Endocrine Abstracts

The relationship between male infertility and plasma testosterone level is not linear and sometimes there could be discordance in the association. This is a case of 41 year old investment banker presented with erectile dysfunction and low libido with intact morning erections referred to Endocrinology clinic after being seen by psychologist and private endocrinologist which started 3 years before for infertility. Puberty was early, normal, at around 9-10 years old age. Previous fathered a pregnancy. He has no history of testicular damage of any sort- torsion or trauma or radiotherapy or surgery. No headache, visual impairments or any pituitary hypo or hyper functioning symptoms. He had no history of androgen or anabolic steroid abuse or supplements and not on any medication. Significant alcohol intake in the past 20 units/ day. Recent abuse of MDMA and Canabinoid (once monthly) to improve sexual functions. Previously tried on testogel which improved his symptoms but due to infertility, stopped and started on Sildenafil which is not very effective for him. Female infertility factors excluded by the fertility clinic. Examination showed a BMI of 24 with normal external genitalia and testicular volumes of 25 ml bilaterally. No eunuchoidal or mooseman pacey habitus, no gynecomastia. Investigations showed high SHBG 104- 133, morning testosterone of 27.1, free testosterone using vermuelen equation is 0.248. Normal prolactin, estradiol 120, TSH 1.29, FT4 21, prolactin 122, LH 4.9, FSH 3.8, normal LFT, ferritin 188. Semen analysis pending. This case illustrates some difficulties sometimes encountered in infertility in which the numbers are alright but subjective and other objective patient’s experience is different from this. The question is what is the right explanation for the seemingly normal free testosterone level but differential symptomatology. How do we approach infertility in this patient with normal gonadotropins and testosterone.