Luteinising hormone-releasing hormone nasal spray as therapy for undescended testicle

Intranasal LH-RH treatment of cryptorchidism. A clinical trial and 5 years follow-up

The effect of intranasal LH-RH on cryptorchidism was investigated in 45 prepubertal boys with 68 undescended testes. A daily dose of 1.2 mg LH-RH was given for 4 weeks. A total of 16 testes (24%) descended. Follow-up examination 5 years later showed that relapse had occurred in two cases. Fifty-two testes did not descend during the LH-RH treatment. However, seven of these testes descended spontaneously during puberty. So far surgical treatment has been carried out in 39 of the remaining 45 testes. Anatomical anomalies (ectopic position of the testis, open processus vaginalis, abnormal epididymis) explained the failure of LH-RH to cause descent in the majority of the surgically treated cases.

LH-RH nasal spray treatment for cryptorchidism. A double-blind, placebo-controlled study

A double-blind, placebo-controlled study of the efficacy of LH-RH nasal spray in treatment of cryptorchidism involving 252 prepuberal boys with 301 undescended testes, showed a success rate of 9% (14 testes) for LH-RH and 8% (10 testes) for placebo. Including a subsequent open study and a second course of LH-RH as required, the rate for LH-RH rose to 18% (48 testes). The follow-up period saw late descent in another 5% (14 testes), in a few cases coinciding with the onset of puberty. Retrospective evaluation revealed a previous scrotal position of the testes for 43% of the boys with success of treatment and even for 17% of the boys with failure of treatment. In many of these cases surgery revealed an anatomical anomaly that might have caused testicular ascent. Hormonal evaluation revealed no abnormalities in cryptorchid boys compared with control subjects, nor was there a divergence in values before and after treatment. The lower the pretreatment testicular position, the better the rate of success.

Therapeutic results in cryptorchidism after combination therapy with LH-RH nasal spray and hCG

Seventy-two boys with 81 cryptorchid testes were treated with combined LH-RH nasal spray and hCG in the period between 1983 and 1985. Cryptocur (LH-RH) was applied as nasal spray at a dose of 1.2 mg daily over a period of 14 days. In all of the patients, hCG treatment was carried out subsequently according to the WHO guidelines with five intramuscular injections at 2-day intervals. Primary treatment results considerably improved using the regimen. The rate of complete descent was 86.4% at the end of therapy and later dropped to 70.6% after 2 years follow-up. These results support the experience of Hadziselimovic et al. with this combined treatment.

Effect of LHRH treatment on testicular descent and hormonal response in cryptorchidism

In a double-blind placebo-controlled study in 49 boys with cryptorchidism the effect of intranasal synthetic LHRH was studied. After 8 weeks improvement in testicular location was found in 13 testes (37%), but this improvement was considered sufficient of only six testes. Placebo resulted in an improved location in 18% of the testes. The mean change in testicular position (expressed in cm) after LHRH therapy was slightly greater than after placebo but only in the squatting position did this difference reach significance. Aggressive behaviour was reported in 23% of the children treated with LHRH. A second LHRH course did not result in significant improvement in any of the patients. At follow-up reascent was frequently seen. The final results in unilateral cryptorchidism are poorer than those in bilateral cryptorchidism. LHRH therapy leads to higher plasma LH levels and a lower FSH in response to an intravenous LHRH test. In 15 boys plasma testosterone levels rose above 0.4 nmol/l. We conclude that intranasal LHRH application has a limited value for the treatment of cryptorchidism but may be suitable as a diagnostic test.

Double-blind, placebo-controlled study of luteinising-hormone-releasing-hormone nasal spray in treatment of undescended testes

In a double-blind, placebo-controlled study, 252 prepubertal boys with 301 undescended testes were treated with luteinising-hormone-releasing-hormone (LHRH), 1.2 mg/day intranasally. After the 8-week double-blind period 10 placebo-treated (8%) and 14 LHRH-treated (9%) testes had completely descended. After a second LHRH course, involving all the subjects in an open study, 48 testes (18%) had descended completely. The lowest success rate (7%) occurred in the youngest age group (1-2 years). Of the successfully treated testes, 75% could be manipulated at least to the scrotal entrance before treatment. In comparison with age-matched controls, the cryptorchid boys' responses to LHRH and human chorionic gonadotropin before treatment did not suggest a deficient hypothalamo-pituitary-gonadal axis or deficient Leydig cell function. After treatment there was no evidence of stimulation of the hypothalamo-pituitary-gonadal axis; serum testosterone did not increase. Surgery was required in 170 patients (196 testes) revealing various anatomical anomalies.

Hormonal therapy of cryptorchidism. A randomized, double-blind study comparing human chorionic gonadotropin and gonadotropin-releasing hormone

We conducted a randomized, double-blind study comparing intranasal gonadotropin-releasing hormone (1.2 mg per day for 28 days) with parenteral human chorionic gonadotropin (3300 IU per week for four weeks) in the treatment of cryptorchidism in 33 boys one to five years old (29 with unilateral and 4 with bilateral cryptorchidism). Testicular descent into the scrotum occurred in 3 of the 16 patients (19 percent) treated with gonadotropin-releasing hormone and in 1 of the 17 (6 percent) treated with human chorionic gonadotropin (P = 0.23). The mean luteinizing hormone and testosterone levels were similar in both groups before treatment. During treatment, the testosterone levels were significantly increased in both groups, but higher levels occurred in the group treated with human chorionic gonadotropin (P less than 0.05). In a parallel (but uncontrolled) study of five boys with retractile testes (defined as a nonscrotal testis that could be manipulated into the bottom of the scrotum) who were originally excluded from the main protocol but were treated with the same regimen of human chorionic gonadotropin, descent into the scrotum occurred in all patients. We conclude that hormonal therapy with either gonadotropin-releasing hormone or human chorionic gonadotropin is, in most cases, ineffective in promoting testicular descent of true cryptorchid testes. However, short-term treatment with human chorionic gonadotropin is very effective in producing descent of retractile testes. These results suggest that the wide discrepancies in apparent efficacy in previous trials of hormonal therapy of cryptorchidism may have been due to inclusion in those studies of various proportions of patients with retractile testes.

Luteinising hormone releasing hormone for incomplete descent of the testis

Forty boys with 54 incompletely descended testes took part in a double blind, controlled trial of intranasal luteinising hormone releasing hormone. In the control (placebo) group of 18 boys there was no significant change in testicular descent and all required orchidopexy; in the 22 treated boys, however, 12 of 29 testes (42%) were found in a lower position. This study supports the idea that a trial of intranasal luteinising hormone releasing hormone (1200 micrograms/day for 28 days) will help clarify the need for orchidopexy in at least 30% of boys with incomplete descent of the testis, particularly those in whom the testes have emerged from the inguinal canal.

Success and relapse rate after treatment of cryptorchidism with intranasal LHRH

In a collaborative study 119 cryptorchid prepubertal children with 67 unilaterally and 104 bilaterally undescended testes were treated for four weeks with intranasal LHRH 1.2 mg daily. The age range was 1 1/12 to 12 3/12 years with a median of 3 10/12 years. Complete descent was observed in 64 testes (37%) and partial descent in another 47 testes (27%). Positive responders were equally distributed in all age groups. At a follow-up of 57 patients at least six months after the end of treatment, 40% of the previously fully descended testes were found at higher locations, more than half at the scrotal neck. We conclude that LHRH therapy for cryptorchidism is effective and without any major side-effects. It may be particularly useful in children of one to three years of age where hCG is practically useless and surgical repair is the only alternative to date. However, efforts should be directed towards elaboration of treatment schedules which would avoid the high relapse rate.

LHRH treatment in unilateral cryptorchidism: effect on testicular descent and hormonal response

Fifty unilaterally cryptorchid boys aged 3 to 8 years were randomly and blindly allocated to treatment with luteinizing hormone releasing hormone or placebo intranasally. In the treated group, no significant descent of the undescended testis was found, whereas a minor downward movement of the scrotal testis occurred (P less than 0.001), probably as a result of decreased retraction by the cremaster muscle. Basal serum testosterone concentrations and testicular volume increased after treatment (P less than 0.01 and P less than 0.001, respectively). The response to an acute LHRH test, 100 micrograms/m2 body surface IV, before and after treatment, showed an increase in the luteinizing hormone peak value and a decrease in the follicle-stimulating hormone response in a significant number of patients (P less than 0.001). In the individual patient, there was a positive correlation between the increase in basal serum testosterone concentration and the degree of downward movement of the undescended testis (P less than 0.05).

Treatment of cryptorchidism with pulsatile luteinizing hormone-releasing hormone (LH-RH)

This preliminary report describes a new method of treating bilateral cryptorchidism that may modify the need for surgical intervention. Four of five boys (3 1/2, 3 1/2, 7, 11 and 12 1/2 years of age) given hourly subcutaneous pulses of luteinizing hormone-releasing hormone (LH-RH, 10 to 100 micrograms/day, given in a 3-min pulse every hour) showed evidence of testicular descent after 3 to 19 weeks. The battery-operated, programmable syringe driver was well tolerated by the boys, and the daily insertion of the scalp-vein needles was managed at home by their parents.

Clinical applications of LHRH and its analogues

The physiological requirement for activation of pituitary gonadotrophin secretion by pulsatile LHRH stimulation is discussed, and compared with the effect of pituitary stimulation by LHRH agonists. Initial stimulation is followed by a phase of progressive pituitary and gonadal inhibition. This inhibition is fully reversible at the end of agonist treatment. Clinical applications of high dose suppression are the treatment of precocious puberty and hormone-dependent tumours (mammary and prostatic carcinoma). In women, agonist administration by nasal spray is a reversible method of inhibiting ovulation, and may also be useful in the treatment of endometriosis. Clinical advantages of agonist therapy are favourable biological tolerance, lack of side effects and rapid reversibility.

Results of early treatment of cryptorchidism with human chorionic gonadotropin

One hundred and fifty-three children with common cryptorchidism, 109 unilateral and 44 bilateral, excluding those with associated malformations or abnormalities, were treated at age 6 to 59 months with human chorionic gonadotropin given as nine intramuscular injections on alternate days. Treatment before age 3 years resulted in complete failure in 81%. At 3 to 4 years of age treatment resulted in failure in 55%, but 19% of the patients showed complete testicular descent and 26% showed partial descent. The percent of failures was increased when the dose of human chorionic gonadotropin was lower than 1,000 IU/m2 injection and when the cryptorchid testis was very high. No correlation was found between endocrine data and the clinical results. The plasma testosterone concentration after the third injection of human chorionic gonadotropin was not significantly different in successfully and unsuccessfully treated patients. However, testosterone levels were significantly lower in patients treated at 36 to 59 months of age than in those treated at an earlier age, in contrast to the significantly better clinical results obtained in the older group. Thus human chorionic gonadotropin is not a valuable means of obtaining descent of undescended testes before age 3 years and is of limited usefulness at age 3 to 4 years.

Treatment of undescended testes with intranasal application of synthetic LH-RH

The effect of intranasal, synthetic LH-RH (Hoe 471) on undescended testes was investigated in: I. a double blind study comprising 50 patients given either placebo or 0.6 mg LH-RH daily and II. an open study comprising 50 patients with a daily dosage of 1.2 mg LH-RH. In both studies LH-RH was given for 4 weeks. Since some patients had bilateral undescended testes, 116 testes were treated in total. Patients' ages varied between 1 1/2 and 10 1/2 years, with a mean of 5 years. Clinical examination before, during and at end of treatment was performed by both the authors independently. In the placebo group, one testicular descent was seen, indicating difficulty in diagnosis. A therapeutic result, i.e. a significant move from the pretreatment location towards the bottom of the scrotum was seen in 60% of the testes, complete descent being seen in about 40%. In a follow-up study 6 months after treatment, in 23 cases with complete descent from a pretreatment inguinal position, relapse was seen in 5 patients (2 were located at scrotal neck, 3 at the pretreatment position i.e. inguinal). The best results were seen on testes located not too far from the scrotal neck, with the higher dosage of LH-RH and in patients less than 6 years of age. No significant hormonal changes (testosterone-, LH- or FSH-levels in peripheral blood) were seen during the study. Side effects were negligible.

Success, relapse and failure after intranasal LHRH treatment of cryptorchidism in 55 prepubertal boys

Synthetic LHRH was given intranasally to 55 prepubertal boys with 67 undescended testes. After a 4-5 week period while receiving a daily dose of 1.2 mg complete testicular descent was seen in 24 testes. Follow-up over 6 to 24 months showed relapse in 4 boys who responded successfully to a second trial with LHRH. In boys with insufficient or no response to an initial trial further treatment with LHRH in 11 cases or HCG in 5 cases also was without effect. Surgical correction after unsuccessful LHRH treatment in 32 boys with 35 undescended testes showed anatomical abnormalities in 28 testes, mostly an open processus vaginalis with or without hernia. Because of its simple and painless administration and the absence of unwanted side effects, intranasal LHRH is well-suited as initial treatment of cryptorchidism, particularly in young children.