Infertility affects 8-12% of couples with male factors contributing to 50% and solely responsible in 20-30% of cases. Male infertility due to hypogonadotrophic hypogonadism (HH) (congenital or acquired) is amenable to treatment.
Since 2010, we have treated 21 men with a median age of 31 years. Causes of HH have included panhypopituitarism (n= 10) [empty sella (2), adenoma (n=3), craniopharyngioma (n=1), pituitary hypoplasia (n=3), CHARGE syndrome (n=1), cranial radiotherapy (n=1)], Kallmann syndrome (n=1), thalassaemia major (n=1) and idiopathic (n=8).
Urinary (Pregnyl®) or recombinant (Ovidrel®) human chorionic gonadotrophin (hCG) as an LH substitute was used based on established protocols. Commencing doses were 1500 IU or 62.5mcg s/cut twice weekly respectively and titrated to serum testosterone. Recombinant FSH was added after 6 months for persisting azoospermia. Wherever possible, our protocol for men previously treated with long-acting injectable testosterone was to move to transdermal testosterone for a minimum of 6 months before gonadotrophin therapy was initiated.
There was variability in time to first appearance of sperm (median 16 (range 4 – 29) months). In androgen treatment-naive men with acquired HH in adulthood, sperm was detected within 8 months for most (n=7) and for 3 men, hCG monotherapy was sufficient. For men with congenital causes of HH, time to first sperm detection was longer (median 19 (12 – 22) months). In our limited cohort, for intramuscular testosterone treated men time to spermatogenesis was a median of 17 (12-22) months and 21 (19 – 22) months for the men treated with transdermal testosterone. To date, 7/15 men actively seeking fertility have had children, with 6 requiring assisted reproduction.
Gonadotrophin therapy is an effective fertility treatment for men with HH. Clinicians should consider longer spermatogenesis times in androgen-treated men and those with congenital HH, together with female factors and high rates of assisted reproduction when counselling.