FERTILITY AND STERILITY
Copyright
©
Vol. 32, No.2, August 1979
1979 The American Fertility Society
Printed in U.s.A.
THE APPROPRIATENESS OF GONADOTROPIN DETERMINATION IN THE WORK-UP OF THE INFERTILE MALE*
MICHEAL J. CHEHVAL, M.D. DONALD J. MEHAN, M.D.t
Departments of Urology, St. Louis University Hospital and St. Mary's Health Center, St. Louis, Missouri
The advent of radioimmunoassay techniques has allowed for accurate determination of gonadotropins and testosterone at a clinical level. It has been stated that "evaluation of male infertility has been greatly facilitated" by these determinations. 1 Some reports have related a significant correlation between the degree of oligospermia and the degree of deviation from normal gonadotropin levels,2-4 whereas other reports have failed to identify any correlation. s-B The present study deals with a critical analysis of gonadotropin and testosterone determinations obtained in the clinical work-up of infertile males, and the usefulness of these studies in establishing the diagnosis and treatment of those males.
FSH levels of the azoospermic group, the oligospermic group, and the asthenospermic group were compared with levels of the control group, utilizing a two-tailed, nonpaired t-test. Identical comparison was carried out for the LH determinations; when LH levels were elevated, testosterone levels were examined to evaluate the pituitarygonadal axis. RESULTS
Serum FSH. There was a significant increase (P < 0.005) in the mean serum FSH level for the azoospermic group (24.4 ± 13 IU/mI) relative to the controls (11 ± 9 IU/mI). There was no significant difference for the oligospermic or asthenospermic menrelativetothecontrols(P >0.10andP >0.50, respectively) (see Fig. 1). Serum LH. The increases in serum LH levels in the azoospermic men (17.4 ± 11 mIU/mI) and the oligospermic group (14.4 ± 15 mIU/mI) relative to the controls (8.4± 4) were significant r.p < 0.01 and
MATERIALS AND METHODS
One hundred and sixty-four males undergoing evaluation of infertility comprise the study group. The men had been attempting pregnancy unsuccessfully for a minimum of 1 year and had been found to have suboptimal semenograms. Of the 164 men, 24 were azoospermic, 60 were oligospermic (less than 20 million sperm/mI), and 80 were asthenospermic (more than 20 million sperm/mI). Ten men of proven paternity constituted the control group. Radioimmunoassay determinations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone were carried out as a single morning determination, usually in a fasting state, prior to initiation of any therapy.
100% 80% 60%
20%
Received February 6, 1979; accepted March 14, 1979. *Presented at the Thirty-Fifth Annual Meeting of The American Fertility Society, February 3 to 7, 1979, San Francisco, Calif. tReprint requests: Donald J. Mehan, M.D., 1035 Bellevue Avenue, No. 406, St. Louis, Mo. 63117.
Azospermla •
Decreased
Oillospermia
~ Normal
Asthenospermla
D Elevated
FIG. 1. Distribution of FSH levels indicating percentage aPnormal for each group.
233
August 1979
COMMUNICATIONS-IN-BRIEF
234 100% 80% 60% 40% 20%
-.i n
co
.'"
:. N
'a
!II
a
iii
~
Normal
0
Elevated
..'"
g
iQ 'a
•;
iii
:.
..•....
~ :or
'a
•;
iii
FIG. 2. Distribution of LH levels indicating percentage abnormal for each group.
P < 0.025, respectively). Levels in asthenospermic men did not differ significantly from those of the controls (P > 0.25 (see Fig. 2). Men who had elevations of serum LH levels were critically evaluated as to the competence of the pituitarygonadal axis by examining serum testosterone levels. Of 14 men, 4 (29%) had a decreased testosterone level but in 7 of 14 (50%) it was normal and in 3 of14 (21%) it was elevated. When the LHlevel was normal, 17% of men had a decreased serum testosterone level and 6% had an elevated level. DISCUSSION
We have drawn several conclusions regarding routine clinical determination of gonadotropins and testosterone: 1. Gonadotropin levels in azoospermic and oligospermic men do vary significantly from normal and can be expected to provide useful information regarding diagnosis. As has been stated by Paulson,9 such determinations can be helpful in establishing a prognosis in response to therapy.
2. Gonadotropin levels in asthenospermic men (more than 20 million sperm/ml) do not vary significantly from normal, and the appropriateness of this determination is dubious. 3. We have been disappointed with serum testosterone determination and have found that a single clinical measurement has provided no useful information either as an isolated value nor in reference to a concomitant serum LH level. This has been noted by at least one other group ofinvestigators.7 In the present atmosphere of cost containment, it would seem reasonable to defer clinical gonadotropin determination on any man with a sperm count of more than 20 million/ml and to defer all routine clinical testosterone determinations in the absence of a specific indication. REFERENCES 1. Snyder PJ: Endocrine evaluation of the infertile male. Urol Clin North Am 5:451, 1978 2. Johnsen SG: In The Human Testis, Edited by E Rosemberg, CA Paulsen. Plenum Press, New York, 1970, p 231 3. Rosen SW, Weintraub BD: Monotropic increase of serum FSH correlated with low sperm count in young men with idiopathic oligospermia and aspermia. J Clin Endocrinol Metab 32:410, 1971 4. Pryor JP, Pugh RCB, Cameron KM, Newton R Jr, Collins WP: Plasma gonadotrophic hormones, testicular biopsy and seminal analysis in men of infertile marriages. Br J Urol 48:709, 1976 5. Leonard JM, Leach RB, Paulsen CA: Program of the 52nd Meeting of The Endocrine Society, St Louis, Mo, June 1970 (abstr 25) 6. Franchimont P, Millet D, Vendrely E, Letawe J, Legros J, Nether A: Relationship between spermatogenesis and serum gonadotropin levels in azoospermia and oligospermia. J Clin Endocrinol Metab 34:1003,1972 7. DeKrester DM, Burger HG, Fortune D, Hudson B, Long AR, Paulsen CA, Taft HP: Hormonal, histological and chromosomal studies in adult males with testicular disorders. J Clin Endocrinol Metab 35:392, 1972 8. Leonard JM, Leach RB, Couture M, Paulsen CA: J Clin Endocrinol Metab 34:209, 1972 9. Paulson DF: Clomiphene citrate in the management of male hypofertility: predictors for treatment selection. Fertil Steril 28:1226, 1977
Copyright
©
Vol. 32, No.2, August 1979
1979 The American Fertility Society
Printed in U.s.A.
THE APPROPRIATENESS OF GONADOTROPIN DETERMINATION IN THE WORK-UP OF THE INFERTILE MALE*
MICHEAL J. CHEHVAL, M.D. DONALD J. MEHAN, M.D.t
Departments of Urology, St. Louis University Hospital and St. Mary's Health Center, St. Louis, Missouri
The advent of radioimmunoassay techniques has allowed for accurate determination of gonadotropins and testosterone at a clinical level. It has been stated that "evaluation of male infertility has been greatly facilitated" by these determinations. 1 Some reports have related a significant correlation between the degree of oligospermia and the degree of deviation from normal gonadotropin levels,2-4 whereas other reports have failed to identify any correlation. s-B The present study deals with a critical analysis of gonadotropin and testosterone determinations obtained in the clinical work-up of infertile males, and the usefulness of these studies in establishing the diagnosis and treatment of those males.
FSH levels of the azoospermic group, the oligospermic group, and the asthenospermic group were compared with levels of the control group, utilizing a two-tailed, nonpaired t-test. Identical comparison was carried out for the LH determinations; when LH levels were elevated, testosterone levels were examined to evaluate the pituitarygonadal axis. RESULTS
Serum FSH. There was a significant increase (P < 0.005) in the mean serum FSH level for the azoospermic group (24.4 ± 13 IU/mI) relative to the controls (11 ± 9 IU/mI). There was no significant difference for the oligospermic or asthenospermic menrelativetothecontrols(P >0.10andP >0.50, respectively) (see Fig. 1). Serum LH. The increases in serum LH levels in the azoospermic men (17.4 ± 11 mIU/mI) and the oligospermic group (14.4 ± 15 mIU/mI) relative to the controls (8.4± 4) were significant r.p < 0.01 and
MATERIALS AND METHODS
One hundred and sixty-four males undergoing evaluation of infertility comprise the study group. The men had been attempting pregnancy unsuccessfully for a minimum of 1 year and had been found to have suboptimal semenograms. Of the 164 men, 24 were azoospermic, 60 were oligospermic (less than 20 million sperm/mI), and 80 were asthenospermic (more than 20 million sperm/mI). Ten men of proven paternity constituted the control group. Radioimmunoassay determinations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone were carried out as a single morning determination, usually in a fasting state, prior to initiation of any therapy.
100% 80% 60%
20%
Received February 6, 1979; accepted March 14, 1979. *Presented at the Thirty-Fifth Annual Meeting of The American Fertility Society, February 3 to 7, 1979, San Francisco, Calif. tReprint requests: Donald J. Mehan, M.D., 1035 Bellevue Avenue, No. 406, St. Louis, Mo. 63117.
Azospermla •
Decreased
Oillospermia
~ Normal
Asthenospermla
D Elevated
FIG. 1. Distribution of FSH levels indicating percentage aPnormal for each group.
233
August 1979
COMMUNICATIONS-IN-BRIEF
234 100% 80% 60% 40% 20%
-.i n
co
.'"
:. N
'a
!II
a
iii
~
Normal
0
Elevated
..'"
g
iQ 'a
•;
iii
:.
..•....
~ :or
'a
•;
iii
FIG. 2. Distribution of LH levels indicating percentage abnormal for each group.
P < 0.025, respectively). Levels in asthenospermic men did not differ significantly from those of the controls (P > 0.25 (see Fig. 2). Men who had elevations of serum LH levels were critically evaluated as to the competence of the pituitarygonadal axis by examining serum testosterone levels. Of 14 men, 4 (29%) had a decreased testosterone level but in 7 of 14 (50%) it was normal and in 3 of14 (21%) it was elevated. When the LHlevel was normal, 17% of men had a decreased serum testosterone level and 6% had an elevated level. DISCUSSION
We have drawn several conclusions regarding routine clinical determination of gonadotropins and testosterone: 1. Gonadotropin levels in azoospermic and oligospermic men do vary significantly from normal and can be expected to provide useful information regarding diagnosis. As has been stated by Paulson,9 such determinations can be helpful in establishing a prognosis in response to therapy.
2. Gonadotropin levels in asthenospermic men (more than 20 million sperm/ml) do not vary significantly from normal, and the appropriateness of this determination is dubious. 3. We have been disappointed with serum testosterone determination and have found that a single clinical measurement has provided no useful information either as an isolated value nor in reference to a concomitant serum LH level. This has been noted by at least one other group ofinvestigators.7 In the present atmosphere of cost containment, it would seem reasonable to defer clinical gonadotropin determination on any man with a sperm count of more than 20 million/ml and to defer all routine clinical testosterone determinations in the absence of a specific indication. REFERENCES 1. Snyder PJ: Endocrine evaluation of the infertile male. Urol Clin North Am 5:451, 1978 2. Johnsen SG: In The Human Testis, Edited by E Rosemberg, CA Paulsen. Plenum Press, New York, 1970, p 231 3. Rosen SW, Weintraub BD: Monotropic increase of serum FSH correlated with low sperm count in young men with idiopathic oligospermia and aspermia. J Clin Endocrinol Metab 32:410, 1971 4. Pryor JP, Pugh RCB, Cameron KM, Newton R Jr, Collins WP: Plasma gonadotrophic hormones, testicular biopsy and seminal analysis in men of infertile marriages. Br J Urol 48:709, 1976 5. Leonard JM, Leach RB, Paulsen CA: Program of the 52nd Meeting of The Endocrine Society, St Louis, Mo, June 1970 (abstr 25) 6. Franchimont P, Millet D, Vendrely E, Letawe J, Legros J, Nether A: Relationship between spermatogenesis and serum gonadotropin levels in azoospermia and oligospermia. J Clin Endocrinol Metab 34:1003,1972 7. DeKrester DM, Burger HG, Fortune D, Hudson B, Long AR, Paulsen CA, Taft HP: Hormonal, histological and chromosomal studies in adult males with testicular disorders. J Clin Endocrinol Metab 35:392, 1972 8. Leonard JM, Leach RB, Couture M, Paulsen CA: J Clin Endocrinol Metab 34:209, 1972 9. Paulson DF: Clomiphene citrate in the management of male hypofertility: predictors for treatment selection. Fertil Steril 28:1226, 1977
