Changes in hormonal profile and seminal parameters with use of aromatase inhibitors in management of infertile men with low testosterone to estradiol ratios

Eligibility for the medical therapy among men with non-obstructive azoospermia-Findings from a multi-centric cross-sectional study

BACKGROUND

Existing literature does not provide accurate epidemiological data regarding the true prevalence of men with non-obstructive azoospermia (NOA) who would be eligible for hormonal optimization therapy, according to specific pre-treatment criteria.

OBJECTIVES

To investigate the characteristics of those men with NOA who would qualify for the medical therapy prior to any SR procedure in a large multi-centric cross-sectional study.

MATERIALS AND METHODS

Complete data from 1644 NOA patients seeking medical help for primary infertility at three tertiary referral centers from USA, Brazil, and Italy were analyzed. Baseline serum hormone levels were collected for all patients. NOA was confirmed after two consecutive semen analyses. Genetic tests, including karyotype analysis and Y microdeletions, were performed on all patients. Patients with secondary hypogonadism (total testosterone (T) levels less than 300 ng/dL and luteinizing hormone (LH) levels less than 8 mIU/mL) were earmarked as potential candidates for receiving clomiphene citrate (CC) and/or human chorionic gonadotropin (hCG). Patients with a T to 17β-estradiol (E2) ratio < 10 were classified as eligible for aromatase inhibitors (AIs) therapy (e.g., anastrazole). A third sub-cohort was created by combining the criteria of the first two sub-cohorts. Descriptive statistics was used to detail overall characteristics and differences between the different sub-cohorts.

RESULTS

Among the 1,644 men, 28% (n = 460) had T < 300 ng/dL and LH < 8 mIU/mL, thereby being potentially suitable for CC and/or hCG, while 37% (n = 607) had a T to E2 ratio < 10 thus potentially suitable for AIs. Lastly, 17.7% (n = 280) met the criteria for potential eligibility for both CC and/or hCG and AIs.

CONCLUSIONS

Findings from this multicentric cross-sectional study reveal that about 30% of men with NOA were eligible for hormonal treatment with CC and/or hCG while 37% were found to be potential candidates for AIs, and 17% for both therapies. Therefore, these findings show that a only a small subset of NOA patients can benefit from medical therapy prior to considering any SR procedures.

Recovery of spermatogenesis after androgenic anabolic steroids abuse in men. A systematic review of the literature

OBJECTIVE

This systematic review aims to evaluate the optimal treatment for male infertility resulting from Anabolic Androgenic Steroids (AAS) abuse.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies that compared different protocols for the recovery of spermatogenesis in patients after AAS use were included.

RESULTS

13 studies investigating different protocols to restore spermatogenesis in patients with AAS abuse met the inclusion criteria. The available agents that showed restoration of spermatogenesis include injectable gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors, but their use is still poorly described in the literature.

CONCLUSIONS

Clinicians need to be aware of the detrimental effects of AAS on spermatogenesis. AAS-associated infertility may be reversible, but sperm production may take over a year to normalize. Both conservative and aggressive treatment can boost spermatogenesis with positive results. Further understanding of male reproductive endocrinology and high-quality data on the field of restoration of spermatogenesis after AAS abuse are warranted.

Effect of oestrogen modulation on semen parameters in men with secondary hypogonadism: Systematic review and meta-analysis

BACKGROUND

Selective oestrogen receptor modulators and aromatase inhibitors stimulate endogenous gonadotrophins and testosterone in men with hypogonadism. There are no systematic reviews/meta-analyses assessing the effects of selective oestrogen receptor modulators/aromatase inhibitors on semen parameters in men with secondary hypogonadism.

OBJECTIVES

To assess the effect of monotherapy or a combination of selective oestrogen receptor modulators/aromatase inhibitors on sperm parameters and/or fertility in men with secondary hypogonadism.

MATERIALS AND METHODS

A systematic search was conducted in PubMed, MEDLINE, Cochrane Library and ClinicalTrials.gov. Study selection and data extraction were performed by two reviewers independently. Randomised controlled trials and non-randomised studies of interventions reporting effects of selective oestrogen receptor modulators and/or aromatase inhibitors on semen parameters or fertility in men with low testosterone with low/normal gonadotrophins were selected. The risk of bias was assessed using ROB-2 and ROBINS-I tools. The results of randomised controlled trials were summarised using vote counting while summarising effect estimates where available. Non-randomised studies of intervention meta-analysis were conducted using the random-effect model. The certainty of evidence was assessed using GRADE.

RESULTS

Five non-randomised studies of interventions (n = 105) of selective oestrogen receptor modulators showed an increase in sperm concentration (pooled mean difference 6.64 million/mL; 95% confidence interval 1.54, 11.74, I2  = 0%) and three non-randomised studies of interventions (n = 83) of selective oestrogen receptor modulators showed an increase in total motile sperm count (pooled mean difference 10.52; 95% confidence interval 1.46-19.59, I2  = 0%), with very low certainty of evidence. The mean body mass index of participants was >30 kg/m2 . Four randomised controlled trials (n = 591) comparing selective oestrogen receptor modulators to placebo showed a heterogeneous effect on sperm concentration. Three included men with overweight or obesity. The results were of very low certainty of evidence. Limited pregnancy or live birth data were available. No studies comparing aromatase inhibitors with placebo or testosterone were found.

DISCUSSION AND CONCLUSION

Current studies are of limited size and quality but suggest that selective oestrogen receptor modulators may improve semen parameters in those patients, particularly when associated with obesity.

[Medical treatments for male infertility]

BACKGROUND

Treatments to stimulate spermatogenesis and antioxidant food supplements are often offered to infertile patients either before sperm extraction surgery to improve results, or as part of medically assisted reproduction or spontaneous fertility to increase the likelihood of a live birth.

METHODS

A bibliographic search limited to English-language literature on men published before 5/2023 was carried out, including clinical trials, literature reviews and meta-analyses on spermatogenesis-stimulating molecules and antioxidant treatments.

RESULTS

Several medical treatments seem capable of improving male fertility: they act mainly by stimulating spermatogenesis through hormones, or by reducing the effects of oxidative stress. With regard to oligoasthenozoospermia, the literature shows that certain hormonal treatments stimulating spermatogenesis are useful. In the case of non-obstructive azoospermia, the value of treatment depends on the patient's FSH and testosterone levels. AOX supplementation appears to improve certain spermogram parameters and have an impact on pregnancy and live birth rates.

CONCLUSION

This review should help urologists gain a better understanding of the various medical treatments and enable them to define an appropriate therapeutic strategy, tailored to the patient and the couple, in order to obtain the best results.

Testosterone and luteinizing hormone predict semen parameter improvement in infertile men treated with anastrozole

OBJECTIVE

To identify patient factors associated with a clinically significant improvement in semen parameters among infertile men treated with the aromatase inhibitor anastrozole.

DESIGN

Multi-institutional retrospective cohort study.

SETTING

Two Tertiary Academic Medical Centers.

PATIENTS

A total of 90 infertile men treated at 2 tertiary academic medical centers who met inclusion criteria and obtained pretreatment and posttreatment semen analyses.

INTERVENTION

Prescription of anastrozole (median 3 mg/wk).

MAIN OUTCOME MEASURES

Upgrade in the World Health Organization sperm concentration category (WHO-SCC). Univariate logistic regression, multivariable logistic regression, and partitioning analyses were performed to identify statistically significant patient factors capable of predicting treatment response.

RESULTS

With anastrozole treatment, 46% (n = 41/90) of men responded favorably with a WHO-SCC upgrade, and 12% (n = 11/90) experienced a downgrade. Responders exhibited lower pretreatment levels of luteinizing hormone (LH, 4.7 vs. 8.3 IU/L) and follicle-stimulating hormone (4.7 vs. 6.7 IU/mL), higher pretreatment levels of testosterone (T, 356 vs. 265 ng/dL), and similar baseline level of estradiol (E2, 73% vs. 70% with detectible level). Baseline semen parameters differed, with anastrozole responders demonstrating higher baseline semen concentration (3.6 vs. 0.3 M/mL) and higher total motile sperm counts (3.7 vs. 0.1 M). Anastrozole therapy converted 29% (n = 26/90) of the cohort to normozoospermia and enabled intrauterine insemination access in 31% (n = 20/64) of previously ineligible patients. Interestingly, neither body mass index nor the baseline E2 level or E2-T ratio was associated with WHO-SCC upgrade. Multivariable logistic regression revealed the T-LH ratio (odds ratio: 1.02, 95% confidence interval: 1.00-1.03) and baseline nonazoospermia (odds ratio: 9.4, 95% confidence interval: 1.1-78.9) to be statistically significant predictors of WHO-SCC upgrade (area under receiver operating characteristic curve: 0.77). The final user-friendly partitioning model consisting of the T-LH ratio ≥100 and baseline non-azoospermia was 98% sensitive and 33% specific for WHO-SCC upgrades (area under the curve: 0.77).

CONCLUSION

Anastrozole therapy decreases serum E2 levels, increases serum gonadotropins, and clinically improves semen parameters in half of men with idiopathic infertility. Nonazoospermic infertile men with T-LH ratios ≥100 are likely to benefit from anastrozole treatment irrespective of baseline E2 level or E2-T ratio. Men with azoospermia rarely respond to anastrozole and should be counseled on alternative treatments.

Multidisciplinary Progress in Obesity Research

Obesity is a chronic disease that endangers human health. In recent years, the phenomenon of obesity has become more and more common, and it has become a global epidemic. Obesity is closely associated with many adverse metabolic changes and diseases, such as insulin resistance, type 2 diabetes mellitus, coronary heart disease, nervous system diseases and some malignant tumors, which have caused a huge burden on the country's medical finance. In most countries of the world, the incidence of cancer caused by obesity is increasing year on year. Diabetes associated with obesity can lead to secondary neuropathy. How to treat obesity and its secondary diseases has become an urgent problem for patients, doctors and society. This article will summarize the multidisciplinary research on obesity and its complications.

Novel androgen therapies including selective androgen receptor modulators

Male hypogonadism is associated with reduced quality of life and the development of co-morbidities including obesity, diabetes mellitus, and dyslipidaemia. The mainstay of treatment for male hypogonadism is testosterone replacement therapy (TRT). However, TRT has recognised side effects including impaired spermatogenesis and there are concerns regarding its use in men with concurrent cardiovascular disease. Thus, there has been an impetus to develop novel androgen therapies for treating male hypogonadism to mitigate the side effects of TRT. This review will discuss the benefits and adverse effects of TRT, and novel therapies including nasal testosterone, aromatase inhibitors, selective oestrogen receptor modulators, and selective androgen receptor modulators.

Obesity and reproduction

PURPOSE OF REVIEW

The objective of this review is to highlight the recent literature on how obesity affects reproductive capacity in men and women.

RECENT FINDINGS

The relationship between fertility and obesity is complex and involves the hypothalamic-pituitary-ovarian axis, neuroendocrine systems and adipose tissue. The exact pathophysiology of how obesity lowers fertility rates is unknown, but is likely multifactorial involving anovulation, insulin resistance and alterations in gonadotropins. In addition, there is controversy on whether oocyte quality or endometrial receptivity plays a larger role in obese infertile women. Data on effects of bariatric surgery and weight loss on obese infertile men and women are mixed.

SUMMARY

Obesity alters the hormonal profile, gonadotropin secretion, embryo development and in-vitro fertilization outcomes in both men and women.

Efficacy and safety of letrozole or anastrozole in the treatment of male infertility with low testosterone-estradiol ratio: a meta-analysis and systematic review

BACKGROUND

Aromatase inhibitors (AIs) have been used to treat male infertility for decades. However, due to the lack of large-scale randomized controlled studies and basic research, the efficacy and safety of AIs in the treatment of male infertility remain controversial. Therefore, it is necessary to conduct an evidence-based preliminary evaluation of the existing clinical trials of AIs in the treatment of male infertility.

METHOD

A comprehensive literature search were performed in PubMed, Embase, Cochrane, CNKI, VIP, CBM, and Wanfang databases through August 2021 for all studies. We conducted a systematic review with meta-analysis of the all available studies reporting sperm conventional parameters, gonadotropin and testosterone levels, and/or the pregnancy rate.

RESULTS

A total of 10 studies involving 666 patients were included. letrozole (LE) or anastrozole (AZ) administration increased significantly sperm concentration, total sperm count, and serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone (T) levels and testosterone to estradiol ratio (T/E2), but E2 levels were significantly reduced compared with baseline values. Compared with the control group, which included selective estrogen receptor modulators (SEMRs) or HCG, LE or AZ did not have any significant effect on sperm concentration, motility and morphology, except that AIs had less effect on sperm motility than the control group (WMD: -2.55; 95% CI:-4.11 to-1.00; P = 0.001).

CONCLUSION

AIs may be effective in the treatment of male infertility. For male infertile patients planning assisted reproduction, discontinuation of AIs for 2-7 days prior to sperm retrieval may increase the success rate of fertilization. Further studies with larger sample sizes are needed to validate these findings. This article is protected by copyright. All rights reserved.

Clinical application of aromatase inhibitors to treat male infertility

BACKGROUND

Infertility affects 15% of men and contributes to nearly half of all cases of infertility. Infertile men usually have impaired spermatogenesis, presenting as azoospermia or various degrees of asthenospermia and oligozoospermia. Spermatogenesis is a complex and coordinated process, which is under precise modulation by the hypothalamic-pituitary-gonadal (HPG) axis. An aberrant hormone profile, especially an imbalance between testosterone (T) and estradiol (E2), plays an essential role in male infertility. In the male, E2 is produced mainly from the conversion of T by the aromatase enzyme. Theoretically, reducing an abnormally elevated T:E2 ratio using aromatase inhibitors (AIs) could restore the balance between T and E2 and optimize the HPG axis to support spermatogenesis. For decades, AIs have been used to treat male infertility empirically. However, owing to the lack of large-scale randomized controlled studies and basic research, the treatment efficacy and safety of AIs in male infertility remain controversial. Therefore, there is a need to summarize the clinical trials and relevant basic research on the application of AIs in the treatment of male infertility.

OBJECTIVE AND RATIONALE

In this narrative review, we summarized the application of AIs in the treatment of male infertility, including the pharmacological mechanisms involved, clinical trials focused on patients with different types of infertility, factors affecting treatment efficacy and the side-effects.

SEARCH METHODS

A literature search was performed using MEDLINE/PubMed and EMBASE, focusing on publications in the past four decades concerning the use of AIs for treating male infertility. The search terms included AI, male infertility, letrozole, anastrozole, testolactone, azoospermia, oligozoospermia, aromatase polymorphisms, obesity and antiestrogens, in various combinations.

OUTCOMES

Clinical studies demonstrate that AIs, especially nonsteroidal letrozole and anastrozole, could significantly inhibit the production of E2 and its negative feedback on the HPG axis, resulting in increased T and FSH production as well as improved semen parameters in infertile men. Large-scale surveys suggest that obesity may result in symptoms of hypogonadism in both fertile and infertile males, such as decreased semen quality and attenuated sexual function, which can be improved by AIs treatment. Polymorphisms of the aromatase gene CYP19A1, including single nucleotide polymorphisms and tetranucleotide TTTA repeats polymorphism (TTTAn), also influence hormone profiles, semen quality and treatment efficacy of AIs in male hypogonadotropic hypogonadism and infertility. The side-effects of AIs in treating male infertility are various, but most are mild and well tolerated.

WIDER IMPLICATIONS

The application of AIs in treating male infertility has been off-label and empirical for decades. This narrative review has summarized the target patients, dose, treatment duration and side-effects of AIs. Polymorphisms of CYP19A1 that may affect AIs treatment efficacy were also summarized, but a full understanding of the mechanisms involved in AIs action requires further study.

Morphological and morphometric changes and epithelial apoptosis are induced in the rat epididymis by long-term letrozole treatment

The epididymis is an organ that plays a key role in sperm maturation. The aim of this study was to examine the association between the chronic treatment of mature male rats with letrozole and morphological evaluation and morphometric values of epididymis as well as changes in the number of apoptotic cells in epididymal epithelium. Adult rats were treated with letrozole for 6 months and the epididymis weight, morphology, morphometric values and the number of apoptotic cells in  the epithelium were examined. Long-term aromatase inhibition resulted in presence of intraepithelial clear vacuoles, hyperplasia of clear cells and a hyperplastic alteration in the epithelium known as a cribriform change. Moreover, changes in diameters of the epididymal duct and the epididymal lumen and changes in the epididymal epithelium height were observed. The number of apoptotic epithelial cells was increased in letrozole-treated group. It can be indicated that chronic treatment with letrozole can affect morphology, morphometric values and apoptosis in the epididymis of adult male rats. Observed changes are similar to that observed in the aging processes and may also be important for patients treated with aromatase inhibitors.

Male hypogonadism: therapeutic choices and pharmacological management

Male hypogonadism, defined as an inadequate testosterone production, recognizes a testicular (primary hypogonadism) or a hypothalamic-pituitary dysfunction (central hypogonadism), although combined forms can also occur. Moreover, it has been known that intensive exercise training might be a cause of functional hypogonadism. Many therapeutic choices are currently available, depending on the timing of hypogonadism onset and fertility issue. The aim of this review was to comprehensively supply therapeutic options and schemes currently available for male hypogonadism, including pharmacological management of primary and central forms. Evidence on testosterone formulations, human chorionic gonadotropin, selective estrogen receptor modulators and aromatase inhibitors will be provided.

A systematic review and meta-analysis of clinical trials implementing aromatase inhibitors to treat male infertility

Aromatase activity has commonly been associated with male infertility characterized by testicular dysfunction with low serum testosterone and/or testosterone to estradiol ratio. In this subset of patients, and particularly in those with hypogonadism, elevated levels of circulating estradiol may establish a negative feedback on the hypothalamic-pituitary-testicular axis by suppressing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) production and impaired spermatogenesis. Hormonal manipulation via different agents such as selective estrogen modulators or aromatase inhibitors to increase endogenous testosterone production and improve spermatogenesis in the setting of infertility is an off-label option for treatment. We carried out a systematic review and meta-analysis of the literature of the past 30 years in order to evaluate the benefits of the use of aromatase inhibitors in the medical management of infertile/hypoandrogenic males. Overall, eight original articles were included and critically evaluated. Either steroidal (Testolactone) or nonsteroidal (Anastrozole and Letrozole) aromatase inhibitors were found to statistically improve all the evaluated hormonal and seminal outcomes with a safe tolerability profile. While the evidence is promising, future prospective randomized placebo-controlled multicenter trials are necessary to better define the efficacy of these medications.

Efficacy of Non-Testosterone-Based Treatment in Hypogonadal Men: A Review

INTRODUCTION

Although testosterone replacement therapy is an effective treatment for hypogonadism, there are safety concerns regarding potential cardiovascular risks and fertility preservation.

OBJECTIVE

To assess the effect of selective estrogen receptor modulator (SERM), aromatase inhibitor, and human chorionic gonadotropin (hCG) on total testosterone (TT) levels and hypogonadism.

METHODS

We performed a systematic literature review from 1987 to 2019 via PubMed, Cochrane review, and Web of Science. Terms used were infertility, hypogonadism, alternative to testosterone therapy, selective estrogen receptor modulator, aromatase inhibitor, and human chorionic gonadotropin. Studies that reported an effect of TT and hypogonadism after treatment of each medication were selected. Hypogonadal symptoms were assessed by the Androgen Deficiency of The Aging Male (ADAM) questionnaire. Aggregated data were analyzed via Chi-squared analysis.

RESULTS

From literature, 25 studies were selected; of which, 12 evaluated efficacy of aromatase inhibitor, 8 evaluated SERMs, and 5 evaluated hCG effects. For SERMs, 512 patients with mean age 42.3 ± 1.94 years showed mean TT before treatment vs after treatment (167.9 ± 202.8 [ng/dl] vs 366.2 ± 32.3 [ng/dl], P < .0001 [180.5-216.1 95% confidence interval {CI}]). For aromatase inhibitor, 375 patients with mean age 54.1 ± 0.67 years showed mean TT before treatment vs after treatment (167.9 ± 202.8 [ng/dl] vs 366.2 ± 32.3 [ng/dl], P < .0001 [180.5-216.1 95% CI]). SERMs also showed ADAM before treatment vs after treatment (4.95 ± 0.28 vs 5.50 ± 0.19, P < .0001 [0.523-0.581 95% CI]). For hCG, 196 patients with mean age 41.7 ± 1.5 years showed mean TT before treatment vs after treatment (284.5 ± 13.6 [ng/dl] vs 565.6 ± 39.7 [ng/dl], P < .0001 [275.2-287.0 95% CI]). In addition, hCG also showed ADAM before treatment vs after treatment (28.1 ± 2.0 vs 30.9 ± 2.3, P < .0001 [2.313 95% CI]).

CONCLUSIONS

Non-testosterone therapies are efficacious in hypogonadal men. Our results show statistically significant improvement in TT and ADAM scores in all 3 medications after treatment. Future studies are warranted to elucidate the relationship between improved hypogonadism and erectile function in the setting of non-testosterone-based treatment. Raheem OA, Chen TT, Le TV, et al. Efficacy of Non-Testosterone-Based Treatment in Hypogonadal Men: A Review. Sex Med Rev 2021;9:381-392.

Efficacy of anastrozole in the treatment of hypogonadal, subfertile men with body mass index ≥25 kg/m2

Background

Anastrozole is a non-steroidal fourth generation aromatase inhibitor that stops the conversion of testosterone to estradiol and has been used as empiric medical therapy for the treatment of male infertility in men with an abnormal testosterone-to-estradiol ratio <10 in order to increase endogenous testosterone levels. This study sought to evaluate the efficacy of anastrozole in the treatment of hypogonadal, subfertile men with body mass index greater than 25 mg/kg² with respect to hormonal profile, semen parameters and overall fertility status.

Methods

Retrospective chart review was performed of hypogonadal, subfertile men with body mass index ≥25 kg/m² who were treated with anastrozole (1 mg daily). Hormonal measurements and semen analysis prior to and after treatment was analyzed in 30 men. Total motile count was calculated from semen analysis. Clinical pregnancy rates were recorded.

Results

Men treated with anastrozole had increases in follicle stimulating hormone (4.8 versus 7.6 IU/L, P<0.0001), luteinizing hormone (3.4 versus 5.4 IU/L, P<0.0001), testosterone (270.6 versus 412 ng/dL, P<0.0001) and testosterone-to-estradiol ratio (9 versus 26.5, P<0.0001) and decrease in estradiol level (32 versus 15.9 pg/mL, P<0.01) after 5 months of therapy. Increases in sperm concentration (7.8 versus 14.2 million/mL, P<0.001), total motile count (12.6 versus 17.7 million, P<0.01) and strict morphology (3.0% versus 3.5%, P<0.05) was appreciated. Clinical pregnancy rate for our cohort was 46.6% (14 of 30), with 71.4% (10 of 14) conceiving through in vitro fertilization, 14.2% (2 of 14) through intrauterine insemination and 14.2% (2 of 14) through natural intercourse.

Conclusions

Anastrozole improves hormonal profiles and semen parameters in hypogonadal, subfertile men with body mass index over 25 kg/m² and may aid in achieving pregnancy especially in conjunction with assisted reproductive techniques.

Effects of letrozole administration on growth and reproductive performance in Markhoz goat bucklings

This study evaluated the growth performance, testicular and semen characteristics, and hormonal profile of Markhoz (Iranian Angora) bucklings injected with letrozole (LTZ). Twenty-eight 4-4.5 month old bucks were randomly assigned into four groups and received either 0.25 mg/kg body weight (BW) LTZ subcutaneously (sc LTZ) or intramuscularly (im LTZ), and also sc (sc CONT) or im (im CONT) controls every week for 3 months. The study was performed at the beginning of the breeding season in Sanandaj Animal Husbandry Research Station (46.99 °E, 35.31 °N). The results showed that LTZ causes increased final body weight (25.78 ± 1.61 kg), higher average daily gain (104 ± 0.03 g/days), and decreased feed conversion ratio (7.81 ± 2.57) (P < 0.05). The pre-slaughter, hot, and cold carcass weights (27.56 ± 2.40, 11.45 ± 1.07 and 11.11 ± 1.05 kg, respectively) were (P < 0.05) heavier in LTZ groups while other carcass characteristics did not differ between groups. No differences occurred between the groups in biochemical parameters, except high-density lipoprotein levels (35.47 ± 2.43 mg/dL) which was higher in LTZ treatments (P < 0.05). LTZ-treated bucks had larger scrotal circumference (20.12 ± 5.75 cm), higher relative testicular weight (560.91 ± 78.59 mg/100 g BW) and volume (175.5 ± 29.71 cm³), greater diameter of seminiferous tubules (224.5 ± 5.21 μm), and number of Sertoli cells (8.39 ± 0.77) (P < 0.05). Semen volume (0.74 ± 0.16 mL), sperm concentration (2.64 ± 0.19 × 10^-9/mL), total sperm per ejaculate (1.95 ± 0.49 × 10^-9), and semen index (1248 ± 323) increased (P < 0.05) by LTZ treatments, while semen pH (6.77), motility (80.91%), progressive motility (76.75%), viability (83.35%), abnormality (13.70%), acrosome integrity (78.06%), and membrane integrity (80.05%) of sperm remained unaffected. Intratesticular and serum testosterone (T) levels (7.97 ± 0.89 ng/mg protein and 2.47 ± 0.59 ng/mL, respectively), serum luteinizing hormone (LH), growth hormone (GH) levels (1.71 ± 0.24 and 3.62 ± 0.33 ng/mL, respectively) of LTZ groups were elevated, whereas intratesticular and serum estradiol (E2) levels (84.14 ± 8.15 pg/mg protein and 32.33 ± 2.16 pg/mL, respectively) decreased (P < 0.05). No differences were recorded between the sc and im routes of LTZ administration in the measured parameters. To conclude, we have found that LTZ treatment improves growth and reproductive functions of goat bucklings associated with increased serum LH and GH, elevated T and reduced E2 levels in both serum and testis.

Non-testosterone management of male hypogonadism: an examination of the existing literature

Testosterone deficiency is defined as a total testosterone level <300 ng/dL confirmed on two early morning lab draws. Testosterone therapy has historically been offered to men with symptomatic testosterone deficiency in the form of injections, gels, or pellets. However, these treatments are invasive or have undesirable effects including the risk of drug transference. Additionally, testosterone therapy has been associated with increases in hematocrit and controversy remains regarding the risk of cardiovascular and thromboembolic events while on testosterone therapy. As such, much interest has recently been focused on alternative treatment options for testosterone deficiency in the form of orally-administered medications with more favorable side effect profiles. Lifestyle modifications and varicocelectomy have been shown to raise endogenous testosterone production. Similarly, SERMs and aromatase inhibitors (AIs) have been shown to raise testosterone levels safely and effectively. Human chorionic gonadotropin (hCG) remains the only FDA-approved non-testosterone treatment option for testosterone deficiency in men. However, this medication is expensive and requires patient-administered injections. Over the counter herbal supplements and designer steroids remain available though they are poorly studied and are associated with the potential for abuse as well as increased hepatic and cardiovascular risks. This review aims to discuss the existing treatment alternatives to traditional testosterone therapy, including efficacy, safety, and side effects of these options. The authors suggest that the SERM clomiphene citrate (CC) holds the greatest promise as a non-testosterone treatment option for testosterone deficiency.

Changes in seminal parameters and hormonal profile with use of aromatase inhibitor in management of aging broiler breeder roosters

An excessive amount of aromatase enzyme reduces reproductive performance in aging roosters. Testosterone metabolism by aromatase enzyme is one of the reasons for reduced testosterone and lower fertility of aging roosters. The purpose of this study was to determine the effects of Exemestane (EX), as a steroidal aromatase inhibitor, on the seminal parameters and reproductive hormones of aging roosters. A total of 20 roosters (45 wk of age) were housed in individual cages and received a standard basal diet and oral EX capsules for 60 D at the daily doses per rooster (mg/rooster) in the following experimental groups: 0 mg (CTRL), 0.25 mg (Ex-0.25), 0.5 mg (Ex-0.5), and 1.5 mg (Ex-1.5). Sperm samples were obtained on days 1, 20, 40, and 60 of experiment. Blood samples were taken on days 1 and 60. The results indicated that different EX dosages affected semen parameters (P < 0.05) other than semen volume, morphology, apoptosis, and acrosome integrity. Various semen characteristics were significant (P < 0.05) during different times of the experiment, with the exception of semen volume, total motility, membrane integrity, morphology, apoptosis, and acrosome integrity. Roosters that received 0.5 mg of EX had higher percentages of sperm concentration, total motility, progressive motility, membrane integrity, viability, and mitochondrial activity (P < 0.05). There were lower concentrations of malondialdehyde in the CTRL (0 mg) and Ex-0.25 groups (P < 0.05). Although there was no significant difference in hormones at day 0 of the experiment (P > 0.05), roosters in the Ex-0.5 had higher concentration of testosterone as well as lower of aromatase activity at day 60 (P < 0.05). It can be concluded that EX improved semen parameters and testosterone, which ultimately can increase fertility in the aging broiler breeder roosters.

Effect of letrozole on spermogram parameters and hormonal profile in infertile men: A clinical trial study

OBJECTIVE

There is no reliable treatment for men with idiopathic infertility, but the relationship between severe sperm production and the ratio of estrogen to testosterone levels has been shown. Aromatase is an enzyme that plays an important role in converting testosterone to estradiol and androstenedione to estrogen. Aromatase inhibitors can increase testosterone and androgen production without increasing the amount of estrogen in circulation. The aim of this study was to evaluate the effect of aromatase inhibitor letrozole on the male infertility.

METHOD

This pre- and post-quasi-experimental clinical trial was carried out on 41 men with an infertility diagnosis. The basic hormonal profile included FSH, LH, testosterone, and estradiol. The ratio of testosterone to serum estradiol was also calculated and recorded. The sperm analysis was performed before the treatment and the seminal parameters were evaluated and recorded. Patients were then treated with letrozole 2.5 mg daily for 4 months. At the end of 4th months, the hormonal profile was studied and seminal analysis performed and recorded.

RESULTS

The levels of FSH, LH, testosterone, and estradiol, and the ratio of testosterone to estradiol increased significantly after letrozole treatment. The sperm concentration, sperm motility, and sperm forward motion significantly increased after letrozole treatment. Sperm morphology only lightly altered.

CONCLUSION

The ratio of testosterone to estradiol levels in infertile men treated with aromatase inhibitor improved and caused changes in sperm parameters. Letrozole may be used to improve sperm parameters in infertile men with low serum testosterone to estradiol ratio.

Frontiers in hormone therapy for male infertility

For a significant number of couples worldwide, infertility is a harsh reality. As specialists in male infertility, much of our armamentarium lacks definitive, evidence-based therapies. For years, we have relied on manipulation of the male hormonal axis to treat those men who help carry the burden of infertility in their partnerships. Indeed, male factor infertility is the sole component of infertility in at least 20% of couples. Further compounding this dilemma is that 25% to 50% of males with infertility have no identifiable etiology and thus present a true management conundrum. This manuscript is an attempt to clarify what therapies exist for the treatment of male factor infertility. We have reviewed the relevant infertility literature honing, our focus on hormonal anomalies and their subsequent impact on fertility. Many of the therapies discussed have been utilized in practice for generations. Thus, this article attempts to provide the evidence-based literature to support the continued use of the current treatment paradigm. Furthermore, we recognize that any review beckons a discussion of what challenges and therapies await on the horizon. For instance, there has been significant interest in restoring spermatogenesis after testosterone replacement therapy (TRT). We explore the adverse long-term spermatogenic outcomes associated with TRT, which with the widespread use of TRT, will inevitably present a great challenge for male infertility specialists. Moreover, we discuss the role of varicocelectomy in the treatment of hypogonadism and infertility, review the association between growth hormone (GH) and male fertility and address the challenges presented by the rising prevalence of obesity.

Combination therapy with clomiphene citrate and anastrozole is a safe and effective alternative for hypoandrogenic subfertile men

OBJECTIVES

To assess the efficacy and safety of combination therapy with clomiphene citrate (CC) and anastrozole (AZ) for male hypoandrogenism.

PATIENTS AND METHODS

We identified patients treated with a combination of CC + AZ in the period 2014 to 2017. Data were gathered on patient characteristics and laboratory values at baseline. Total testosterone, bioavailable testosterone, oestradiol and testosterone:oestradiol ratio were measured before combination therapy (treatment with CC only) and at CC + AZ combination therapy follow-ups. Treatment side effects were recorded; prostatic-specific antigen and haematocrit levels were measured to assess safety after 6 months. As a secondary outcome, semen characteristics were compared at baseline and after at least 3 months of combination therapy when these data were available. Data were analysed using a paired t-test and Wilcoxon's signed-rank test.

RESULTS

A total of 51 men were included, with a mean age of 35.4 ± 7.4 years and a mean body mass index of 35.0 ± 8.0 kg/m² . After CC treatment, total testosterone, bioavailable testosterone, and oestradiol levels all significantly increased. AZ was added in all patients with hyperoestrogenaemia (oestradiol >50 pg/mL) or a testosterone:oestradiol ratio <10. CC + AZ therapy maintained therapeutic total testosterone and bioavailable testosterone levels while also normalizing oestradiol levels and testosterone:oestradiol ratio. Eleven patients experienced side effects: anxiety/irritability, n = 5; decreased libido, n = 4; elevated (>54%) haematocrit, n = 2.

CONCLUSION

Combination therapy with CC + AZ is an effective and safe alternative for patients with elevated oestradiol level or low testosterone:oestradiol ratio.

Integrated analysis miRNA and mRNA profiling in patients with severe oligozoospermia reveals miR-34c-3p downregulates PLCXD3 expression

Our previous research suggested that an integrated analysis of microRNA (miRNA) and messenger RNA (mRNA) expression is helpful to explore miRNA-mRNA interactions and to uncover the molecular mechanisms of male infertility. In this study, microarrays were used to compare the differences in the miRNA and mRNA expression profiles in the testicular tissues of severe oligozoospermia (SO) patients with obstructive azoospermia (OA) controls with normal spermatogenesis. Four miRNAs (miR-1246, miR-375, miR-410, and miR-758) and six mRNAs (SLC1A3, PRKAR2B, HYDIN, WDR65, PRDX1, and ADATMS5) were selected to validate the microarray data using quantitative real-time PCR. Using statistical calculations and bioinformatics predictions, we identified 33 differentially expressed miRNAs and 1,239 differentially expressed mRNAs, among which one potential miRNA-target gene pair, miR-34c-3p and PLCXD3 (Phosphatidylinositol-Specific Phospholipase C, X Domain Containing 3), was identified. Immunohistochemical analysis indicated that PLCXD3 was located within the germ cells of the mouse and human testis. Moreover, we found that miR-34c-3p was able to decrease PLCXD3 expression in mouse (GC-1 and TM4) and human (NCM460) cell lines, presumably indicating the possibility that miR-34c-3p acts as an intracellular mediator in germinal lineage differentiation. Notably, we reported the expression of the PLCXD3 protein in a man with normal spermatogenesis and the lack of the PLCXD3 protein in a man with SO. Therefore, the identified miRNA and mRNA may represent a potentially novel molecular regulatory network and therapeutic targets for the study or treatment of SO, which might provide a better understanding of the molecular basis of spermatogenesis dysfunction.

Outcomes of anastrozole in oligozoospermic hypoandrogenic subfertile men

OBJECTIVE

To determine whether the change in sperm parameters in subfertile hypoandrogenic men treated with anastrozole is correlated to the magnitude of increase in testosterone (T) to estrogen ratio in men responding to treatment.

DESIGN

Retrospective study.

SETTING

Male fertility clinic.

PATIENT(S)

The study group consisted of 86 subfertile hypoandrogenic men with low T/estradiol (E₂) ratio (n = 78) or a prior aversive reaction to clomiphene citrate (n = 8).

INTERVENTION(S)

All patients were treated with 1 mg anastrozole daily, administered orally.

MAIN OUTCOME MEASURE(S)

Hormone analysis and semen analysis before and after treatment were performed. Hormone analysis included measurements of total T, E₂, sex-hormone binding globulin, albumin, FSH, and LH, and bioavailable T was calculated. Total motile sperm count was calculated from the semen analysis.

RESULT(S)

In all, 95.3% of patients had an increased serum T and decreased serum E₂ after treatment with anastrozole. Sperm concentration and total motile counts improved in 18 of 21 subfertile hypoandrogenic oligozoospermic men treated with anastrozole. In these men the magnitude of total motile count increase was significantly correlated with the change in the T/E₂ ratio. No improvement was seen in semen parameters of men with azoospermia, cryptozoospermia, or normozoospermia at presentation.

CONCLUSION(S)

Approximately 95% of men with hypoandrogenism responded with improved endocrine parameters, and a subset of oligozoospermic men (approximately 25% of all patients) displayed significantly improved sperm parameters. In that subset, increase in sperm parameters was correlated with the change in the T/E₂ ratio, which argues for a physiologic effect of treatment.

Hormone-Based Treatments in Subfertile Males

Subfertility is defined as the condition of being less than normally fertile though still capable of effecting fertilization. When these subfertile couples seek assistance for conception, a thorough evaluation of male endocrine function is often overlooked. Spermatogenesis is a complex process where even subtle alterations in this process can lead to subfertility or infertility. Male endocrine abnormalities may suggest a specific diagnosis contributing to subfertility; however, in many patients, the underlying etiology is still unknown. Optimizing underlying endocrine abnormalities may improve spermatogenesis and fertility. This manuscript reviews reproductive endocrine abnormalities and hormone-based treatments.

The Role of Estrogen Modulators in Male Hypogonadism and Infertility

Estradiol, normally considered a female hormone, appears to play a significant role in men in a variety of physiologic functions, such as bone metabolism, cardiovascular health, and testicular function. As such, estradiol has been targeted by male reproductive and sexual medicine specialists to help treat conditions such as infertility and hypogonadism. The compounds that modulate estradiol levels in these clinical conditions are referred to as selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs). In a certain subset of infertile men, particularly those with hypogonadism, or those who have a low serum testosterone to estradiol ratio, there is some evidence suggesting that SERMs and AIs can reverse the low serum testosterone levels or the testosterone to estradiol imbalance and occasionally improve any associated infertile or subfertile state. This review focuses on the role these SERMs and AIs play in the aforementioned reproductive conditions.

Current medical management of endocrine-related male infertility

Male factor contributes to 50%-60% of overall infertility but is solely responsible in only 20% of couples. Although most male factor infertility is ascertained from an abnormal semen analysis, other male factors can be contributory especially if the sample returns normal. Male infertility can be due to identifiable hormonal or anatomical etiologies that may be reversible or irreversible. This manuscript will highlight existing guidelines and our recommendations for hormone evaluation for male infertility and empiric therapies including multivitamins, estrogen receptor modulators (clomiphene), estrogen conversion blockers (anastrozole), and hormone replacement.

Hyperestrogenism and low serum testosterone-17β-estradiol ratio are associated with non-bacterial male accessory gland inflammation

This study evaluated the serum concentrations of the main sex hormones in selected patients with non-bacterial male accessory gland infection (MAGI). The results suggest that the mean serum concentrations of 17β-estradiol (method : chemiluminescence) in these patients are significantly higher compared to the controls (55.0 ± 15.0 vs. 26.5 ± 12.0 pg/mL; P <0.05) and the percentage of patients with MAGI and associated hyperestrogenism (according to the laboratory range used in this study) was significantly higher (25.00% vs. 3.00%; P <0.05). Moreover, the percentage of patients with non-bacterial MAGI and associated testosterone deficiency (serum total testosterone <2.49 ng/mL) was significantly higher (18.00% vs. 2.00%; P <0.05). Finally, patients with non-bacterial MAGI showed a significantly lower total testosterone-17β-estradiol ratio compared to the controls (72.7 vs. 173.0; P <0.05). The results of this study, with some limitations (in particular the method applied for the determination of serum concentrations of 17β-estradiol) represent in our opinion, a topic worthy of further investigation for a correct endocrinological characterization of these patients, useful for clinical practice.

Medical treatment of male infertility

The majority of male infertility is idiopathic. However, there are multiple known causes of male infertility, and some of these causes can be treated medically with high success rates. In cases of idiopathic or genetic causes of male infertility, medical management is typically empirical; in most instances medical therapy represents off-label use that is not specifically approved by the FDA. Understanding the hypothalamic-pituitary-gonadal (HPG) axis and the effect of estrogen excess is critical for the assessment and treatment of male infertility. The use of certain medical treatment has been associated with an increase in sperm production or motility, and primarily focuses on optimizing testosterone (T) production from the Leydig cells, increasing follicle-stimulating hormone (FSH) levels to stimulate Sertoli cells and spermatogenesis, and normalizing the T to estrogen ratio.

Empirical Drug Therapy for Idiopathic Male Infertility: What is the New Evidence?

Idiopathic male infertility is empirically managed using a number of drugs. We reviewed 64 articles published in the last 10 years on such drug therapy. There was severe heterogeneity in data along with poor definition of outcome parameters. Pregnancy or live birth rate was not reported in many studies. Antiestrogens appear to improve pregnancy rates while there is some data supporting the use of aromatase inhibitors. Antioxidants significantly increase the rate of both live birth and pregnancy but the data are limited. However, valid end-points based on data are limited for the empirical use of drugs in idiopathic male infertility.

Metabolic study of androsta-1,4,6-triene-3,17-dione in horses using liquid chromatography/high resolution mass spectrometry

Androsta-1,4,6-triene-3,17-dione (ATD) is an irreversible steroidal aromatase inhibitor and is marketed as a supplement. It has been reported to effectively reduce estrogen biosynthesis and significantly increase the levels of endogenous steroids such as dihydrotestosterone and testosterone in human. ATD abuses have been reported in human sports. Its metabolism in human has been studied, and the in vitro metabolic study of ATD in horses has been reported, however, little is known about its biotransformation and elimination in horses. This paper describes the in vitro and in vivo metabolism studies of ATD in horses, with an objective of identifying the target metabolites with the longest detection time for controlling ATD abuse. In vitro metabolism studies of ATD were performed using homogenized horse liver. ATD was found to be extensively metabolized, and its metabolites could not be easily characterized by gas chromatography/mass spectrometry (GC/MS) due to insufficient sensitivity. Liquid chromatography/high resolution mass spectrometry (LC/HRMS) was therefore employed for the identification of in vitro metabolites. The major biotransformations observed were combinations of reduction of the olefin groups and/or the keto group at either C3 or C17 position. In addition, mono-hydroxylation in the D-ring was observed along with reduction of the olefin groups and/or the keto group at C17 position. Fourteen in vitro metabolites, including two epimers of androsta-1,4,6-trien-17-ol-3-one (M1a, M1b), androsta-4,6-diene-3,17-dione (M2), boldione (M3), androsta-4,6-diene-17β-ol-3-one (M4), androsta-4,6-diene-3-ol-17-one (M5), boldenone and epi-boldenone (M6a, M6b), four stereoisomers of hydroxylated androsta-1,4,6-trien-17-ol-3-one (M7a to M7d), and two epimers of androsta-1,4-diene-16α,17-diol (M8a, M8b), were identified. The identities of all metabolites, except M1a, M5, M7a to M7d, were confirmed by matching with authentic reference standards using LC/HRMS. For the in vivo metabolism studies, two thoroughbred geldings were each administered with 800 mg of ATD by stomach tubing. ATD, and twelve out of the fourteen in vitro metabolites, including M1a, M1b, M2, M4, M5, M6, M7a to M7d, M8a and M8b, were detected in post-administration urine. Two additional urinary metabolites, namely stereoisomers of hydroxylated androsta-4,6-dien-17-ol-3-one (M9a, M9b), were tentatively identified by mass spectral interpretation. Elevated level of testosterone was also observed. In post-administration blood samples, only the parent drug, M1b and M2 were identified. This study showed that the detection of ATD administration would be best achieved by either monitoring the metabolites M1b (androsta-1,4,6-trien-17β-ol-3-one) or M4 (both excreted as sulfate conjugates) in urine, which could be detected for up to a maximum of 77 h post-administration. The analyte of choice for plasma is M1b, which could be detected for up to 28 h post administration.

Multivariate analysis to predict letrozole efficacy in improving sperm count of non-obstructive azoospermic and cryptozoospermic patients: a pilot study

We tested the hypothesis that letrozole increases sperm count in non-obstructive azoospermic or cryptozoospermic patients with a testosterone (T)/17-beta-2-oestradiol (E2) ratio <10. Forty-six patients with no chromosomal aberrations were randomized into two groups: 22 received letrozole 2.5 mg per day for 6 months (Group 1: 6 azoospermic + 16 cryptozoospermic patients), while 24 received a placebo (Group 2: 5 azoospermic + 19 cryptozoospermic patients). The following data were collected: two semen analyses, clinical history, scrotal Duplex scans, body mass index (BMI), Y microdeletion, karyotype and cystic fibrosis screens and follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, T and prolactin levels. Both before and after letrozole or placebo administration, the patients underwent two semen analyses and hormonal assessments. The differences were evaluated using the Mann-Whitney U test. The relationships between sperm concentration after letrozole administration with respect to FSH, T/E2 ratio, bilateral testicle volume and BMI before letrozole administration were assessed using multivariate analysis. The side effects were assessed using the chi-square test. Group 1 had sperm concentration (medians: 400-1.290 × 10(6) ml(-1); P<0.01) and motility (medians: class A from 2% to 15%; P<0.01), FSH, LH and T significantly increased, while Group 2 did not. E2 levels diminished significantly in Group 1, but not in Group 2. Eight patients in Group 1 demonstrated side effects, whereas no patient side effects were observed in Group 2. The sperm concentration after letrozole administration is inversely related to T/E2, FSH and BMI; a direct relationship emerged between sperm concentration and testicular volume.

Coadministration of anastrozole sustains therapeutic testosterone levels in hypogonadal men undergoing testosterone pellet insertion

INTRODUCTION

Current U.S. Food and Drug Administration-approved therapies for hypogonadism involve testosterone (T) replacement. Testosterone pellets (TP) require a minor office procedure every 3 to 4 months. The need for repeated insertions increases the likelihood of a complication. Anastrozole (AZ) is an aromatase inhibitor that has been used off-label for the treatment of male hypogonadism. AZ increases T levels by lowering serum estradiol (E2) levels and increasing gonadotropin (GTP) levels.

AIM

We hypothesized that the concomitant use of AZ with TP insertions would sustain therapeutic T levels and increase the interval between TP insertions.

METHODS

Men treated with TP for hypogonadism at an academic center were offered AZ (1 mg/day) at the time of TP reinsertion as a way of potentially decreasing the frequency of TP insertions. Total T (TT), free T (FT), sex hormone binding globulin, E2, luteinizing hormone (LH), and follicle-stimulating hormone FSH levels were obtained prior to T replacement and at 6 and 15 weeks from TP insertion. Men were re-implanted at 16 weeks if their TT levels were less than 350 ng/dL and their symptoms recurred. We retrospectively reviewed our records of men who underwent TP, TP, and AZ from 2011 to 2012. Demographics, TT, FT, LH, FSH, and E2 levels were recorded. Data were analyzed with anova and a Tukey's test.

MAIN OUTCOME MEASURE

TT level at 6, 15, or >15 weeks from TP insertion.

RESULTS

Thirty-eight men with 65 insertions were analyzed. The TP AZ group had significantly higher TT and FT levels than the TP group at >120 days (P < 0.05). The TP group had significantly higher E2 levels at all time points (P < 0.01). GTP levels remained stable in the TP AZ group. Average time to reinsertion in TP AZ was 198 days vs. 128 days in the TP group.

CONCLUSION

Men on TP AZ maintain therapeutic T levels longer than men on TP alone and have significantly less GTP suppression.

Aromatase inhibitors in male sex

Aromatase inhibitors (AI) have been used in males in idiopathic short stature, constitutional delay of puberty, precocious puberty, gynecomastia, oligospermia, hypogonadism related to obesity and ageing. This retrospective study echoed the benefit of AI in Indian males in varied conditions.

Aromatase inhibitors for male infertility

Some men with severely defective sperm production commonly have excess aromatase activity, reflected by low serum testosterone and relatively elevated estradiol levels. Aromatase inhibitors can increase endogenous testosterone production and serum testosterone levels. Treatment of infertile males with the aromatase inhibitors testolactone, anastrazole, and letrozole has been associated with increased sperm production and return of sperm to the ejaculate in men with non-obstructive azoospermia. Use of the aromatase inhibitors anastrazole (1 mg/day) and letrozole (2.5 mg/day) represent off-label use of these agents for impaired spermatogenesis in men with excess aromatase activity (abnormal testosterone/estradiol [T/E] ratios). Side effects have rarely been reported. Randomized controlled trials are needed to define the magnitude of benefit of aromatase inhibitor treatment for infertile men.