Endocrine Abstracts

Introduction: One of the main challenges in the management of male hypogonadotropic hypogonadism (HH) is in the restoration of fertility. We describe 2 patients with HH and discuss the difficulties involved in their management.

Case (1): A 23-year-old Chinese man presented with lack of secondary sexual characteristics. Examination revealed Tanner Stage 2 with descended testes measuring 6 ml bilaterally. Laboratory results: total testosterone (TT) <1 nmol/l, LH <1 IU/l, FSH <1 IU/l. Other anterior pituitary hormones and MRI pituitary were normal. As patient desired fertility soon, hCG 2000 units twice weekly was initiated with increase in TT levels to 15 nmol/l (RI: 5–30). Male sexual characteristics developed with enlargement of the testes to 15 ml bilaterally. However, semen analysis performed a year later showed persistence of azoospermia despite a normal TT level. As he could not afford human menopausal gonadotropin, hCG therapy was continued.

Case (2): A 22-year-old Chinese man was referred for delayed puberty. Examination revealed micropenis and testes that were descended but measured 2 ml bilaterally. Laboratory results: TT: 2 nmol/l, LH 2 IU/l, FSH 3 IU/l. Other anterior pituitary hormones and MRI pituitary were normal. hCG was started but he failed to attain normal TT levels despite doses of up to 4000 units thrice weekly. Testosterone was subsequently started with the understanding that fertility would not be achievable. Secondary sexual characteristics eventually developed.

Learning point: Despite the presence of good prognostic features such as improvement in testicular size/normalisation of serum testosterone, azoospermia persisted in the 1st case after hCG treatment. However, it may take up to 24 months before a normal sperm count is attained post gonadotropin treatment. The cost of gonadotropins is a significant limiting factor in the management of HH.