18-year-old man was admitted to our hospital for hypogonadism. Examination of genitalia revealed Tanner G1PH1, whereas both testes were elastically palpated and developed up to 18 ml. Endocrinological evaluations revealed normogonadotropic hypogonadism and there were normal responses after GnRH and hCG stimulation. Intratesticular testosterone concentration was almost normal (1.34 x 10(3) ng/g). By PCR direct sequencing, homozygous Trp (8) Arg and Ile (15) Thr mutations in exon 2 of LH beta were detected. Normal virilization and improved semen parameters were achieved after hCG supplementation. To our knowledge, this is the first case of fertile eunuch syndrome with homozygous Trp (8) Arg and Ile (15) Thr mutations in beta subunit of LH gene.

The fertile eunuch variant of idiopathic hypogonadotropic hypogonadism: spontaneous reversal associated with a homozygous mutation in the gonadotropin-releasing hormone receptor

Mutations in the GnRH receptor (GnRH-R) gene have been reported to cause idiopathic hypogonadotropic hypogonadism (IHH). Herein, we describe a 26-yr-old male with a mild phenotypic form of IHH, the fertile eunuch syndrome (IHH in the presence of normal testicular size and some degree of spermatogenesis), associated with a homozygous mutation (Gln106Arg) in the GnRH-R. This mutation, located in the first extracellular loop of the GnRH-R, has been previously shown to decrease but not eliminate GnRH binding. The proband had hypogonadal testosterone levels, detectable but apulsatile gonadotropin secretion, and a normal adult male testicular size of 17 mL at baseline. After only 4 months of treatment with hCG alone, he developed sperm in his ejaculate and his wife conceived. Following cessation of hCG therapy, the patient demonstrated reversal of his hypogonadotropism as evidenced by normal adult male testosterone levels and the appearance of pulsatile luteinizing hormone secretion. This case thus expands the emerging clinical spectrum of GnRH-R mutations, provides the first genetic basis for the fertile eunuch variant of IHH and documents the occurrence of reversible IHH in a patient with a GnRH-R mutation.

The lost voice: a history of the castrato

Under the influence of testicular secretion, the male vocal cords increase in length by 67% in adult men compared with prepubertal boys, whereas in the female the increase is only 24%. This greater length and an increase in vocal cord mass is responsible for the lowering of pitch of the male voice during puberty. From the late 16th century, castration was carried out in Italy to preserve the unbroken male voice into adult life, but the high pitch was accompanied by fully grown resonating chambers and a large thoracic capacity, giving rise to the unique voice of the castrato. The initial stimulus for the production of castrati came from the Sistine Chapel in Rome, to provide singers for the complex church music of the time. The second reason was the coming of opera to Italy at the beginning of the 17th century. Boys were castrated between the ages of 7 and 9 years, and underwent a long period of voice training. A small number became international opera stars, of whom the most famous was Farinelli, whose voice ranged over three octaves. By the end of the 18th century, fashions in opera had changed so that the castrati declined except in the Vatican, where the Sistine Chapel continued to employ castrati until 1903. The last of the castrati was Alessandro Moreschi, who died in 1924 and made gramophone recordings that provide the only direct evidence of a castrato's singing voice.

Case report: olfactory function in a fertile eunuch with Kallmann syndrome

The olfactory and gonadal dysfunction in Kallmann syndrome share a common embryologic pathophysiology. To characterize further the linkage between the hypogonadotropic hypogonadism and anosmia, the authors performed a detailed evaluation of olfactory function in a patient with Kallman Syndrome having the rare variant of partial gonadotropin deficiency (fertile eunuch). The subject was seen initially at age 16 years because of delayed puberty. He received testosterone replacement therapy and subsequently completed pubertal development. As an adult, while untreated, he had subnormal levels of serum testosterone, low gonadotropins, and normal response to luteinizing hormone- releasing hormone. He also had impotence that was reversible with testosterone therapy, and a normal sperm count. Despite the mild degree of hypogonadism, olfactory function was completely absent, and the response to nasal trigeminal stimulants was markedly attenuated. Complete anosmia may therefore be associated with gonadotropin deficiency that is only partial; the presence of anosmia does not predict the need for gonadotropin therapy to attain fertility.

Subcutaneous gonadotropin therapy in male patients with hypogonadotropic hypogonadism

OBJECTIVE

The response to subcutaneous (SC) gonadotropin replacement therapy, using human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) or hCG alone, was evaluated in male hypothalamic hypogonadism.

DESIGN

Sixteen patients with hypothalamic hypogonadism were treated with gonadotropins for induction of puberty and normalization of spermatogenesis. The results were analyzed retrospectively.

SETTING

The study was carried out in a clinical endocrinology department providing tertiary care and in private practices of endocrinology.

PATIENTS

Eight patients with idiopathic hypogonadotropic hypogonadism and eight patients with Kallmann's syndrome in prepubertal or early pubertal stages.

INTERVENTIONS

Human chorionic gonadotropin and hMG were administered SC in individual dosages.

MAIN OUTCOME MEASURES

Increase of serum testosterone (T), testicular volume, semen volume, and sperm count were evaluated.

RESULTS

Normalization of serum T and complete sexual maturation was achieved in all patients. Spermatogenesis was induced in all but two patients. Seven patients showed normal findings in semen volume and sperm count, and two patients had semen quality close to normal. In five patients sperm count remained less than 10 x 10(6)/mL.

CONCLUSIONS

The results obtained by SC gonadotropin replacement prove this mode of administration to be effective in stimulating steroidogenesis and spermatogenesis in hypogonadotropic males.

Kallmann's syndrome and chemosensory evoked potentials

Kallmann's syndrome is generally assessed by history and subjective tests of olfactory function. In this study three patients suffering from Kallmann's syndrome were investigated with more objective techniques, including the recording of chemosensory evoked potentials (CSEPs). After testing olfactory function by means of a simple odor identification test, anosmia was confirmed in only one patient, since the other two patients were able to distinguish between several odorants. However, investigations in which CSEPs were employed indicated that all three patients had complete loss of their olfaction as well as hypersensitivity of the trigeminal nerve. These findings prove the usefulness of CSEPs in clinical investigations of the sense of smell.

The luteinizing hormone-releasing hormone pulse generator in men: abnormalities and clinical management

Most men with hypogonadotropic eunuchoidism have absent luteinizing hormone and presumably absent luteinizing hormone-releasing hormone pulses. Pulsatile luteinizing hormone-releasing hormone therapy is effective in restoring normal gonadotropin secretion and testicular function and inducing fertility in men with hypogonadotropic eunuchoidism. Furthermore, pulsatile (versus continuous) luteinizing hormone-releasing stimulation of the pituitary gland is an absolute requirement for normal gonadotropin secretion. Men with idiopathic oligoazoospermia and selective elevation of follicle-stimulating hormone levels have slow luteinizing hormone and presumably luteinizing hormone-releasing pulse frequency. In these men, pulsatile luteinizing hormone--releasing treatment is effective in decreasing serum follicle-stimulating hormone levels, but it is unclear whether spermatogenesis and fertility are improved.

Blood-testis barrier in men with idiopathic hypogonadotropic eunuchoidism and postpuberal pituiary failure

Immature-type Sertoli cells in the testes of idiopathic hypogonadotropic eunuchoidism (17-30 years of age) had no specialized junctions. The specialized Sertoli junctions that blocked the penetration of lanthanum were formed six months to two years after hCG treatment (5000 IU twice a week) in patients of hypogonadotropic eunuchoidism. In two patients with postpubertal pituitary failure (one had a ectopic pinealoma, irradiated one year ago, and the other had a pituitary adenoma, hypophysectomized four years ago), the ultrastructural integrity of these Sertoli junctions was maintained. Therefore, it may be suggested that the development of the blood-testis barrier is dependent on gonadotropins, but the maintenance of the blood-testis barrier is not.

Consecutive administrative of synthetic LRH in the evaluation of gonadotrophin reserve in children

Initial injection of synthetic luteinizing hormone releasing hormone (LRH) into 40 children elicited no response in LH and follicle stimulating hormone (FSH) in 15 patients with pituitary dwarfism, one with Kallmann's syndrome and in 3 anorexia nervosa patients. These patients were further treated with LRH for periods of either 3 or 14 days and the second LRH test showed an increase in LH and/or FSH in 67% of the patients with pituitary dwarfism, in the Kallmann's syndrome and in all of the anorexia nervosa patients. This result suggested that while pituitary gonadotrophs did not respond at the first LRH test because of the chronic absence of stimulation, consecutive LRH therapy, however, restored the ability to secrete LH and FSH and indicated that the pituitary was not the site of the primary lesion in these patients. The LRH test following consecutive administration of LRH may be valuable in determining whether the lesion is located in the hypothalamus or the pituitary.

[Hypogonadism in the male]

The hypogonadism of man and its causes are described in short form. A scheme of the gradual diagnostics explains the possibilities of the diagnostic approach. At the same time is dealt with the therapeutic measures and their indications.

Induction of spermatogenesis in hypogonadotrophic hypogonadism

A young male who presented with isolated bihormonal gonadotrophin deficiency is described, Basal levels of LH and FSH were low and there was no response to clomiphene citrate or LHRH. The remaining anterior pituitary function was intact. The administration of a combination of human menopausal gonadotrophin and human chorionic gonadotrophin caused testicular maturation with spermatogenesis and full androgenization. The patient was able to father a child.

Fertile eunuch syndrome versus classic hypogonadotrophic hypogonadism

The functioning of the hypothalamo-pituitary-target organs axis was assessed in 3 patients with 'fertile eunuch' syndrome (FE) and 6 patients with 'classic' hypogonadotrophic hypogonadism (HH) with or without hyposmia. Both groups of patients did not differ from each other with regard to basal serum prolactin levels, pituitary growth hormone and thyrotrophin reserve and the thyroid or adrenal gland function. Both groups differed, however, with respect to the hypothalamo-pituitary-gonadal function: 1. the pituitary LH response to exogenous LH-RH was (low)-normal in FE and blunted in HH; 2. the basal FSH levels were normal in FE and undetectable in HH; 3. the basal LH levels were normal in FE and 3/6 patients with HH and low in the remaining three; 4. the basal and HCG stimulated plasma testosterone concentrations were significantly higher in FE than HH. The data suggest that FE represents a less severe form of LH-RH deficiency, rather than a distinct disorder.

[Bioelectrical activity of the brain in men with hypogonadism]

Bioelectrical activity of the brain was studied in 51 patients with primary and in 36 with secondary hypogonadism. In the patients examined there was a change of both the amplitude and frequency characteristics of the EEG curves; organization of the basic rhythm was disturbed, and paroxysmal activity discharges appeared. The EEG data in primary hypogonadism pointed to reduction in the reactive properties of the cortex and brain stem; in secondary hypogonadism--diffuse affection of the diencephalic region was testified to.

The fertile eunuch syndrome. An isolated leydig-cell failure?

In two patients exhibiting eunuchoid features in association with normal sized testes and complete spermatogenesis concommittant with only occasional Leydig cells between the tubuli, (proven by testicular biopsy) an attempt was made to elucidate the factors leading to this condition. Both patients responded with significant rise in both plasma FSH and LH after administration of synthetic GnRH indicating pituitary responsiveness. However, no rise in either FSH or LH could be observed after administration of clomiphene citrate during three weeks of treatment indicating hypothalamic unresponsiveness to chemical stimuli. Although plasma testosterone levels rose significantly after administration of Human Chorionic Gonadotropin, estradiol remained unchanged during three weeks of HCG administration. A hypothesis is discussed which defines this syndrome in these two cases as primary Leydig cells failure, expressed in the inability of these to transform testosterone into estrogens, thus depriving pituitary and hypothalamus from a proper steroidal milieu necessary to adequate functioning.

Suprasellar disturbance in the syndrome of fertile eunuchoidism: case report

A case of fertile eunuchoidism is presented. The diagnosis was established on the basis of low androgen secretion in the presence of active spermatogenesis, increase in testosterone output after gonadotrophin stimulation, and adequate peripheral response to exogenous testosterone. Resistance to clomiphene stimulation but normal pituitary response to LH-RH was elicited indicating a suprasellar disturbance as the cause of the disorder.

Evaluation of gonadotrophin analyses in male hypogonadism

Urinary total hypophyseal gonadotrophin (HG) analyses in 56 healthy men and 282 patients with a great variety of forms of male hypogonadism showed that in some clinical conditions HG is decreased, in others increased while in some others the HG level is normal.

It has been shown, however, that primary damage of the germinal epithelium per se causes an increase of the HG level. It is necessary, therefore, to take the functional state of the germinal epithelium into account when HG excretion is used as a parameter of function and responsiveness of the hypophysis.

By the testicular biopsy score count method described by the author, a figure (mean score, MS) is obtained which expresses the spermatogenetic state. Analysis of 284 patients with primary testicular disorders established a correlation between the log gonadotrophin value (log HG) and MS. It was found that the HG level in the control group of apparently healthy men was considerably higher than that corresponding to perfect spermatogenesis. The question whether »ideal« men with perfect spermatogenesis or »average healthy« men should be used as controls in gonadotrophin assays is a dilemma.

By using the regression equation between log HG and MS the influence of various spermatogenetic states on the HG level was eliminated by transforming, in each patient, the log HG value to the value corresponding to a fixed mean score of 1.0. These transformed log HG values were then evaluated in the various disorders. Decreased values were found in hypopituitarism, infantilism, eunuchoidism, adiposogenital dystrophy (in adults) and hypogonadism secondary to metabolic disease. In all other conditions, the HG level corresponded to the spermatogenetic state. No extra-tubular factors seem to influence the HG level and no case of primary overproduction of gonadotrophins was found.

The value of transforming gonadotrophin values to a defined spermatogenetic state in clinical and experimental studies is discussed.

A study of human testicular function by the use of human menopausal gonadotrophin and of human chorionic gonadotrophin in male hypogonadotrophic eunuchoidism and infantilism

Two adult men with severe hypogonadotrophic hypogonadism (persisting infantilism) were observed during long-term treatment with chorionic gonadotrophin (HCG) (23 and 6 months respectively) followed by treatment with human menopausal gonadotrophin (HMG) (for 7 and 12 months) and finally by combined treatment with HMG plus HCG (for 12 and 9 months). A study of hormone excretion, testicular biopsies and the clinical course showed that HMG given alone had little effect. Development of the testicular tubules was dependent upon the addition of HCG to the HMG, and the combined treatment induced a complete gonadal maturation. This LH action is presumably a direct effect on the tubules rather than indirect through Leydig cell stimulation. HMG acts synergistically with HCG in Leydig cell stimulation, and the results thus indicate a close interaction between FSH and LH on all testicular elements. No lasting effect of the long-term treatment was found. HMG has no antigenic properties in the human.