Endocrine Abstracts

A 33-year-old male with a background of idiopathic hypogonadotrophic hypogonadism was referred to the endocrine clinic to discuss fertility. He was originally diagnosed overseas when presented with delayed puberty in late teens. He had a normal pituitary MRI and since then he had been on testosterone replacement; other pituitary function was normal. He was not anosmic however no other information was available from diagnosis. When he attended the clinic the patient and his wife were keen to conceive. At the time he was on testosterone injection every 3 months. He reported normal sexual function and libido. On examination he was post pubertal and his testes were 3 ml each. Following discussion, he discontinued testosterone and started HCG 3000 units twice weekly. In subsequent clinical review semen analysis showed he remained azoospermic therefore FSH was added at a dose of 150 units 3 times a week. Gradually, over the following 2 years, sperm count improved with a range 0.5–1,000,000/ml. At the same time his wife was found to have normal ovulatory cycles as well as normal hysterosalpingography. Twenty eight months after starting FSH, while on the IVF waiting list, the couple conceived naturally and had a healthy baby born. Following the birth of the baby the patient discontinued FSH therapy however remained on HCG as he was keen to have another baby in the future. Three years later he restarted FSH. On this occasion his wife conceived naturally however she had a miscarriage. Sadly, soon after this, patient’s wife passed away and the patient switched from HCG and FSH to testosterone replacement. Most recently the patient returned to the clinic because he had a new partner and was keen to be fertile again. At that stage his testosterone was stopped, and he started HCG therapy with a view to measure sperm count and consider adding FSH.

Discussion points

1. Initiation of FSH from first appointment, before/coincident with HCG?

2. Storage of sperm after 1st conception?

3. What’s the optimal sperm count? These individuals might have high fertility with very low sperm counts.