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Maintenance of Spermatogenesis in Hypogonadotropic Hypogonadal European Journal of Endocrinology (2002) 147 617–624 ISSN 0804-4643 CLINICAL STUDY Maintenance of spermatogenesis in hypogonadotropic hypogonadal men with human chorionic gonadotropin alone Marion Depenbusch, Sigrid von Eckardstein, Manuela Simoni and Eberhard Nieschlag Institute of Reproductive Medicine of the University, Domagkstr. 11, D-48149 Mu¨nster, Germany (Correspondence should be addressed to E Nieschlag; Email: [email protected]) Abstract Objective: It is generally accepted that both gonadotropins LH and FSH are necessary for initiation and maintenance of spermatogenesis. We investigated the relative importance of FSH for the maintenance of spermatogenesis in hypogonadotropic men. Subjects and methods: 13 patients with gonadotropin deficiency due to idiopathic hypogonadotropic hypogonadism (IHH), Kallmann syndrome or pituitary insufficiency were analyzed retrospectively. They had been treated with gonadotropin-releasing hormone (GnRH) ðn ¼ 1Þ or human chorionic gonadotropin/human menopausal gonadotropin (hCG/hMG) ðn ¼ 12Þ for induction of spermato- genesis. After successful induction of spermatogenesis they were treated with hCG alone for main- tenance of secondary sex characteristics and in order to check whether sperm production could be maintained by hCG alone. Serum LH, FSH and testosterone levels, semen parameters and testicular volume were determined every three to six months. Results: After spermatogenesis had been successfully induced by treatment with GnRH or hCG/hMG, hCG treatment alone continued for 3–24 months. After 12 months under hCG alone, sperm counts decreased gradually but remained present in all patients except one who became azoospermic. Testicular volume decreased only slightly and reached 87% of the volume achieved with hCG/ hMG. During treatment with hCG alone, FSH and LH levels were suppressed to below the detection limit of the assay. Conclusion: Once spermatogenesis is induced in patients with secondary hypogonadism by GnRH or hCG/hMG treatment, it can be maintained in most of the patients qualitatively by hCG alone, in the absence of FSH, for extended periods. However, the decreasing sperm counts indicate that FSH is essential for maintenance of quantitatively normal spermatogenesis. European Journal of Endocrinology 147 617–624 Introduction primates and humans might be species-specifically regulated. Earlier case reports showed that spermato- In male hypogonadotropic hypogonadism testosterone genesis can be maintained in idiopathic hypogonado- therapy is sufficient for maturation and maintenance tropic hypogonadism (IHH) patients with hCG alone of secondary sex characteristics. For stimulation of (11), and Vicari (1992) demonstrated that spermato- spermatogenesis administration of gonadotropins is genesis can even be induced with hCG alone in IHH necessary. If pulsatile gonadotropin-releasing hormone patients, but the addition of hMG improved the sperm (GnRH) is not indicated or desired, human chorionic output in some patients (12). Therefore FSH and LH/ gonadotropin (hCG) is used as the source of luteinizing testosterone in combination and alone seem to be suffi- hormone (LH) activity to stimulate testosterone cient to maintain spermatogenesis to a certain extent secretion by Leydig cells, whereas human menopausal (13). gonadotropin (hMG) is used as the source of follicle- Hypogonadotropic hypogonadism (HH) provides a stimulating hormone (FSH) (1). More recently, recom- pathological situation which allows the relative contri- binant gonadotropins have also been used clinically butions of LH and FSH for human spermatogenesis to (2–4). be studied, as these patients do not produce gonado- Several animal studies have investigated the relative tropins, and differential substitution of either hCG or contributions of both gonadotropins for induction and hMG is possible. In this study we demonstrate that maintenance of spermatogenesis (5–10). However, spermatogenesis in HH patients, once induced by maintenance of spermatogenesis in rats, non-human administration of GnRH or hCG/hMG, can in most of q 2002 Society of the European Journal of Endocrinology Online version via http://www.eje.org Downloaded from Bioscientifica.com at 10/01/2021 04:45:25PM via free access 618 M Depenbusch and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2002) 147 the patients be maintained qualitatively with hCG alone for extended periods. (mill/ml) (phase 4) hCG alone Subjects and methods at end of Subjects In an open uncontrolled retrospective trial we studied 13 of all patients with secondary hypogonadism who were treated with GnRH or hCG/hMG for induction of Sperm concentration spermatogenesis. The selection criterion for these 13 patients was, that after spermatogenesis had been successfully induced, they were treated with hCG instead of testosterone preparations for the main- (months) (phase 4) hCG/hMG or GnRH hCG alone tenance of secondary sex characteristics. Gonadotropin deficiency resulted from IHH ðn ¼ 3Þ; Kallmann syn- drome ðn ¼ 4Þ or pituitary insufficiency (pre-pubertal: n ¼ 2; post-pubertal: n ¼ 4). In most cases pituitary insufficiency was due to pituitary tumors (Table 1). Some patients had a history of treated unilateral or bilateral maldescended testes: all patients with IHH, Duration of treatment one patient with Kallmann syndrome and one with hCG/hMG or GnRH post-pubertal pituitary insufficiency. Clinical examin- ations had been performed at intervals of 3 to 6 months. Patients’ ages ranged from 19 to 38 years at the beginning of treatment, all were azoospermic and had serum LH and FSH levels below the normal range. NoNoNo 9 9 32 4 24 21.5 11 1.2 0.5 2.5 0.4 0.1 Treatment Patients with secondary hypogonadism can be effec- tively treated with pulsatile GnRH or hCG/hMG in order to induce spermatogenesis (14). In this study one patient received pulsatile GnRH (5 mg/120 min) and 12 patients received hCG/hMG therapy according to common clinical guidelines with 3 £ 150 IU hMG subcutaneously per week and individually adapted hCG doses ranging from 2 £ 500 to 2500 IU per week (1). After successful induction of spermatogenesis testosterone production was maintained with hCG instead of substituting testosterone. Treatment was continued as long as patients preferred hCG over testosterone substitution. For analysis of data we differentiated 4 different phases of treatment. (craniopharyngeoma surgery, radiation) (craniopharyngeoma surgery) (craniopharyngeoma surgery) Phase 1 – testosterone treatment Patients received either testosterone enanthate (Testoviron-Depot-250, Schering, Berlin, Germany) 250 mg/14–28 days intra- muscularly, or transdermal testosterone (Testoderm 15, (years) Ferring, Kiel, Germany) 15 mg/day applied on the scrotum. Age (at start of hCG treatment, phase 2) Phase 2 – hCG alone treatment (only in those Characteristics of the hypogonadotropic hypogonadal men included in the analysis. patients subsequently treated with hCG/hMG) Patients received 500–2500 IU hCG (Choragon 1500, Ferring; Primogonyl, Schering; Pregnesin 5000, Patient no.12345678 199 32 3710 2411 2412 Kallmann syndrome 2113 Kallmann syndrome 32 Kallmann syndrome Diagnosis 21 Kallmann syndrome IHH 27 IHH IHH 38 Pituitary 32 insufficiency pre-pubertal 33 Pituitary 29 insufficiency pre-pubertal Maldescended Pituitary testis insufficiency post-pubertal (adenoma) Pituitary insufficiency post-pubertal Pituitary insufficiency post-pubertal Pituitary insufficiency post-pubertal No No Yes No No No No 25 19 8 Yes 5 Yes 43 Yes 27 20 57 3 10 4 5 16 16 9 6 2.4 210 6 9.8 0.1 15 5.1 25 1.1 74.3 3 3.3 9.0 0.6 0 0.1 97.5 4.8 3.1 5.8 0.1 8.3 3.6 7.2 Table 1 Serono, Unterschleißheim, Germany; Predalon 500, www.eje.org Downloaded from Bioscientifica.com at 10/01/2021 04:45:25PM via free access EUROPEAN JOURNAL OF ENDOCRINOLOGY (2002) 147 FSH maintenance of spermatogenesis in hypogonadotropic men 619 Organon, Oberschleißheim, Germany), twice per week performed every three to six months. Blood samples subcutaneously. were drawn for hormone measurements as well as hematology and clinical chemistry (data not shown). Phase 3 – hCG/hMG treatment While continuing the same dosage of hCG, each patient simultaneously Hormone analysis LH and FSH were analyzed by received 150 IU hMG (Menogon, Ferring; Fertinorm immunofluorometric assays (Delfia, Wallac, Freiburg, HP 150, Serono; Gonal-F 150, Serono), three times Germany). The lower detection limits were 0.12 IU/l weekly subcutaneously. Pulsatile GnRH treatment: the for LH and 0.25 IU/l for FSH. The normal range is patient received 5 mg GnRH/120 min subcutaneously 2–10 IU/l for LH and 1–7 IU/l for FSH. Interassay using a Zyklomat pulse set (Lutrelef, Ferring). variance of all assays did not exceed 6.5% for LH and 4.5% for FSH. Serum testosterone was determined Phase 4 – hCG alone treatment Immediately after using a commercial fluoroimmunoassay (Delfia, successful induction of spermatogenesis with GnRH or Wallac). The lower detection limit was 0.5 nmol/l. hCG/hMG or achievement of pregnancy, patients The normal range for testosterone is above 12 nmol/l. continued to receive individual doses of hCG Interassay variance of all assays did not exceed 12.9%. (500–2500 IU twice weekly) subcutaneously, adjusted to trough serum testosterone levels to be maintained Semen analysis Semen parameters were analyzed in the normal range. according to WHO guidelines (15) and subjected to internal (16) and external (17) quality control. Methods Testicular volume Determination of testicular volume During the course of treatment, physical and
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