Infertility: Nonsurgical Management

From UrologySchool.com
Jump to navigation Jump to search

See 2015 CUA Azoospermia Guideline Notes

General Principles§

  • Advise couples with advanced paternal age (≥40) that there is an increased risk of adverse health outcomes for their offspring.
    • Effects of male age on reproductive function
      • Reproductive function
      • Sexual function
      • Testicular morphology
      • Semen parameters (except sperm concentration, semen parameters decrease as age increases)
      • Infections of the accessory glands
      • Vascular disease
      • Genetics (sperm aneuploidies, aneuploidies in off-spring, sperm DNA integrity, telomeres, epigenetics)
      • Fertility
      • Miscarriage
      • C-section
      • Pre-eclampsia
      • Trophobalst disease
      • Preterm birth
      • Adverse outcome in offspring
    • Genetic counseling may be appropriate for couples with advanced paternal age to discuss the magnitude of these risks

Selective estrogen receptor modulators (e.g. clomophene (clomid), tamoxifen)

  • MOA: acts as an agonist or antagonist on different estrogen receptors.
    • Agonists on receptors in bone, improving bone health
    • Antagonists on receptors on the hypothalamus and pituitary, resulting in increased GnRH and ultimately increased LH, FSH, and intratesticular testosterone.
      • In men normal binding of estrogen at these receptors functions as an indirect negative feedback mechanism of endogenous testosterone production to down-regulate GnRH and subsequently pituitary gonadotropin production.
  • Benefits
    1. Increased testosterone
      • Testosterone increase is more than that achieved with anastrazole
    2. Increased sperm counts
      • See Risk Calculator for expected changes for men with infertility who are given clomiphene citrate
  • Indications
    • Currently, no FDA approval for using SERMs for male hypogonadism
      • Clomiphene citrate is the most commonly used SERM for treating hypogonadism when fertility must be maintained. However, this remains an off-label use.
        • Enclomiphene citrate, the functional stereoisomer of clomiphene citrate, is currently in commercial development. Its potential advantage is avoidance of the estrogenic side effects of its enantiomer zuclomiphene.
    • Consider in patients with low testosterone, borderline high/high FSH (lazy pituitary)
  • Administration
    • Typically dosing starts at 25 mg daily and can be increased up to 100 mg daily.
  • Adverse events
    • No specific adverse effects attributed to clomiphene or enclomiphene citrate in males.
    • Same theoretical risk of testosterone replacement exists

Aromatase inhibitors (anastrazole or letrozole)

  • MOA: inhibit aromatase from converting testosterone to estradiol (E2)
    • Estradiol is an indirect mediator of testosterone feedback inhibition of the HPT axis. Therefore, aromatase inhibition in men can result in decreased estrogen levels and ultimately increased gonadotropin production
  • May restore FSH, LH, and testosterone levels in patients with elevated estradiol (T/E ratios <10), such as those with obesity or Klinefelter syndrome (tend to have more adipose tissue)
  • Limited data to improve sperm parameters
  • Adverse events
    • Theoretical risk of decreasing bone mineral density as they decrease E2.
    • Same theoretical risk of testosterone replacement exists

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

Growth Hormone (GH)

  • Also known as somatotropin
  • Single most important hormone for normal growth.
  • Acts through its mediator, insulin-like growth factor-1 (IGF-1)
  • GH and IGF-1 regulate gonadal steroidogenesis and spermatogenesis via receptors on pituitary gonadotrophs, Sertoli cells, Leydig cells and germ cells. GH and IGF1 also reduce SHBG levels, potentially increasing androgen bioavailability.
  • GH for androgen replacement is off-label.

Vitamins

  • Little evidence to support the routine use of vitamins to improve pregnancy rates

References

  • Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 24
  • Khan MA, Pagani RL, Ohlander SJ. 2019 AUA Update: Exogenous Testosterone and Male Reproduction
  • Gupta N, David M, Kohler TS. 2017 AUA Update: Treatment of Male Hypogonadism: Alternatives to Testosterone