Editing Infertility: Nonsurgical Management (section)

== Hormones (gonadotropins (hCG, FSH) ==

* The advantage of injectable gonadotropin vs pulsatile GnRH for the treatment of hypogonadotropic hypogonadism is that the injectable gonadotropin bypasses the need for a pump and screening for functionality of the pituitary gland.
* '''hCG'''
** '''MOA: stimulate testosterone production by mimicking LH'''
*** '''hCG has the same structure as the beta unit for LH'''
** '''When used in conjunction with exogenous testosterone administration, may reverse azoospermia and maintain elevated intratesticular testosterone levels'''
*** '''By directly stimulating Leydig cells, intratesticular testosterone increases regardless of the extent of negative feedback on the HPG axis, improving spermatogenesis.'''
*** Greater effect seen in males with initial testes length >4cm
*** '''Effect improved with addition of FSH''' or hMG
**** Most experts treat with hCG alone for 3 to 6 months after which spermatogenesis induction occurs in some cases.
**** For patients without adequate spermatogenesis induction, treatment proceeds with the addition of FSH
** '''FDA approved for treatment of pituitary hypogonadism in males'''
** Classically used to treat hypogonadotropic hypogonadism, such as Kallmann syndrome.
* FSH
** When given alone or in combination with testosterone, has proven unsuccessful at inducing spermatogenesis or maintaining spermatogenesis in those previously induced with hCG/FSH, confirming the need for maintenance of elevated intratesticular testosterone.
* '''Not used frequently due to cost'''
** hCG is more expensive than clomiphene citrate and anastrozole, and requires multiple weekly subcutaneous injections.
* Adverse events
** hCG is generally well tolerated but there are reports of gynecomastia in up to a third of the patients, which should be monitored.
*** If gynecomastia does occur, anastrazole would be the first line treatment option.
** '''Same theoretical risk of testosterone replacement exists'''