Re: A challenging panhypopituitarism case

Androlog Mail

Regarding challenging case of 27-men with panhypopituitarism.
The treatment to achieve fertility should follow the same principals
as we would use for any anosmic men with hypogonadic hypogonadism
(HH) or idiopathic hypogonadism. In addition his thyroid hormones,
growth hormone, and corticosteroids have to be replaced if indeed he
has panhypopituiatrism.
Hcg like Pregnyl should be used in much lower dose as typical dosing
in men is 1,000 U SQ every day, or (more commonly) 3,500 U IM three
times a week. Alternatively because of shortage of Pregnyl one could
use Ovidrel 250 to 500 mg three times a week. Hcg tends to increase
estradiol level and we have just recently achieved spontaneous
pregnancy is similar patient after 4 year of treatment but over last
year he was also taking Arimdiex 1 mg daily which increased his sperm
concentration to 8 mil/ml. Hence I would check his estradiol level.
I personally treat every patient with anosmic HH or IHH with FSH at
the same time as hCG, I start them on Repronex which has 75 IU of LH
and 75 IU of FSH 3 times a week for 6 months, then 75 IU every day
for 1-2 years, then 150 IU 5 days a week for another year. I use hCG
to achieve adequate testosterone level as most men will sooner or
later complain of their erectile dysfunction if T level is too low.
The reason for early use of FSH are published studies indicating the
during puberty Sertoli cells undergo differentiation into mature
Sertoli cells, and we know that normal Sertoli cell function is
necessary for optimal spermatogenesis and steroidogenesis - for
example isolated human Leydig cells producemore testosterone per
100,000 cells per 24 then when they are co-cultured with Seroli
cells, then when they are cultured without Sertoli cells.
The timing to start sperm production is similar to events occurring
during puberty. From studies done in 60s and 70s in Europe it takes
18-24 months for sperm to occur in morning urine, thus I tell my
patients that it will take at least 12 months before we will check
semen for sperm production, but those are all men who have not
initiated puberty and/or had bilaterally undescended testes which is
consistent with more severe HH.
Treatment with hCG will not result in elevation of FSH or LH as most
of commercial lab assays for LH have minimal cross-reactivity with
hCG. However when we use Repronex (human menopausal gonadotropins
from postmenopausal women) we can measure LH, FSH, and hCG in low
dose as urine of postmenopausal women normally has hCG. Please
remember that Repronex is standardized to human LH and FSH 2nd WHO
standard (1964) and this standard is not applicable to hCG.
The reasons for his low testosterone may be lack of GH - you can
measure IGF-1, poor compliance, and anti-hCG antibodies. To exclude
latest - Repronex would be an excellent option.

Best regards.

-- 
Darius A. Paduch, MD., PhD
dap2013@med.cornell.edu
Assistant Professor of Urology and Reproductive Medicine
Staff Scientist, Population Council
Department of Urology
Weill Cornell Medical College
525 E 68th St., F -924A
New York, NY 10021
office: 212-746-5309
lab: 212-327-8740
fax: 212-746-7287