A 33-year-old man is referred for evaluation of male infertility. He and his 29 years old wife have been trying to conceive for last 2 years. She is gravida (G0), para (P0) with complete medical evaluation revealing regular ovulatory cycles and normal reproductive anatomy with no history of reproductive tract disorders, pelvic infection or surgery. The couple has had unprotected vaginal intercourse at least 2–3 times a week, having undergone a normal puberty and well previously, he complains of poor libido and poor erection with decreased volume of ejaculate for past 1 year. He shaves once a week. There is no past history of any chronic ailments or any reproductive disorders, and has taken no medications or any illicit drugs. He has no family history of hypogonadism, cleft palate or infertility; he has 2 brothers who have fathered children. He works as a software professional with no habitual smoking or drinking. He has never fathered a child. He is well virilized with normal male voice and normal upper/lower segment ratio. His body mass index (BMI) is 33.5 kg/m2 with bilateral nontender gynecomastia; a normal genitourinary examination with normally descended testes that are 12 mL bilaterally and easily palpable vasa deferentia. His laboratory tests (performed at 8.00 am) reveal total testosterone 220 ng/dL (N: 300–1000 ng/dL), luteinizing hormone (LH)-2 mIU/mL, follicle stimulating hormone (FSH)-6 mIU/ mL. Hematogram, urine analysis, hepatic and renal profiles, serum prolactin, thyroid profile and iron studies are normal. Repeat hormonal analysis reveal similar results. The seminal fluid analysis yields no sperms with volume of 2.45 mL, normal pH (≥7.2) and fructose. Repeat semen analysis shows similar results. Sella imaging reveals no hypothalamic/pituitary abnormality.
Treatment options for the patient discussed.
Medicine
This patient has a presentation consistent with adult onset idiopathic hypogonadotropic hypogonadism. The patient is advised to quit smoking and refrain from excessive drinking. He is advised to lose 5–10% of body weight via lifestyle changes. His symptoms of low libido and his low serum T and inappropriately normal gonadotropin levels suggest hypogonadotropism. His physical examination, normal seminal fluid volume, pH and fructose levels make obstruction unlikely. By history and evaluation, the wife is likely to be ovulatory and fertile. The patient would be offered gonadotropin therapy. It is reasonable to offer hCG therapy followed by rhFSH therapy if necessary. His testicular volumes are >6 cc; his sperm concentrations might rapidly increase with hCG therapy alone. Recombinant FSH would be added after 6 months of hCG if conception has not occurred and sperm concentration remains <10 million/mL. I would discuss the option of referral for ART without gonadotropin therapy now, but a short course of gonadotropin therapy might obviate the need for ART or improve the success rate of ART. Because his wife is 29 years old and close to entering the typical time for declining fertility, he should not be treated with gonadotropin therapy for more than 12–15 months before considering ART. If he has persistent absence of spermatogenesis despite gonadotropin therapy, the diagnosis of adult onset idiopathic hypogonadotropic hypogonadism must be reconsidered. He then must be treated as a man with idiopathic spermatogenic failure, and he should be provided genetic counseling before offering genetic testing or initiating ART.
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