Editing Infertility: Management (section)

===== Options (3): =====

# '''hCG'''
# '''FSH'''
# '''GnRH'''
#*

====== hCG ======
*'''<span style="color:#ff0000">Mechanism of Action: stimulates testosterone production from Leydig cells by mimicking LH</span>'''
**'''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
*'''Indications'''
**'''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.

* '''Indications'''
** '''<span style="color:#ff0000">Infertility associated with hypogonadotropic hypogonadism</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
** '''<span style="color:#ff0000">Not FDA-approved for use in males[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]</span>'''
* '''hCG/FSH 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'''

====== GnRH ======

* Pulsatile GnRH is not currently approved in the US or Europe[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]