title: Predictors of outcome of long-term GnRH therapy in men with idiopathic hypogonadotropic hypogonadism.
abstract: GnRH treatment is successful in inducing virilization and spermatogenesis in men with idiopathic hypogonadotropic hypogonadism (IHH). However, a small subset of IHH men, poorly characterized to date, fail to reach a normal testicular volume (TV) and produce sperm on this therapy. To determine predictors of outcome in terms of TV and sperm count, we studied 76 IHH men (38% with anosmia) undergoing GnRH therapy for 12-24 months. The population was stratified according to the baseline degree of prior pubertal development: absent (group 1, n = 52), partial (group 2, n = 18), or complete (adult onset HH; group 3, n = 6). Cryptorchidism was recorded in 40% of group 1, 5% of group 2, and none in group 3. Pulsatile GnRH therapy was initiated at 5-25 ng/kg per pulse sc and titrated to attain normal adult male testosterone (T) levels. LH, FSH, T, and inhibin B (I(B)) levels were measured serially, and maximum sperm count was recorded. A longitudinal mixed effects model was used to determine predictors of final TV. LH (97%) and T (93%) levels were normalized in the majority of IHH men. Groups 2 and 3 achieved a normal adult testicular size (92%), FSH (96%), I(B) levels (93%), and sperm in their ejaculate (100%). However, given their prior complete puberty and thus primed gonadotropes and testes, group 3 responded faster, normalizing androgen production by 2 months and completing spermatogenesis by 6 months. In contrast, group 1 failed to normalize TV (11 +/- 0.4 ml) and I(B) levels (92 +/- 6 pg/ml) by 24 months, despite normalization of their FSH levels (11 +/- 2 IU/liter). Similarly, sperm counts of group 1 plateaued well below the normal range (median of 3 x 10(6)/ml) with 18% remaining azoospermic. The independent predictors of outcome of long-term GnRH therapy were: 1) the presence of some prior pubertal development (positive predictor; group effect (beta) = 4.3; P = 0.003); 2) a baseline I(B) less than 60 pg/ml (negative predictor; beta = -3.7; P = 0.009); and 3) prior cryptorchidism (negative predictor; beta = -1.8; P = 0.05). Notably, anosmia was not an independent predictor of outcome when adjusted for other baseline variables. Our conclusions are: 1) pulsatile GnRH therapy in IHH men is very successful in inducing androgen production and spermatogenesis; 2) normalization of the LH-Leydig cell-T axis is achieved more uniformly than the FSH-Sertoli cell-I(B) axis during GnRH therapy; and 3) favorable predictors for achieving an adult testicular size and consequently optimizing spermatogenesis are prior history of sexual maturation, a baseline I(B) greater than 60 pg/ml, and absence of cryptorchidism.
authors.affiliation: Reproductive Endocrine Unit of the Department of Medicine, National Center for Infertility Research, General Clinical Research Center, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. npitteloud@partners.org
authors.forename: Nelly
authors.initials: N
authors.lastname: Pitteloud
authors.forename: Frances J
authors.initials: FJ
authors.lastname: Hayes
authors.forename: Andrew
authors.initials: A
authors.lastname: Dwyer
authors.forename: Paul A
authors.initials: PA
authors.lastname: Boepple
authors.forename: Hang
authors.initials: H
authors.lastname: Lee
authors.forename: William F
authors.initials: WF
authors.lastname: Crowley
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D003456:Cryptorchidism / Q000453:epidemiology; D004334:Drug Administration Schedule; D007987:Gonadotropin-Releasing Hormone / Q000627:therapeutic use*; D006801:Humans; D007006:Hypogonadism / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D011627:Puberty; D013076:Sperm Count; D013737:Testis / Q000033:anatomy & histology; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007987:Gonadotropin-Releasing Hormone