Androlog Mail
I have a perplexing endocrine case and would appreciate comments from
colleagues.
The patient is a 37 year old healthy man who had a right orchiopexy
for torsion at age 18. He does not know if the left side was pexed at
that time.
I first saw him in 1999 when he and his then 33 year old wife were
trying for their first pregnancy. He had a left varicocele which was
small-to-moderate size. His left testis had a volume of about 15 ml.
and its consistency was normal. His right testis had a volume of
about 10-12 ml and its consistency was soft. His sperm concentration
was 40 M/ml, his motility was 60% and Kruger morphology showed 15%
normal forms. I recommended against a varicocele repair. His wife got
pregnant in January 2000 and they had a healthy boy in October 2000.
Trying for a second pregnancy, he had another S/A in July 2002. The
sperm count was zero . The semen pH and volume were normal. On 29 Jul
02, his left testis was the same size and consistency as it was in
1999 and the varicocele was still present. His right testis was
replaced by a hard mass. I did a radical right orchiectomy on 30 Jul
02. Pathology was pure typical seminoma. Pre- and post-op serum beta-
HCG and alpha fetoprotein have been normal. Tumor staging showed no
metastasis. He had 2450 rads of adjuvant XRT to his retroperitoneum in
September 2002. His S/A have continued to show azoospermia to the
present time.
Here's the endocrine puzzle. He has hyperprolactinemia and
hypotestosteronemia. He is not taking any medications. The following
are his endocrine values:
Date PRL FSH LH Testosterone
Normal values 1.6-18.8 1-8 2-13 280-800
30 Jul 02 7.5 88
08 Aug 02 64.2 7.3 3.8 179
16 Aug 02 74.5 7.7 2.7 277
26 Aug 02 303
29 Oct 02 69.1
06 Nov 02 8.9 2.5 197
28 Feb 03 70.5 8.8 4.6 216
23 May 03 77.9 11.4 3.5 151
A cranial MRI scan was normal in November 2002.
Among many questions are:
What is the cause of the hyperprolactinemia?
Are the low T values related to the hyperprolactinemia?
Would treatment of hyperprolactinemia affect this patient's
azoospermia?
The pituitary responds normally to azoospermia by producing a high FSH
but the pituitary is not responding to the low testosterone with a
high LH. How can that be explained?
Would bromocryptine or cabergoline be the better treatment for
hyperprolactinemia?
Any thoughts or suggestions would be very much appreciated by me and
by the patient.
Ira Sharlip
ISharlip@aol.com
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