Endocrinology of male infertility: evaluation and treatment

The Molecular Basis of Male Infertility in Obesity: A Literature Review

The rising incidence of obesity has coincided with rising levels of poor reproductive outcomes. The molecular basis for the association of infertility in obese males is now being explained through various mechanisms. Insulin resistance, hyperglycemia, and changes in serum and gonadal concentrations of adipokines, like leptin, adiponectin, resistin, and ghrelin have been implicated as causes of male infertility in obese males. The effects of obesity and hypogonadism form a vicious cycle whereby dysregulation of the hypothalamic-pituitary-testicular axis-due to the effect of the release of multiple mediators, thus decreasing GnRH release from the hypothalamus-causes decreases in LH and FSH levels. This leads to lower levels of testosterone, which further increases adiposity because of increased lipogenesis. Cytokines such as TNF-α and interleukins, sirtuins, and other inflammatory mediators like reactive oxygen species are known to affect fertility in obese male adults. There is evidence that parental obesity can be transferred through subsequent generations to offspring through epigenetic marks. Thus, negative expressions like obesity and infertility have been linked to epigenetic marks being altered in previous generations. The interesting aspect is that these epigenetic expressions can be reverted by removing the triggering factors. These positive modifications are also transmitted to subsequent generations.

Nonsurgical Management of Oligozoospermia

Male infertility secondary to oligozoospermia is surprisingly common. Although a majority of cases are idiopathic, oligozoospermia can be caused by endocrine dysfunction, anatomic abnormalities, medications, or environmental exposures. The work-up includes excluding reversible factors such as hormonal deficiency, medication effects, and retrograde ejaculation and identifying any underlying genetic syndrome and treating reversible medical causes. If no reversible cause is found, appropriate referrals to urology and assisted reproductive technology should be initiated. Lastly, clinicians should be aware of and respond to the psychological and general health ramifications of a diagnosis of oligozoospermia as part of the comprehensive care of men and couples struggling with a diagnosis of infertility.

Effect of Venlafaxine, Pramipexole, and Valsartan on Spermatogenesis in Male Rats

The study's aim was to explore the effect of venlafaxine, valsartan, and pramipexole on spermatogenesis. It was hypothesized that these drugs may affect the male fertility because of their long-term use in treatment of depression, hypertension, and Parkinson's diseases. Male rats were given venlafaxine, valsartan, and pramipexole at low- and high-dose levels orally once daily for 10 weeks. Testosterone (25 mg/kg) was given as a standard via an intramuscular route once weekly. Rats were sacrificed after blood collection by cardiac puncture, and testes were removed. Sperm parameters were examined from spermatozoa of the cauda epididymis, and testes were treated for histopathological analysis. Results showed nonsignificant effect of venlafaxine on the sperm count, whereas a decreased sperm count was noted in all the treatment groups as compared to that of the control except valsartan at a low dose, which significantly (p < 0.001) raised the sperm count (96.26 ± 2.4) in reference with the control value (49.13 ± 2.3). Treatments had variable effects on total sperm motility and morphological parameters, but valsartan at a low dose showed maximum sperm motility (71.55 ± 0.7) among all. DNA integrity of spermatozoa remained intact in all groups. Luteinizing hormone and follicle-stimulating hormone levels decreased, and testosterone levels increased in all treatment groups as compared to control values, which indicate fertility. Histopathology revealed normal texture of testes with venlafaxine and valsartan, but testicular damage occurred with high-dose pramipexole. It is concluded that the use of venlafaxine, valsartan, and pramipexole at a low dose is devoid of any harmful effect on spermatogenesis, whereas pramipexole at a high dose adversely affect it.

An Evaluation of Reported Follicle-stimulating Hormone, Luteinizing Hormone, Estradiol, and Prolactin Reference Ranges in the United States

OBJECTIVE

To characterize US clinical laboratory reference range reporting and testing methods of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin.

METHODS

One hundred and seventeen US laboratories were surveyed. Outcomes measured were variation in lower and upper limits of normal male reference ranges for serum FSH, LH, estradiol, and prolactin, method of analysis and source of reference range RESULTS: The upper limit of normal reference ranges for FSH, LH, estradiol, and prolactin varied substantially across laboratories compared to the lower limits. The range of upper limits of FSH, LH, estradiol, and prolactin respectively are 7.9-20.0, 4.9-86.5, 37.7-77.0, and 7.4-25.0. Ninety-four percent of laboratories performed measurements on in-house high throughput analyzer utilizing immunoassays. Seventy percent of reported reference ranges for each hormone were based on validation studies of the analyzer's package insert values. Ten percent of laboratories derived their own reference ranges. Both the validation studies and derivations were based on a limited number of patient samples, ranging from 20 to 200.

CONCLUSION

Current reference ranges are based on small population studies of men with unknown medical histories, sexual or reproductive function. Influence of race and age has not been evaluated and could potentially be important in normal variation. The absence of standard information has yielded a spectrum of upper and lower normal values, which could delay an appropriate male infertility evaluation. Our findings highlight the need for a large population study of males with known normal sexual and reproductive function to formulate more accurate clinical reference ranges.

Indications for the use of human chorionic gonadotropic hormone for the management of infertility in hypogonadal men

Hypogonadism among men desiring fertility preservation presents a unique challenge to physicians. Over the past decade the number of younger men with hypogonadism has increased dramatically. These men are often treated with testosterone replacement therapy (TRT) which can result in azoospermia and potentially infertility. Human chorionic gonadotropin (hCG) therapy can help re-establish or maintain spermatogenesis in hypogonadal men. We review the indications, and discuss the current evidence for the role of hCG in men with hypogonadisms.

High-energy diets: a threat for male fertility?

Male fertility is declining in developed countries, as well as in developing countries. External factors linked to lifestyle, such as eating disorders, negatively affect spermatogenesis, both at central and gonadal levels. The overconsumption of high-energy diets (HED) alters the functioning of the male reproductive axis and consequently affects the testicular physiology, disrupting its metabolism and bioenergetic capacity. Testicular metabolism presents unique characteristics, partly because of its cellular heterogeneity and to the specific functions that each cell type plays within the testicular environment. Disruption of the tightly regulated metabolic pathways leads to adverse reproductive outcomes, such as inefficient energy supply to germ cells, sperm defects or spermatogenesis arrest. Testicular metabolic alterations induced by HED intake may also lead to mitochondrial dysfunction, which is closely associated to reactive oxygen species (ROS) overproduction and oxidative stress. ROS easily target spermatozoa DNA and lipids, contributing to decreased sperm quality. Thus, understanding the detrimental effects of HED overconsumption on the pathways underlying testicular metabolism and sperm production is imperative; otherwise, one may favour a transgenerational amplification of subfertility. Herein, we present an up-to-date overview of the effects of HED on testicular metabolism, sperm parameters and the subsequent consequences for male fertility.

Male infertility: non-surgical therapy

Infertility is defined as the inability of a couple to conceive after 12 months of unprotected intercourse and affects 15% of couples with male component of 50%. The failure of spermatogenesis can result from hypothalamic, pituitary or testicular disorders although in the majority of cases it remains idiopathic. The diagnostic process includes medical history, semen analysis, hormonal studies, genetic studies and radiological evaluation.

Targeted hormonal therapies are available for patients whose infertility is caused by altered levels of androgens, prolactin, or TSH. Main treatments aim to restore normal sexual function by administering testosterone and to increase spermatogenesis with pulsatile GnRH.

Fertility in men suffering from hypogonadotrophic hypogonadism can be restored through hormone therapy using GnRH or with the use of gonadotropins when there is hypothalamic failure. In the past, treatment options for the factors of idiopathic male infertility were mainly based on the use of anti-estrogens that cause an increased secretion of FSH and LH and therefore of testosterone.

Oxytocin promotes the progression of the sperm and increases the conversion of testosterone into dihydrotestosterone. The aromatase's inhibitors decrease the conversion of androgens to estrogens, increasing serum levels of androgens, resulting in an increased release of gonadotropins.

Two areas showed interesting future perspectives for the treatment of infertility: gene therapy and transplantation of spermatogonial stem cells.

Sperm retrieval and quality evaluation

Technical refinements in sperm retrieval methods and the application of advanced reproductive technologies (ART) using surgically retrieved sperm have enabled biological paternity in azoospermic men who were considered untreatable 20 years ago. Achievement of optimal reproductive outcomes in these patients benefits greatly from a multistep, interdisciplinary process of sperm acquisition that involves reproductive endocrinologists, urologists, or other specialists in male subfertility, and laboratory personnel with expertise in characterizing and isolating sperm from surgically retrieved specimens. The critical steps in this process are discussed in this chapter.

Hormonal control of Sertoli cell metabolism regulates spermatogenesis

Hormonal regulation is essential to spermatogenesis. Sertoli cells (SCs) have functions that reach far beyond the physical support of germ cells, as they are responsible for creating the adequate ionic and metabolic environment for germ cell development. Thus, much attention has been given to the metabolic functioning of SCs. During spermatogenesis, germ cells are provided with suitable metabolic substrates, in a set of events mediated by SCs. Multiple signaling cascades regulate SC function and several of these signaling pathways are hormone-dependent and cell-specific. Within the seminiferous tubules, only SCs possess receptors for some hormones rendering them major targets for the hormonal signaling that regulates spermatogenesis. Although the mechanisms by which SCs fulfill their own and germ cells metabolic needs are mostly studied in vitro, SC metabolism is unquestionably a regulation point for germ cell development and the hormonal control of these processes is required for a normal spermatogenesis.

Effect of Argan and Olive Oil Consumption on the Hormonal Profile of Androgens Among Healthy Adult Moroccan Men

This study aimed to assess the effect of virgin argan oil (VAO) and extra virgin olive oil (EVO) on the hormonal profile of androgens and anthropometric parameters among healthy adult Moroccan men during a controlled nutritional intervention. The study was carried out on 60 young and healthy male volunteers aged between 23 and 40 years old. During a stabilization period of 2 weeks they consumed butter. The group was then randomized into two categories, the first one consuming VAO and the second EVO for 3 weeks. Testosterone (T), luteinizing hormone (LH) and dehydroepiandrosterone (DHEAS) serum concentrations were measured at the beginning of the study and at the end of each period. The Mann-Whitney test was used to compare the two groups (VAO and EVO) during each step of the study. Differences in androgens and anthropometric parameters between the baseline and after 3 weeks of the diet in the VAO and EVO groups were analyzed using the Wilcoxon test. T and LH serum concentrations significantly increased after the intervention period. T levels increased by 19.9% and 17.4% (p < 0.0001), and LH levels by 18.5% (p < 0.007) and 42.6% ( p < 0.0001), respectively, for VAO and EVO ( p < 0.0001). However, DHEAS serum concentrations, body weight, body mass index, arterial pressure and daily energetic intake did not show any significant variation after the intervention with either argan or olive oils. The results suggest that consumption of AVO and EVO might be the origin of a positive action on the androgen hormonal profile of men.

Interpretation of the semen analysis and initial male factor management

A practical approach to semen analysis (SA) interpretation and the initial management of subfertile men is presented. Each parameter of the SA is described and management recommendations based upon SA findings are provided. The indications for and interpretation of adjunctive diagnostic testing for male factor subfertility are also discussed.

Medical therapy for spermatogenic failure

Medical treatment of men with primary spermatogenic failure remains largely ineffective in contrast to those with secondary testicular failure. Treatment has been attempted with a multitude of agents ranging from hormones to nutritional supplements (antioxidants). While some studies have demonstrated benefit to some treatments, no treatments have consistently demonstrated efficacy nor has it been possible to reliably identify patients likely to benefit. Idiopathic spermatogenic failure likely results from multiple discrete defects in sperm production that are as yet unidentified. A better understanding of these defects will yield more effective treatment options and appropriate triage of patients to specific therapeutic regimens. This review focuses on the rationale and current evidence for hormonal and antioxidant therapy in medical treatment of male infertility, spermatogenic failure in particular. Although empiric medical therapy for spermatogenic failure has been largely replaced by assisted reproductive techniques, both treatment modalities could play a role, perhaps as combination therapy.

Contemporary management of male infertility

Knowledge of normal male reproductive function and familiarity with the diagnostic evaluation and treatment of male subfertility is beneficial for most physicians. Male subfertility is often correctable, may be genetically transmissible, and may be associated with occult health-threatening conditions. Herein we present an overview of male reproductive medicine, which has been revolutionized in the past two decades by dramatic scientific and therapeutic advances. The development of intracytoplasmic sperm injection and its successful application to sperm retrieved from the epididymis or testis have made biological paternity possible in men previously considered sterile. Microsurgical techniques for vasal-epididymal reconstruction and sperm retrieval have been refined. Novel tests of semen quality have been developed. Medical therapies to improve sperm production, such as estrogen receptor modulation and aromatase inhibition, have been used increasingly in clinical practice. Finally, associations between male subfertility and a spectrum of health-threatening conditions have been recognized.

Decreased levels of genuine large free hCG alpha in men presenting with abnormal semen analysis

BACKGROUND

The pregnancy hormone human chorionic gonadotropin (hCG) and its free subunits (hCG alpha, hCG beta) are produced in the male reproductive tract and found in high concentrations in seminal fluid, in particular hCG alpha. This study aimed to elucidate changes in peptide hormone profiles in patients showing abnormal semen analyses and to determine the genuineness of the highly abundant hCG alpha.

METHODS

Seminal plasma was obtained from 45 male patients undergoing semen analysis during infertility workups. Comprehensive peptide hormone profiles were established by a panel of immunofluorometric assays for hCG, hCG alpha, hCG beta and its metabolite hCG beta core fragment, placental lactogen, growth hormone and prolactin in seminal plasma of patients with abnormal semen analysis results (n = 29) versus normozoospermic men (n = 16). The molecular identity of large hyperglycosylated hCG alpha was analyzed by mass-spectrometry and selective deglycosylation.

RESULTS

hCG alpha levels were found to be significantly lower in men with impaired semen quality (1346 +/- 191 vs. 2753 +/- 533 ng/ml, P = 0.022). Moreover, patients with reduced sperm count had reduced intact hCG levels compared with normozoospermic men (0.097 +/- 0.022 vs. 0.203 +/- 0.040 ng/ml, P = 0.028). Using mass-spectrometry, the biochemical identity of hCG alpha purified from seminal plasma was verified. Under non-reducing conditions in SDS-PAGE, hCG alpha isolated from seminal plasma migrated in a manner comparable with large free hCG alpha with an apparent molecular mass (Mr, app) of 24 kDa, while hCG alpha dissociated from pregnancy-derived holo-hCG migrated at approximately 22 kDa. After deglycosylation with PNGase F under denaturing conditions, all hCG alpha variants showed an Mr, app of 15 kDa, indicating identical amino acid backbones.

CONCLUSIONS

The findings indicate a pathophysiological relevance of hCG, particularly its free alpha subunit, in spermatogenesis. The alternative glycosylation pattern on the free large hCG alpha in seminal plasma might reflect a modified function of this subunit in the male reproductive tract.

Endocrine disrupting chemicals: Multiple effects on testicular signaling and spermatogenesis

In the past 200 years, an enormous number of synthetic chemicals with diverse structural features have been produced for industrial, medical and domestic purposes. These chemicals, originally thought to have little or no biological toxicity, are widely used in our daily lives as well as are commonly present in foods. It was not until the first World Wildlife Federation Wingspread Conference held in 1994 were concerns about the endocrine disrupting (ED) effects of these chemicals articulated. The potential hazardous effects of endocrine disrupting chemicals (EDCs) on human health and ecological well-being are one of the global concerns that affect the health and propagation of human beings. Considerable numbers of studies indicated that endocrine disruption is linked to "the developmental basis of adult disease," highlighting the significant effects of EDC exposure on a developing organism, leading to the propensity of an individual to develop a disease or dysfunction in later life. In this review, we intend to provide environmental, epidemiological and experimental data to associate pollutant exposure with reproductive disorders, in particular on the development and function of the male reproductive system. Possible effects of pollutant exposure on the processes of embryonic development, like sex determination and masculinization are described. In addition, the effects of pollutant exposure on hypothalamus-pituitary-gonadal axis, testicular signaling, steroidogenesis and spermatogenesis are also discussed.

Natural course of idiopathic oligozoospermia: comparison of mild, moderate and severe forms

OBJECTIVES

To investigate the natural courses of mild, moderate and severe idiopathic oligozoospermia, and which factors or semen variables were of utmost importance in predicting the courses.

METHODS

A total of 208 men (age 29-47years) who were diagnosed with mild, moderate and severe idiopathic oligozoospermia in a 9-year-period between January 2000 and December 2008 were followed up for more than 6months.

RESULTS

Overall, 16 (24.6%) of 65 patients with severe oligozoospermia developed azoospermia, whereas two (3.1%) patients with moderate oligozoospermia developed azoospermia and none of the patients with mild oligozoospermia developed azoospermia. Initial follicle stimulating hormone level and testicular volume between the subgroups were significantly different (P=0.0071 and 0.0039, respectively). The subgroup of patients who became azoospermic (n=18) showed statistically significant differences in terms of body mass index and the level of prolactin (PRL) from the subgroup that maintained the initial lingering sperm count (n=190; P=0.0086 and 0.0154, respectively). As the vitality of semen variables increased 1%, the risk of progression to azoospermia diminished by 0.892-fold, according to Cox's proportional hazards model analysis. A receiver operating characteristic curve analysis showed that the area under the curve was 0.755 and the sperm concentration value with the highest sensitivity and specificity was the reference value of 3-5 million/mL, with a sensitivity of 0.746 and specificity of 0.711 (P=0.01).

CONCLUSIONS

Patients with severe oligozoospermia should be warned of the possibility of becoming azoospermic and hence sperm freezing should be encouraged as early as possible.

A local autocrine axis in the testes that regulates spermatogenesis

Spermiation--the release of mature spermatozoa from Sertoli cells into the seminiferous tubule lumen--occurs by the disruption of an anchoring device known as the apical ectoplasmic specialization (apical ES). At the same time, the blood-testis barrier (BTB) undergoes extensive restructuring to facilitate the transit of preleptotene spermatocytes. While these two cellular events take place at opposite ends of the Sertoli cell epithelium, the events are in fact tightly coordinated, as any disruption in either process will lead to infertility. A local regulatory axis exists between the apical ES and the BTB in which biologically active laminin fragments produced at the apical ES by the action of matrix metalloproteinase 2 can regulate BTB restructuring directly or indirectly via the hemidesmosome. Equally important, polarity proteins play a crucial part in coordinating cellular events within this apical ES-BTB-hemidesmosome axis. Additionally, testosterone and cytokines work in concert to facilitate BTB restructuring, which enables the transit of spermatocytes while maintaining immunological barrier function. Herein, we will discuss this important autocrine-based cellular axis that parallels the hormonal-based hypothalamic-pituitary-testicular axis that regulates spermatogenesis. This local regulatory axis is the emerging target for male contraception.

Clomiphene citrate and enclomiphene for the treatment of hypogonadal androgen deficiency

Hypogonadism has a number of important clinical consequences related to androgen deficiency and impaired spermatogenesis. The cause of this condition is multifactorial and can result from hypothalamic, pituitary or gonadal dysfunction as well as factors that affect hormonal signaling along the hypothalamic-pituitary-gonadal axis. While testosterone replacement is the most common treatment, it can paradoxically lead to infertility, and may be a less physiologic therapy for patients with secondary hypogonadism due to pituitary dysfunction. Clomiphene citrate, and its derivatives, may allow for restoration of gonadal function by restoring physiologic pituitary function in a subset of patients with hypogonadism.