Endocrine and exocrine profiles of men with testicular tumors before orchiectomy

Male infertility and urological tumors: Pathogenesis and therapeutical implications

Most genitourinary tract cancers have a negative impact on male fertility. Although testicular cancers have the worst impact, other tumors such as prostate, bladder, and penis are diagnosed early and treated in relatively younger patients in which couple fertility can be an important concern. The purpose of this review is to highlight both the pathogenetic mechanisms of damage to male fertility in the context of the main urological cancers and the methods of preserving male fertility in an oncological setting, in light of the most recent scientific evidence. A systematic review of available literature was carried out on the main scientific search engines, such as PubMed, Clinicaltrials.Gov, and Google scholar. Three hundred twenty-five relevant articles on this subject were identified, 98 of which were selected being the most relevant to the purpose of this review. There is a strong evidence in literature that all of the genitourinary oncological therapies have a deep negative impact on male fertility: orchiectomy, partial orchiectomy, retroperitoneal lymphadenectomy (RPLND), radical cystectomy, prostatectomy, penectomy, as well as radiotherapy, chemotherapy, and hormonal androgen suppression. Preservation of fertility is possible and includes cryopreservation, hormonal manipulation with GnRH analogs before chemotherapy, androgen replacement. Germ cell auto transplantation is an intriguing strategy with future perspectives. Careful evaluation of male fertility must be a key point before treating genitourinary tumors, taking into account patients' age and couples' perspectives. Informed consent should provide adequate information to the patient about the current state of his fertility and about the balance between risks and benefits in oncological terms. Standard approaches to genitourinary tumors should include a multidisciplinary team with urologists, oncologists, radiotherapists, psycho-sexologists, andrologists, gynecologists, and reproductive endocrinologists.

Onco-TESE (Testicular Sperm Extraction): Insights from a Tertiary Center and Comprehensive Literature Analysis

Background and Objectives: The peak of incidence of testicular cancer (TC) occurs among individuals in their reproductive age, emphasizing the importance of fertility preservation as an integral aspect of disease management. Sperm cryopreservation performed before orchiectomy is ineffective in azoospermic men, necessitating alternative approaches such as microdissection testicular sperm extraction (mTESE) at the time of orchiectomy (onco-mTESE) to obtain viable sperm. This study presents the findings from our institution's experience with onco-mTESE and critically discusses our results in light of the existing body of literature. Materials and Methods: This is a tertiary center retrospective analysis of onco-mTESE procedures performed at a single center between December 2011 and July 2022. The included patients were post-puberal men with testicular tumors requiring orchiectomy, along with concomitant severe oligozoospermia or azoospermia. Bilateral mTESE was performed in all cases. Surgical outcomes, sperm retrieval rates, the usage of preserved viable sperm, assistive reproductive techniques' results, and post-operative serum testosterone were recorded. Results: A total of nine patients were included, with a median age of 34 (IQR 29-36) years. All patients had germ cell tumors (GCTs), with seminomatous and non-seminomatous GCTs accounting for 44.4% (n = 4) and 55.6% (n = 5) of patients, respectively. Sperm retrieval occurred in three (33%) patients: one patient in the ipsilateral testis, one in the contralateral testis, and one in both testes. No complications were reported during the procedure, and no post-operative hypogonadism was observed. Among the three patients with successful sperm retrieval, an intracytoplasmic sperm injection (ICSI) was performed in two patients, resulting in two pregnancies, leading to one healthy live birth and one miscarriage. Conclusions: In the context of TC, it is essential to conduct a thorough evaluation of testicular function, including a semen analysis and cryopreservation. Onco-mTESE has proven its safety in preserving fertility in azoospermic cases while ensuring the efficacy of oncological treatment.

Testicular Tissue Banking for Fertility Preservation in Young Boys: Which Patients Should Be Included?

Due to the growing number of young patients at risk of germ cell loss, there is a need to preserve spermatogonial stem cells for patients who are not able to bank spermatozoa. Worldwide, more and more clinics are implementing testicular tissue (TT) banking programs, making it a novel, yet indispensable, discipline in the field of fertility preservation. Previously, TT cryopreservation was predominantly offered to young cancer patients before starting gonadotoxic chemo- or radiotherapy. Nowadays, most centers also bank TT from patients with non-malignant conditions who need gonadotoxic conditioning therapy prior to hematopoietic stem cell (HSCT) or bone marrow transplantation (BMT). Additionally, some centers include patients who suffer from genetic or developmental disorders associated with prepubertal germ cell loss or patients who already had a previous round of chemo- or radiotherapy. It is important to note that the surgical removal of TT is an invasive procedure. Moreover, TT cryopreservation is still considered experimental as restoration methods are not yet clinically available. For this reason, TT banking should preferably only be offered to patients who are at significant risk of becoming infertile. In our view, TT cryopreservation is recommended for young cancer patients in need of high-risk chemo- and/or radiotherapy, regardless of previous low-risk treatment. Likewise, TT banking is advised for patients with non-malignant disorders such as sickle cell disease, beta-thalassemia, and bone marrow failure, who need high-risk conditioning therapy before HSCT/BMT. TT retrieval during orchidopexy is also proposed for patients with bilateral cryptorchidism. Since patients with a medium- to low-risk treatment generally maintain their fertility, TT banking is not advised for this group. Also for Klinefelter patients, TT banking is not recommended as it does not give better outcomes than a testicular sperm extraction later in life.

Hypogonadism and cancer survivorship

PURPOSE OF REVIEW

Hypogonadism is highly prevalent among not only patients with a history of prior treatment for cancer, but also among those patients with a new oncologic diagnosis who have not yet received any cancer therapy. Hypogonadism can cause a wide array of signs and symptoms including: deceased muscle mass; increased fat mass; decreased energy, mood, and overall sense of well being; diminished bone mineral density; infertility; and impaired libido and sexual function. This purpose of this manuscript is to review the mechanisms by which cancer and oncologic treatment regimens can adversely affect the hypothalamic pituitary gonadal axis, resulting in hypogonadism. Risks and benefits associated with the treatment of testosterone deficiency are also discussed, which are important considerations for clinicians caring for affected patients.

RECENT FINDINGS

Hypogonadism has a high prevalence in the setting of cancer and is an important survivorship issue. Recent randomized controlled trials confirm testosterone's therapeutic benefits in terms of sexual function, mood body composition, and bone health, but the specific benefits in terms of quality of life are less clear.

SUMMARY

More prospective studies are needed to further delineate the risks, benefits, and overall outcomes of testosterone replacement therapy in patients with cancer and cancer survivors.

Oncofertility in adult and pediatric populations: options and barriers

Cancer and its treatments can affect fertility in a variety of ways, and recent advances in cancer detection and treatment have led to an increasing number of cancer survivors for whom future fertility is a primary concern. Oncofertility is the study of interactions between cancer, anti-cancer therapy, fertility, and reproductive health. Fertility preservation aims to optimize fertility potential before initiation of gonadotoxic therapies. Sperm cryopreservation from an ejaculated sample is the gold standard for adults and post-pubertal adolescents, though added maneuvers such as medical therapy, penile vibratory stimulation, and electroejaculation can be employed when appropriate. When all these approaches fail, testicular sperm extraction can be used to obtain and cryopreserve testicular sperm from the azoospermic patient. Fertility preservation in the pre-pubertal pediatric patient is still experimental, but recent scientific breakthroughs with use of spermatogonial stem cells and testicular tissue transplantation offer great promise for the future. While there may be several practical, cultural, religious, and other barriers to fertility preservation, the establishment of a dedicated fertility preservation team can help to overcome these obstacles and optimize the utilization of fertility preservation in cancer patients of all ages.

Acute Myeloid Leukemia Affects Mouse Sperm Parameters, Spontaneous Acrosome Reaction, and Fertility Capacity

Leukemia is one of the most common cancers in patients of reproductive age. It is well known that chemotherapy, used as anti-cancer therapy, adversely affects male fertility. Moreover, the negative effect of leukemia on sperm quality, even before chemotherapy treatment, has been reported. However, the mechanisms behind this disease's effect on sperm quality remains unknown. In this study, we examine the direct effect of leukemia and chemotherapy alone and in combination on sperm parameters and male fertility. For this, we developed an acute myeloid leukemia (AML) mouse model (mice were treated with AML cells C1498 and developed leukemia); these mice then received cytarabine chemotherapy. Our findings reveal a significant reduction in sperm concentration and motility and a significant increase in abnormal morphology and spontaneous acrosome reaction of the sperm following AML and chemotherapy treatment, alone and in combination. We also found a reduction in male fertility and the number of delivered offspring. Our results support previous findings that AML impairs sperm parameters and show for the first time that AML increases spontaneous acrosome reaction and decreases male fertility capacity and number of offspring.

Serum Gonadotropin Levels in Patients with Germ-Cell Tumors of the Testis: Interrelations, Possible Cross-Reactions and Interpretation of Beta-Hcg Level

The concentration of FSH, LH, LTH, testosterone and beta-hCG was estimated in 177 serum samples from 86 patients with malignant germ-cell tumors of the testis. The objectives of the investigation were the following: the detection of interrelations of hypophyseal gonadotropins at different beta-hCG levels; the determination of the significance of borderline values of beta-hCG; the analysis of the effect of elevated concentrations of beta-hCG on pituitary gonadotropins: the detection of possible cross-reactions during gonadotropin determinations. The RIA method was used to estimate levels of three gonadotropins. The results revealed that there was no cross-reaction between FSH and beta-hCG at RIA assays. When the serum level of beta-hCG of tumor origin exceeded 100 U/l a subtotal inhibition of FSH secretion was observed. Pathologically increased values of beta-hCG were found not only in serum with subnormal FSH levels, but also when FSH levels were excessively elevated (exceeding 50 U/l). In the latter case the elevated beta-hCG levels could possibly be the consequence of the secretion of beta subunits by the hypophysis or a cross-reaction with LH, and not of a tumor. With values of beta-hCG over 100 U/l cross-reaction with LH occurs, so the true LH levels cannot be assessed. For an adequate interpretation of elevated values of beta-hCG in the serum (i.e. whether they are tumor-derived or not), it is necessary to have values of FSH from the same serum sample.

Fertility Preservation in Young Men Treated for Malignancies: Options for Precancer Treatment

INTRODUCTION

Fertility preservation (FP) is an essential component of treatment for young men with a new cancer diagnosis.

AIM

To discuss the barriers and recommendations for FP along with the impacts of cancer and cancer treatment on fertility, and to present the various options for FP in young men prior to cancer treatment.

METHODS

Literature Review.

MAIN OUTCOME MEASURE

To evaluate the options for FP in young men, including novel and experimental options for pre-pubertal boys.

RESULTS

With the advent of assisted reproductive technologies, fertility can be successfully preserved in the majority of post-pubertal patients with sperm cryopreservation, neurostimulatory methods of ejaculation, or surgical sperm retrieval procedures.

CONCLUSIONS

All men with a new diagnosis of cancer, including adolescents and children, should be offered FP prior to undergoing treatment. Sperm cryopreservation, the mainstay of FP, should be encouraged regardless of the treatment plan. Even without significant abnormalities on semen analysis, prompt referral to a male fertility specialist is recommended. Coward RM, Kovac JR, Smith RP, and Lipshultz LI. Fertility preservation in young mentreated for malignancies: Options for precancer treatment. Sex Med Rev 2013;1:123-134.

Male reproductive cancers and infertility: a mutual relationship

Reproductive dysfunction and malignancies related to the male gender represent a serious health concern, whose incidence has significantly risen over the past years. Prior to treatment, testicular or prostate cancer patients often display poor semen characteristics similar to subfertile or infertile patients. This fact is underscored by cases where the malignancy is often diagnosed in males who undergo a general fertility screening. This review aims to examine the associations between male infertility and reproductive cancers focusing on common etiologies and biological mechanisms underlining these pathologies. Furthermore, we discuss compelling epidemiological data hypothesizing that male reproductive failure may act as a precursor of future andrological malignancies, including testicular or prostate cancer, thus providing a stimulus for a more specific research in male reproductive health and emphasizing the importance of this relation for physicians taking care of male patients with a reproductive disease.

Focus issue on male infertility

Male infertility problems can occur when sperms are limited in number or function. In this paper, we describe the clinical evaluation of male infertility. A detailed history, physical examination, and basic semen analysis are required. In addition, ultrasound, karyotyping, and hormonal studies are needed to determine specific causes of infertility. In addition, the World Health Organization (WHO, 2009) has developed a manual to provide guidance in performing a comprehensive semen analysis. Among the possible reasons for male infertility, nonobstructive azoospermia is the least treatable, because few or no mature sperm may be produced. In many cases, men with nonobstructive azoospermia typically have small-volume testes and elevated FSH. Although treatment may not completely restore the quality of semen from men with subnormal fertility, in some cases a successful pregnancy can still be achieved through assisted reproductive technology.

Effects of anti-neoplastic treatment on sperm aneuploidy rate in patients with testicular tumor: a longitudinal study

OBJECTIVE

The adjuvant radio/chemotherapy, usually employed after orchidectomy in patients with testicular tumors, allows a long-term survival with a consequent increased request for fertility. However, little is known about the effects of the anti-neoplastic treatment on sperm cytogenetic asset. Therefore, this prospective, longitudinal study was designed to evaluate the effects of radio- and/or chemotherapy on sperm chromosome.

METHODS

Eleven patients with testicular tumor were enrolled and underwent sperm aneuploidy rate evaluation before and after 3, 6, 9, 12, 18, 24, and 36 months from radio- and/or chemo-therapy ending. A double and triple multicolor fluorescence in-situ hybridizations for chromosomes 8, 12, 18, X and Y were used to evaluate the sperm aneuploidy rate. To define normal sperm aneuploidy rate, 18 healthy, normozoospermic men were selected as controls.

RESULTS

Before treatment, testicular tumor patients had a higher total sperm aneuploidy rate compared with normal men. Total sperm aneuploidy rate showed a slight, but statistically significant increase 6 months after anti-neoplastic treatment. This increase was mainly related to the high sperm aneuploidy rate found in 2 patients which remained elevated up to 12 months in both of them.

CONCLUSION

These results showed that anti-neoplastic treatment caused only slight and transient sperm malsegregation events in patients with testicular tumor. However, since a subset of them had an elevated sperm aneuploidy rate for about 1 yr, we suggest to counsel them to refrain from fatherhood for this length of time.

Intratubular germ cell neoplasms of the testis and bilateral testicular tumors: clinical significance and management options

Objectives:

Intratubular germ cell neoplasia (ITGCN) is the precursor lesion for invasive testicular germ cell tumors (TGCTs) of adolescents and young adults. The rising incidence of these tumors has prompted a rigorous investigation of the etiology, diagnosis and management of ITGCN. Bilateral testicular cancer is closely linked with ITGCN, as patients with unilateral testicular cancer are at the highest risk for a future malignancy in the contralateral testicle.

Methods:

A literature review directed at ITGCN and bilateral testis cancer was performed using the Medline/PubMed database. Our review focused on the pathogenesis, risk factors, diagnosis and treatment regimens utilized.

Results:

Major advances have been made in the understanding of ITGCN over the past 30 years. There is evidence that TGCTs arise from ITGCN, ITGCN is closely related to fetal gonocytes, and that events in pre- and perinatal period may result in abnormal persistence of fetal gonocytes leading to ITGCN and subsequent TGCT. Controversy exists regarding the need to biopsy men at increased risk of TGCT, as well as the best approach to managing patients with known ITGCN. Bilateral testicular cancer has excellent outcomes in the current era of platinum-based chemotherapy.

Conclusion:

The optimal management of patients at risk for ITGCN and future TGCT is still a matter of debate. Individualization of management, including biopsy and treatment, should be based on risk factors for TGCT, compliance with potential surveillance, and patient preferences particularly with regard to fertility.

Anticancer chemotherapeutic agents and testicular dysfunction

The improvement of the survival rates of various cancer patients has resulted in increased focus on the long-term complications of treatment. Most anticancer chemotherapeutic agents are gonadotoxic, and sterility is therefore one of the most common complications for cancer survivors. The degree of gonadal dysfunction induced by anticancer chemotherapeutic agents seems to be drug specific and dose related. Following the development of new chemotherapeutic agents that have high benefit-to-risk ratios, sufficient sperm can be acquired by collection of ejaculated semen after the treatment in relatively many cases, and assisted reproductive techniques enable conceptions with even severe spermatogenesis dysfunction. However, anticancer chemotherapeutic agents have consistently exhibited the potential to induce permanent azoospermia. Cryopreservation of semen, which is currently the only proven successful option for future fertility preservation in male cancer patients, should certainly be recommended before cancer therapy. However, to date, no established effective methods have shown the capability to protect gonadal function from anticancer treatment in prepubertal cancer patients.

The genetic and phenotypic basis of infertility in men with pediatric urologic disorders

Male factor is a major component of infertility for many couples. The presence of congenital genitourinary anomalies in male partners can cause male infertility. We reviewed the state-of-the-art treatment and outcomes for male infertility caused by pediatric urologic disorders. Disorders were classified by whether they led to infertility through pre-testis, testicular, or post-testis effects. Despite the complexity of pediatric urologic disorders that can affect fertility, natural paternity and paternity through assisted reproductive technology are common. Given the significant recent advances in infertility treatments, paternity with many currently untreatable pediatric disorders is likely in the future.

Farnesoid X receptor, through the binding with steroidogenic factor 1-responsive element, inhibits aromatase expression in tumor Leydig cells

The farnesoid X receptor (FXR) is a member of the nuclear receptor superfamily that regulates bile acid homeostasis. It is expressed in the liver and the gastrointestinal tract, but also in several non-enterohepatic tissues including testis. Recently, FXR was identified as a negative modulator of the androgen-estrogen-converting aromatase enzyme in human breast cancer cells. In the present study we detected the expression of FXR in Leydig normal and tumor cell lines and in rat testes tissue. We found, in rat Leydig tumor cells, R2C, that FXR activation by the primary bile acid chenodeoxycholic acid (CDCA) or a synthetic agonist GW4064, through a SHP-independent mechanism, down-regulates aromatase expression in terms of mRNA, protein levels, and its enzymatic activity. Transient transfection experiments, using vector containing rat aromatase promoter PII, evidenced that CDCA reduces basal aromatase promoter activity. Mutagenesis studies, electrophoretic mobility shift, and chromatin immunoprecipitation analysis reveal that FXR is able to compete with steroidogenic factor 1 in binding to a common sequence present in the aromatase promoter region interfering negatively with its activity. Finally, the FXR-mediated anti-proliferative effects exerted by CDCA on tumor Leydig cells are at least in part due to an inhibition of estrogen-dependent cell growth. In conclusion our findings identify for the first time the activators of FXR as negative modulators of the aromatase enzyme in Leydig tumor cell lines.

The novel hormone INSL3 is expressed in human testicular Leydig cell tumors: a clinical and immunohistochemical study

Insulin-like 3 (INSL3) is a novel peptidic hormone member of the relaxin-insulin-like family of peptide factors. It is almost exclusively produced by Leydig cells within the testis and participates to the complex mechanisms leading to physiological testicular descent during embryonic development. We performed a retrospective study evaluating clinical and histopathological characteristics of 13 patients surgically treated for testicular tumor and diagnosed to be affected by Leydig cell tumor (LCT). Furthermore, it was possible to retrieve the archived paraffin embedded tumor together with neighboring healthy testicular tissue of all subjects affected by LCT (12 benign and 1 malignant form), that were analyzed for INSL-3 expression. Immunohistochemical analysis of the tumor sections of the 13 patients affected by LCT demonstrated constitutive expression of INSL3 protein in all LCT, irrespective of the histological pattern of each LCT and with no significant differences of staining intensity between all tumors. In particular, no gross differences were evident between the staining for INSL3 in the 12 benign LCTs and the only one showing malignant clinical behavior. The present study shows that LCTs, a very rare form of testicular tumor with no proven specific serum and histological markers, express a novel member of the relaxin-insulin-like family of peptide factors previously identified as a secretory product of Leydig cells and named INSL3. Thus, there could be the possibility to evaluate the expression and secretion of this novel hormone as a marker of this rare testicular tumor.

Insulin-like growth factor-I, regulating aromatase expression through steroidogenic factor 1, supports estrogen-dependent tumor Leydig cell proliferation

The aim of this study was to investigate the role of estrogens in Leydig cell tumor proliferation. We used R2C rat Leydig tumor cells and testicular samples from Fischer rats with a developed Leydig tumor. Both experimental models express high levels of aromatase and estrogen receptor alpha (ERalpha). Treatment with exogenous 17beta-estradiol (E(2)) induced proliferation of R2C cells and up-regulation of cell cycle regulators cyclin D1 and cyclin E, the expression of which was blocked by addition of antiestrogens. These observations led us to hypothesize an E(2)/ERalpha-dependent mechanism for Leydig cell tumor proliferation. In determining the molecular mechanism responsible for aromatase overexpression, we found that total and phosphorylated levels of transcription factors cyclic AMP-responsive element binding protein and steroidogenic factor 1 (SF-1) were higher in tumor samples. Moreover, we found that tumor Leydig cells produce high levels of insulin-like growth factor I (IGF-I), which increased aromatase mRNA, protein, and activity as a consequence of increased total and phosphorylated SF-1 levels. Specific inhibitors of IGF-I receptor, protein kinase C, and phosphatidylinositol 3-kinase determined a reduction in SF-1 expression and in IGF-I-dependent SF-1 recruitment to the aromatase PII promoter. The same inhibitors also inhibited aromatase expression and activity and, consequently, R2C cell proliferation. We can conclude that one of the molecular mechanisms determining Leydig cell tumorigenesis is an excessive estrogen production that stimulates a short autocrine loop determining cell proliferation. In addition, cell-produced IGF-I amplifies estrogen signaling through an SF-1-dependent up-regulation of aromatase expression. The identification of this molecular mechanism will be helpful in defining new therapeutic approaches for Leydig cell tumors.

Effect of cancer and cancer treatment on human reproduction

Cancer affecting children and individuals of reproductive age is associated with dilemmas concerning the ability to have a child and whether this child will be healthy. This is particularly true in light of the recent advances in the early detection of cancer and its effective treatment, which has improved survival rates. Both the cancer itself and its treatment have tremendous adverse effects on human reproduction and may result in the complete termination of reproductive ability both in men and women. Even in situations when conception is successfully achieved following cancer diagnosis and treatment, there are concerns regarding the potential increased risk of adverse obstetric and perinatal outcomes. This is especially true when pregnancy occurs shortly after cancer treatment. Moreover, there is a potential risk of chromosomal abnormalities and malformations in the offspring due to possible genetic defects in the germ cells induced by chemotherapy and radiotherapy. In addition, there is (at least theoretically) an increased risk of cancer developing in the offspring, particularly with hereditary cancer syndromes. A multidisciplinary team aware of the possible consequences of cancer treatment on reproduction is very much needed to provide optimal care for these patients after proper counseling regarding the potential adverse effects of cancer treatment on reproduction.

Infertility and testis cancer

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Does histopathologic tumor type or vascular invasion influence spermatogenesis in testicular cancer?

OBJECTIVE

To assess the quality and activity of spermatogenesis in the contralateral healthy testicle at the time of orchiectomy and to assess whether any tumor-related factor such as tumor type or vascular invasion is a risk factor for impaired spermatogenesis.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Seventy-six patients undergoing orchiectomy for seminoma or nonseminomatous germ cell tumor (NSGCT).

INTERVENTION(S)

Open biopsy of contralateral healthy testicle at the time of orchiectomy.

MAIN OUTCOME MEASURE(S)

Quality of spermatogenesis using median and highest Johnsen score in correlation with histopathologic tumor type, vascular invasion, and serum tumor markers and hormone levels.

RESULT(S)

Contralateral spermatogenesis is reduced in seminomas and in NSGCTs, with median Johnsen scores of 8.9 and 8.6, respectively. Similar results were seen in tumors with vascular invasion (median Johnsen score 8.8 [range 8.2-9.5]) and without vascular invasion (median Johnsen score 8.8 [range 8.1-9.2]). Areas with good-quality spermatogenesis were found in 88.9% of seminoma and 92.5% of NSGCT biopsies.

CONCLUSION(S)

Testicular cancer is associated with impaired spermatogenesis, but neither the histopathologic tumor type nor the presence of vascular invasion correlated with significantly reduced spermatogenesis.

Diagnostic approach to the infertile male patient

There are several objectives to be achieved during the diagnostic evaluation of a male partner of an infertile partnership. The first is to identify whether or not there is a male factor present and, if so, whether this is attributable to an underlying medical illness. The second is to identify the cause of reduced male fertility and whether or not it is amenable to therapeutic intervention.

Paternity following treatment for testicular cancer

BACKGROUND

Studies of fertility in men treated for testicular cancer have mainly addressed serum follicle-stimulating hormone levels and sperm parameters. We assessed post-treatment paternity among long-term survivors of testicular cancer.

METHODS

Men (n = 1814) who had been treated for unilateral testicular cancer in Norway during 1980 through 1994 were invited to participate in a national multi-center follow-up survey in 1998 through 2002. The participants were allocated to five groups according to the treatment received after orchiectomy, including treatment at relapse (surveillance, retroperitoneal lymph node dissection, radiotherapy, low-dose chemotherapy [i.e., < or = 850 mg cisplatin], and high-dose chemotherapy [i.e., > 850 mg cisplatin]). Cox proportional hazards analysis was used to assess predictive factors for post-treatment paternity. Statistical tests were two-sided.

RESULTS

A total of 1433 men were assessable, of whom 827 were fathers at diagnosis. Post-treatment conception was attempted by 554 men, among whom the overall 15-year actuarial post-treatment paternity rate was 71% (95% confidence interval [CI] = 66% to 75%) without the use of cryopreserved semen. This rate ranged from 48% (95% CI = 30% to 69%) in the high-dose chemotherapy group to 92% (95% CI = 78% to 98%) in the surveillance group (P < .001). The median actuarial time from diagnosis to the birth of the first child after treatment was 6.6 years overall but varied according to treatment. Assisted reproductive technologies were used by 22% of the couples who attempted conception after treatment. Dry ejaculation, treatment group, pretreatment fatherhood, and marital status were statistically significant independent predictors for post-treatment fatherhood, with dry ejaculation as the most important negative factor.

CONCLUSIONS

Although the overall paternity rate after treatment for testicular cancer was high, the ability to conceive and the time to conception reflected the intensity of treatment. These data may help inform patients about their future ability to father biological children.

Quality of life in survivors of testicular cancer

The objective of this review was to give an overview of findings concerning quality of life (QOL) in general as well as its domains in survivors of testicular cancer. QOL on the group level was equal to that of men of the same age in the general population. Treatment strategies hardly influenced the QOL. The anxiety level, but not depression, was higher among survivors, while sexual functioning hardly differed from the male population norm. Patients to be treated for testicular cancer should be told about the outlook for good QOL, and the low risk of mental and physical long-term effects.

Normal semen parameters in cancer patients presenting for cryopreservation before gonadotoxic therapy

Similar sperm qualities in men with and without cancer were found. Patient and physician awareness and early referral for sperm banking are essential in preserving fertility potential in men with malignancies.

Testicular Function in Patients with Testicular Cancer Treated with Bleomycin-Etoposide-Carboplatin (BEC90) Combination Chemotherapy

OBJECTIVE

To investigate the impact of bleomycin-etoposide-carboplatin combination chemotherapy on long-term fertility in patients with testicular germ cell tumors.

METHODS

Twenty-five patients with high risk stage I and IM non-seminomatous germ cell tumors (NSGCT, Group A) and 44 with advanced seminoma or NSGCT (Group B) were treated with bleomycin 30 mg (days 2, 9, 16), etoposide 165 mg/m(2) (days 1-3) and carboplatin 400mg/m(2) or AUC 5 (day 1) (BEC(90)). Treatment was repeated every 3 weeks. Group A patients received 2 cycles of BEC(90), while Group B ones received 4 to 5 cycles of BEC(90). Sperm count and hormonal analyses were examined pre- and post-chemotherapy. Counts were classified as normospermia (NS) if >20 x 10(6)ml(-1), oligospermia (OS) if 1-20 x 10(6)ml(-1) and azoospermia (AS) if <1 x 10(6)ml(-1).

RESULTS

Patients were followed for a median of 2.9 years post-chemotherapy. The post-orchidectomy median luteinizing hormone (LH) serum levels were slightly above the upper normal limit while the serum levels of follicle stimulating hormone (FSH) and testosterone (T) were within the reference interval. Thirty-eight (55%) patients had NS pre-chemotherapy. None of the 14 NS patients who received 2 cycles of BEC(90) had AS post-chemotherapy, while only 1 of the 24 NS patients who were treated with > or =4 cycles of BEC(90) had AS post-treatment. Among the NS patients, 93% and 83%, respectively, remained NS following chemotherapy. Overall, 90% of patients had recovery (61% NS, 29% OS) of spermatogenesis after treatment. The median FSH serum values were significantly elevated at least 1-year post-chemotherapy when compared with the pre-treatment levels. Eighteen months post-chemotherapy the median FSH values had returned to the reference limits. Serum LH and T levels were unaffected by treatment. The pre-treatment sperm count and the bulk of disease were significantly associated with recovery of spermatogenesis. No association was found between recovery of spermatogenesis and 2 or > or =4 cycles of chemotherapy, age > or =30 years and post-chemotherapy lymph node dissection. Thirteen patients (4 with OS) fathered 16 children. No congenital abnormalities occurred in any of these children.

CONCLUSION

The BEC(90) regimen has no major effect on fertility and Leydig cell function. However, carboplatin-based chemotherapy has been proved less effective than cisplatin-based chemotherapy and is not currently used in the treatment of testicular cancer.

Infertility despite surgery for cryptorchidism in childhood can be classified by patients with normal or elevated follicle-stimulating hormone and identified at orchidopexy

OBJECTIVE

To analyse infertility despite orchidopexy in childhood.

PATIENTS AND METHODS

The study comprised patients with cryptorchidism (70 bilateral and 65 unilateral) who had a simultaneous biopsy taken at orchidopexy in childhood, and in adulthood had analyses of semen and FSH. In adulthood 42 formerly bilateral cryptorchid boys had repeat testicular biopsies taken. Infertility was suspected in men with < 5 million sperm/mL in the best sample of semen and concomitant poor sperm motility, and who were classified by follicle-stimulating hormone (FSH) values. At orchidopexy the number of spermatogonia/tubule and the germ cell differentiation were measured. In adulthood the percentage of tubules with complete spermatogenesis, spermatogenic arrest and Sertoli-cell only status was assessed.

RESULTS

Infertility was suspected in 38 of 70 (54%) of formerly bilateral and six of 65 (9%) formerly unilateral cryptorchid patients. High FSH values were expected in these suspected infertile patients, but 15 of 38 (59%) formerly bilateral and five of six formerly unilateral cryptorchid patients had normal FSH values. These patients were identified in childhood at orchidopexy; those with bilateral cryptorchidism generally presented with germ cells, but the mean number of spermatogonia per tubule was < 30% of the lowest normal value, and the germ cells were seldom normally differentiated, whereas those with unilateral cryptorchidism generally lacked germ cells in the biopsies. No patients had a decreased FSH value.

CONCLUSION

Despite surgery for cryptorchidism, infertility was probable in a third (44 of 135) of the patients. We expected high FSH values in these patients, but in 45% (20/44) the FSH values were normal. These patients may have relative FSH deficiency. At orchidopexy these patients were identified to be bilaterally cryptorchid with few germ cells and those unilaterally cryptorchid had none in the biopsy. After orchidopexy in childhood, additional hormonal treatment, e.g. recombinant FSH or buserelin, may be indicated in these patients.

The impact of chemotherapy on male fertility: a survey of the biologic basis and clinical aspects

The introduction of cisplatin-based polychemotherapy has led to cure rates of up to 90% for the most frequent malignant diseases seen in young men. In view of these high cure rates, increasing clinical importance is now being attached to chemotherapy-induced fertility disorders. Comparative studies examining the impact of cytotoxic chemotherapy on gametogenesis demonstrate significant cytostatic- and dose-specific differences. The extensive literature on possible teratogenic effects of chemotherapy provides no evidence suggesting that offspring of patients with a history of chemotherapy have an increased risk of malformations. However, these studies, the scope and follow-up of which may still be inadequate, have failed to eliminate the fear of such risk. Hormonal protection from chemotherapy-induced testicular damage has thus far succeeded only in animal models pretreated by application of gonadotropin-releasing hormone agonists combined with nonsteroidal antiandrogens or testosterone plus 17 beta-estradiol. The same holds true for hormone therapy aimed at stimulating the recovery of spermatogenesis after chemotherapy-induced testicular damage. Cryopreservation of germ cells can be suggested to patients undergoing cytostatic therapy. In some cases, testicular extraction of spermatozoa can also be offered as a novel approach.

Spermatogenesis after unilateral orchiectomy for testicular cancer in patients following surveillance policy

PURPOSE

Only limited information is available on the natural course of spermatogenesis in patients with testicular cancer who underwent unilateral orchiectomy and surveillance. We analyze long-term exocrine function of the remaining testicle in patients following surveillance policy.

MATERIALS AND METHODS

Sperm counts and serum follicle-stimulating hormone (FSH) levels were available in 60 nonrelapsing cases approximately 3 weeks (baseline), 1 year and 2 years or greater after orchiectomy. Contralateral testicular cancer subsequently developed in 2 men.

RESULTS

At baseline 36 patients were normospermic (10 or greater x 106/ml.), 7 were azoospermic and 17 were oligospermic. After 1 year 45 patients were normospermic. Mean sperm concentrations increased significantly from 26 to 39 x 106/ml. during year 1 after orchiectomy. Elevated serum FSH at baseline was associated with incomplete recovery of spermatogenesis, although sperm counts improved in 3 of 7 patients. Furthermore, in the 2 initially oligospermic patients with subsequent contralateral testicle cancer transient normospermia was observed after 1 year. After orchiectomy fatherhood was recorded in 28 men and was assisted by fertilization using fresh semen in 2.

CONCLUSIONS

In nonrelapsing testicular cancer cases on surveillance, initially reduced spermatogenesis recovers during year 1 after orchiectomy especially if baseline serum FSH is normal. Transient recovery also occurs in patients in whom contralateral testicular cancer subsequently develops. In high risk patients and in initially oligospermic patients with plans for future fatherhood, the period of improved spermatogenesis may be used for multiple semen cryopreservations enabling subsequent assisted fertilization.

Effects of cancer and anti-neoplastic treatment on the human testicular function

Men with testicular neoplasia (TN) and Hodgkin's disease (HD) are those who more frequently require treatment for fertility because these malignancies affect patients during the reproductive age and because the early diagnosis and the improved anti-neoplastic treatments cure most of these patients. Although some of them can father a child spontaneously, assisted reproductive techniques allow fatherhood to patients with severe spermatogenesis impairment and this possibility has raised concern about the long-term consequence of the testicular damage induced by chemo- and/or radiotherapy. This paper reviews the effects of cancer per se and of anti-neoplastic treatments on gonadal function, sperm aneuploidy rate and sperm DNA integrity. A debate is still open as to whether TN or HD per se may impair spermatogenesis. Many studies have shown that this is the case, albeit others have challenged this view. Chemo- and/or radiotherapy affects negatively gonadal function, rendering almost all patients azoospermics. However, spontaneous pregnancies and a high degree of spermatogenesis recovery occur with time. A large body of literature on sperm chromosome complement suggests an increased rate of structural and numerical chromosome abnormalities in patients with cancer during anti-neoplastic treatment. A minority of them has, however, shown that this effect disappears with time. An interesting and relatively new aspect is the study of sperm DNA integrity in patients with TN and HD particularly following chemo- and/or radiotherapy. The scanty information available seems to suggest that these patients have a permanent or at least a long-lasting DNA fragmentation in their spermatozoa.

Risk of testicular cancer in men with abnormal semen characteristics: cohort study

OBJECTIVE

To explore the associations between semen characteristics and subsequent risk of testicular cancer.

DESIGN

Cohort study.

PARTICIPANTS

32 442 men who had a semen analysis done at the Sperm Analysis Laboratory in Copenhagen during 1963-95.

MAIN OUTCOME MEASURE

Standardised incidence ratios of testicular cancer compared with total population of Danish men.

RESULTS

Men in couples with fertility problems were more likely to develop testicular cancer than other men (89 cases, standardised incidence ratio 1.6; 95% confidence interval 1.3 to 1.9). The risk was relatively constant with increasing time between semen analysis and cancer diagnosis. Analysis according to specific semen characteristics showed that low semen concentration (standardised incidence ratio 2.3), poor motility of the spermatozoa (2.5), and high proportion of morphologically abnormal spermatozoa (3.0) were all associated with an increased risk of testicular cancer. The only other cancer group that showed increased incidence was "peritoneum and other digestive organs" (six cases; 3.7, 1.3 to 8.0). Of these, two cases were probably and two cases were possibly extragonadal germ cell tumours.

CONCLUSIONS

The results point towards the existence of common aetiological factors for low semen quality and testicular cancer. Low semen quality may also be associated with increased incidence of extragonadal germ cell tumours.

Comparative tolerability of chemotherapy regimens for germ cell cancer

Germ cell tumours, even at an advanced stage, represent a unique model of malignant curable disease since >80% of patients are expected to be cured after appropriate therapy: surgery and radiotherapy in early stages, and chemotherapy and surgery in advanced stages. In advanced stages, serum tumour marker levels as well as extrapulmonary (brain, liver and bone) visceral metastases are the most important prognostic factors that affect treatment modalities. 'Gold standard' regimens for germ cell cancer currently include etoposide plus cisplatin with (BEP) or without (EP) bleomycin. In patients with good risk disease (90% cure rate), the optimal regimen of chemotherapy should combine the best efficacy and the least toxicity. As a result of randomised trials, 3 regimens can be currently recommended: (i) 4 cycles of EP; (ii) 4 cycles of BEP (with etoposide 350 mg/m2 per cycle); or (iii) 3 cycles of BEP (with etoposide 500 mg/m2 per cycle). In patients with poor risk disease, 4 cycles of BEP (with etoposide 500 mg/m2 per cycle) allow a disappointing cure rate of 50%. The long term toxicity of these regimens (gonadal toxicity and secondary malignancies) appears to be negligible and clearly does not challenge current standard strategies.

Semen quality and reproductive hormones before orchiectomy in men with testicular cancer

PURPOSE

To obtain information about preorchiectomy gonadal function in patients with testicular germ cell cancer to improve the clinical management of fertility and other andrologic aspects in these men.

PATIENTS AND METHODS

In group 1, a group of 83 consecutive patients with testicular germ cell cancer (TGCC) investigated before orchiectomy, semen analysis was carried out in 63 patients and hormonal investigations, including measurement of follicle-stimulating hormone, luteinizing hormone (LH), testosterone, estradiol, sex hormone-binding globulin (SHBG), inhibin B, and human chorionic gonadotropin (hCG), in 71 patients. Hormone levels in patients with elevated hCG (n = 41) were analyzed separately. To discriminate between general cancer effects and specific effects associated with TGCC, the same analyses were carried out in a group of 45 consecutive male patients with malignant lymphoma (group 2). Group 3 comprised 141 men employed in a Danish company who served as controls in the comparison of semen parameters. As a control group in hormone investigations, 193 men were selected randomly from the Danish National Personal Register to make up group 4.

RESULTS

We found significantly lower sperm concentration (median, 15 x 10(6)/mL; range, 0 to 128 x 10(6)/mL) and total sperm count (median, 29 x 10(6)/mL; range, 0 to 589 x 10(6)) in patients with testicular cancer than in patients with malignant lymphomas (sperm concentration: median, 48 x 10(6)/mL; range, 0.04 to 250 x 10(6)/mL; sperm count: median, 146 x 10(6); range, 0.05 to 418 x 10(6)) (P < .001 and P < .001) and healthy men (sperm concentration: median, 48 x 10(6)/mL; range, 0 to 402 x 10(6)/mL; sperm count: median, 162 x 10(6); range, 0 to 1253 x 10(6)) (P < .001 and P < .001). FSH levels were increased in men with testicular cancer (median, 5.7 IU/L; range, 2.0 to 27 IU/L) compared with both men with malignant lymphomas (median, 3.3 IU/L; range, 1.01 to 12.0 IU/L) and healthy controls (median, 4.1 IU/L; range, 1.04 to 21 IU/L)(P = .001 and P = .007, respectively). Surprisingly, we found significantly lower LH in the group of men with TGCC (median, 3.6 IU/L; range, 1.12 to 11.9 IU/L) than in healthy men (median, 4.7 IU/L; range, 1.3 to 11.9 IU/L) (P = .01). We could not detect any differences between men with testicular cancer and men with malignant lymphomas and healthy men with regard to serum levels of testosterone, SHBG, and estradiol. Men with testicular cancer who had increased hCG levels had significantly lower LH and significantly higher testosterone and estradiol than those without detectable hCG levels.

CONCLUSION

Spermatogenesis is already impaired in men with testicular cancer before orchiectomy. Neither local suppression of spermatogenesis by tumor pressure nor a general cancer effect seems to fully explain this impairment. The most likely explanation is preexisting impairment of spermatogenesis in the contralateral testis in men with testicular cancer. The question of whether also a pre-existing Leydig cell dysfunction is present in men with testicular cancer could not be answered in this study because the tumor seems to have a direct effect on the Leydig cells. Men with testicular cancer had low LH values as compared with controls. We speculate that increased intratesticular level of hCG also in men without measurable serum hCG may play a role by exerting LH-like effects on the Leydig cells, causing increased testosterone and estrogen levels and low LH values in the blood.

Impaired testicular function in patients with carcinoma-in-situ of the testis

PURPOSE

To elucidate the biologic association between germ cell neoplasia and testicular dysfunction, through investigation of Leydig cell function and semen quality in men with carcinoma-in-situ (CIS) of the testis.

PATIENTS AND METHODS

We examined two groups of men, unilaterally orchidectomized for testicular cancer. Biopsy of the contralateral testis had showed CIS in a group of 24 patients and no evidence of CIS in the other group of 30 patients. Semen quality and serum levels of testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were compared in these two groups of men after orchidectomy but before further treatment for testicular cancer.

RESULTS

Significantly higher LH levels (median, 8.1 IU/L v 4.8 IU/L; P < .001) and generally lower testosterone levels (median, 12.5 nmol/L v 15.5 nmol/L; P = .13) were found in the CIS group. The proportion of patients with Leydig cell dysfunction was higher in the group of patients with CIS (11 of 24) than in the group of patients without (two of 30) (P = .01). Sperm concentration and total sperm count were significantly lower (P < .001) in patients with CIS (median, 0.03 x 10(6)/mL and 0.10 x 10(6), respectively) than in patients without (median, 9.1 x 10(6)/mL and 32 x 10(6), respectively), whereas the levels of FSH were significantly higher (P < .001) in the former group of men (median, 19.6 IU/L v 9.0 IU/L).

CONCLUSION

Not only spermatogenesis but also Leydig cell function is impaired in testes with CIS. This impairment could be due to common factors in the pathogenesis of germ cell neoplasm and testicular dysfunction. Alternatively, CIS cells may have a negative impact on Leydig cell function.

Long-term side effects of treatment for testis cancer

Patients newly diagnosed with testis cancer can now expect excellent results with respect to long-term, disease-free survival after treatment. Given the young age of presentation for many of these patients, the long-term consequences of curing testis cancer have become a major concern. Surgery, radiation, and chemotherapy for testis cancer have all been associated with potential long-term side-effects. Consequently, new treatment regimens have been directed toward minimizing these possible side-effects while at the same time maintaining high cure rates (i.e., limiting the size of radiation fields, decreasing the number of chemotherapy cycles, eliminating bleomycin). Patients and physicians must be made aware of the potential adverse side effects of treatment for testis cancer. At the present time, however, it appears that the beneficial effects of such treatment, with respect to overall and disease-free survival, far outweigh the limited probability of persistent treatment-related side effects in patients newly diagnosed with testis cancer.

Fertility issues and their management in men with testis cancer

Although a curable malignancy, testis cancer and its treatment have unique associated morbidities that largely affect reproductive dysfunction. In this focused review, the factors that contribute to infertility in men with testis cancer are outlined. The treatment-specific risks to fertility that accompany cancer management are also discussed. Contemporary methods of overcoming infertility in testis cancer patients are addressed, and several exciting and promising experimental approaches to the preservation or restoration of fertility for men with testis cancer are presented.

Gonadal function in men with testicular cancer: biological and clinical aspects

This paper reviews current knowledge about the effect of testicular germ cell cancer (TGCC) on gonadal function and of cancer treatment on spermatogenesis and Leydig cell function. It is well documented that testicular cancer is associated with impaired spermatogenic function and some patients already have impairment of Leydig cell function before orchidectomy. The degree of spermatogenic dysfunction is higher than what can be explained by local tumour effect and by a general cancer effect, since patients with other malignant diseases have normal, or only slightly decreased, semen quality. Furthermore, sperm counts after orchidectomy are further reduced to less than half of the values in healthy men, even in patients cured from the cancer disease after orchidectomy alone. These observations are supported by histological investigations which have shown a high prevalence of abnormalities of spermatogenesis in the contralateral testis in patients with unilateral TGCC. The association between testicular cancer and poor gonadal function is very interesting both from a biological and from a therapeutic point of view. Firstly, the increase in incidence of testicular cancer has been suggested to be associated with a general decline in male reproductive health and it seems likely that the development of TGCC shares common aetiologic factors with development of other types of testicular dysfunction. This suggestion is supported by the observation that men with various types of gonadal dysfunction such as testicular dysgenesis, androgen insensitivity syndrome, and cryptorchidism have increased risk of testicular cancer. Secondly, the general cure rate in patients with testicular cancer exceeds 90% and the quality of life, including fertility aspects, is therefore important in the management of these patients. Spermatogenesis is already so severely impaired before treatment that fertility is lower than in healthy men. Moreover, radiotherapy and chemotherapy both induce dose-dependent impairment of spermatogenesis and recovery of spermatogenesis after treatment may be long lasting even more than five years in some patients. Sufficient androgen production is seen in the majority of the patients, but some patients suffer from testosterone deficiency. The effect of chemotherapy on Leydig cell function also seems to be dose-dependent. In conclusion there is no doubt that testicular cancer is associated with poor gonadal function even before treatment. Furthermore, the treatment of testicular cancer may have a serious impact on the gonadal function in these patients, most of whom are in the reproductive age. Moreover, the epidemiological and clinical data indicate a common aetiology between testicular germ cell cancer and other abnormalities in male reproductive health (such as infertility and cryptorchidism). These observations are in agreement with the suggestions of hormonal involvement in the aetiology of testicular cancer. Generally, men with TGCC need counselling about their reproductive function with respect to semen cryopreservation, chance of recovery of spermatogenesis, fertility, and the possible need for androgen replacement.

Fertility after chemotherapy for testicular germ cell cancer

OBJECTIVE

To investigate the impact of cytostatic chemotherapy on long-term fertility in patients with testicular germ cell cancer.

BACKGROUND

Many patients with testicular germ cell cancer show impaired spermatogenesis before undergoing cytotoxic chemotherapy. The known infertility before treatment and the reversibility of the fertility problems observed in some of them after successful anticancer treatment so far have prevented an assessment of the true impact of chemotherapy on long-term fertility. The introduction of a wait-and-see strategy (surveillance) for patients with testicular cancer and recent prospective trials comparing patients with and without cytotoxic chemotherapy now have provided the means for estimating the extent to which chemotherapy itself affects long-term fertility.

RESULT(S)

Whether spermatogenesis is impaired irreversibly by chemotherapy is determined by the cumulative dose of cisplatin. At cumulative doses > 400 mg/m2, irreversible impairment of gonadal function should be expected.

CONCLUSION(S)

At cumulative cisplatin doses < 400 mg (equivalent to 4 courses of state-of-the-art treatment), chemotherapy is unlikely to cause irreversible damage to fertility.

Endocrinological late effects after chemotherapy for testicular cancer

Type and extent of endocrinological alterations were studied in long-term disease-free survivors after cisplatin-based chemotherapy for testicular cancer. A total of 63 patients with a median age of 30 (19-53) years, and median follow-up of 42 (16-128) months were included. Elevated serum follicle-stimulating hormone (FSH) levels were found in 63% of patients, 24% showed pathologically elevated luteinising hormone (LH) levels with normal and 10% with subnormal testosterone levels. The degree of gonadotropin elevation was highly significantly correlated with the cumulative platinum (P) dose. Patients treated with platinum-vinblastine-bleomycin regimens showed higher gonadotropin levels than those treated with platinum-etoposide-bleomycin. The adrenal androgen dehydroepiandrosterone (DHEA), pathologically elevated in 68% of patients, was significantly correlated with the cumulative doses of chemotherapy (ctx) used and to the gonadotropin levels. Treatment variables, such as type and dose of cytotoxic agents used, as well as degree of gonadotropin elevation were further correlated with changes in oestron, testosterone and 17 alpha-OH-progesterone levels. Cholesterol levels were elevated in 32% of patients and significant interactions between the steroid hormone levels and cardiovascular risk factors could be shown.