Treatment of idiopathic hypogonadotropic hypogonadism in men with luteinizing hormone-releasing hormone: a comparison of treatment with daily injections and with the pulsatile infusion pump

Treatment of idiopathic hypogonadotropic hypogonadism in men with luteinizing hormone-releasing hormone: a comparison of treatment with daily injections and with the pulsatile infusion pump

FERTILITY AND STERILITY Copyright ~ Vol. 47, No.3, March 1987 Printed in U.8A. 1987 The American Fertility Society Treatment of idiopathic hypogon...

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FERTILITY AND STERILITY Copyright

~

Vol. 47, No.3, March 1987 Printed in U.8A.

1987 The American Fertility Society

Treatment of idiopathic hypogonadotropic hypogonadism in men with luteinizing hormone-releasing hormone: a comparison of treatment with daily injections and with the pulsatile infusion pump

Avner A. Shargil, M.D.* Consulting Endocrinology Clinic, United Sick Fund, Petach-Tikua, Israel

Thirty husbands in childless couples, aged 24 to 35 years, were treated with luteinizing hormone-releasing hormone (LH-RH) for idiopathic hypogonadotropic hypogonadism (lHH) of peripubertal (incomplete) type. They were azoospermic or oligospermic, with < 1.5 x 106 1ml nonmotile spermatozoa. The diagnosis of IHH was based on clinical and laboratory features and testicular biopsy specimen study and was further supported by results of stimulation tests and gonadotropin-releasing hormone (GnRH) test. Two treatment modalities were used: subcutaneous injections of 500 fLg LH -RH twice daily; and perpetual subcutaneous injection, via portable infusion pump, of 25 nglkg LH -RH, at 90-minute intervals. Two patients required a short second period of pulsatile treatment to cause a second pregnancy of their spouses. The pump proved to yield better results, compared with intermittent injections, in respect to endocrine responses, spermatogenesis, and fertility capacity. Normal levels of luteinizing hormone and follicle-stimulating hormone were reached in 2 to 3 weeks and normal testosterone levels in 8 to 10 weeks from the start of treatment. Sperm counts rose to > 60 x 1061ml viable spermatozoa with < 15% of abnormal forms in 3 to 5 months, and the wives conceived. Of a total of 18 deliveries of healthy infants, 12 offspring were identified genetically with their fathers. Four women were still pregnant at the conclusion of the study. The pump was well tolerated, without special operational problems to the patients. Pulsatile treatment is therefore recommended in the treatment of well-diagnosed and carefully selected cases of incomplete IHH. Fertil SteriI47:492, 1987

In 1971, Schally and his group1 identified and produced a synthetic decapeptide that was undistinguishable from the natural gonadotropin-releasing hormone (GnRH); it was named luteinizing hormone-releasing hormone (LH-RH). Normal GnRH secretion from the hypothalamus is needed to maintain adequate gonadotropin function of the anterior pituitary, when the hypophysis per se is intacL2-7 LH-RH has been used to Received September 25,1985; revised and accepted November 26, 1986. *Reprint requests: Avner A. Shargil, M.D., Consulting Endocrinology Clinic, United Sick Fund, P.O. Box 765, 49 107 Petach-Tikva, Israel. 492

Shargil Treatment of IHH in men with LH-RH

achieve that goal in hypothalamic or idiopathic hypogonadotropic hypogonadism (IHH).4,6-10 Normal gonadotropin secretion may be disturbed by various types or degrees of primary failure of GnRH secretion, as in IHH, for which LH-RH treatment can be therapeutically effective. 6 Other factors that inhibit normal secretion include structural damage to the hypothalamic-pituitary axis 11 and chemical disturbances and receptor changes in the pituitary gland. 5, 12-15 In these cases, the success rate for LH-RH therapy is low, at best. To get closer to the diagnosis of IHH, we checked the responses of serum LH and folliclestimulating hormone (FSH) to LH-RH,7, 16, 17 as Fertility and Sterility

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well as spermatogenesis and steroidogeneSis. 15, 17-20 For that same purpose, human chorionic gonadotropin (hCG) tests and clo~iphene citrate (CC) tests were performed. In our series, there was no patient with olfactory disturbances, as might be expected in view of the Mediterranean origin of most of the patients and the age of recognition of the syndrome. 21 The patients' type of IHH and their responses to the CC test are discussed below. Since 1975, 30 men, 24 to 35 years old, married for 2 to 8 years without children, were treated with LH-RH for IHH. Group A was composed of 18 patients treated with intermittent injections of LH-RH in doses of 1000 j.Lg/day 6 with partial success. This method has been subject to criticism. 10 Other investigators 14 have reported differences in response to different doses ofLH-RH, regimens of treatment, types of analogs, and several other factors. After the pulsatile pattern of GnRH was reported2-4 and the pulsatile method for LH-RH injections established and available,9, 18, 19, 22 the last 12 patients, group B, were treated by means of a pulsatile pump. Two of the patients in group A, who wanted a second baby, were also treated with the pump. A modified Medix (Medix Electronics Ltd., Ness-Ziona, Israel) portable computerized pulsatile infusion pump was used for that purpose. LH-RH was infused into subcutaneous tissue of the abdominal wall in doses of 25 nglkg, at 90-minute intervals. 17 , 19,22,23 MATERIALS AND METHODS PATIENTS

Thirty patients took part in the study, and all gave informed consent. The diagnosis of incomplete IHH (adult type, peri pubertal) was established in 28 patients. Of these, 15 had been treated, at least 1 year before admission to the study, with testosterone (T), gonadotropins, or a combination of the two. The other two patients were admitted within 6 months of their last treatment with gonadotropins and possibly with LH-RH analogs combined with unidentified hormones. Therefore, no definite conclusion as to the degree and type of IHH could be drawn from the results of their examinations. Both groups had the same proportion of pretreated and untreated patients. All 30 patients had been sterile throughout their married lives before treatment with LH-RH. Vol. 47, No.3, March 1987

They had poor masculine stature, decreased hair growth, and scanty beard growth with a shaving frequency of two to four times per month. Their genitalia were underdeveloped, with juvenile penis and testicular volume of 2 to 8 ml (2 to 6 ml [mean, 3.8 mll among those not treated previously, and 5 to 8 ml [mean, 6.7 ml] among those who had had hormonal treatment in the past). All lacked libido, and impotency was the rule. When not on T, a few had infrequent weak erections, and ejaculations were very rare. These data confirm clinically the diagnosis of hypogonadism. None of the patients, 93% of whom were of Mediterranean or Near Eastern origin, suffered anosmia or hyposmia, and none had cryptorchidism or any other related lesions. In most cases, a testicular biopsy specimen was performed and revealed retardation of testicular' development and function, with only moderate increase of connective tissue in a few patients. Some foci were eventually found, showing preliminary spermatogenesis, practically without mature spermatozoa. There was no case in which basic normal testicular components were absent. A detailed questionnaire, concerning past history and detailed family history as well as past treatments and investigations was presented, but because anamnesis was received at an age of> 24 years, the past history data were incomplete, based mainly on recollection. Therefore, we relied only on the data collected since the patient's referral for treatment. The laboratory data on admission were as follows. Roentgenogram of the skull, sella turcica, and bone age estimation were within normal limits. Sex chromatin study showed a male pattern. Pubertal stage estimation (Tanner) was stage 3 in two patients, stage 2 in most patients, and stage 1 to 2 in several patients. It was always lower than expected for the patient's chronologic age. However, in keeping with the low T levels, which reached 1.9 ng/ml in only one case (range in most cases, 0.7 to 1.3 ng/ml, with five cases as low as 0.4 to 0.6 ng/ml). Sperm counts were mostly azoospermic, with few patients having severe oligospermia of only immature sperms. FSH levels were always < 2.5 mIU/ml and generally < 2.0 mIU/ml. LH levels were 2.5 mIU/ml in one case, 2.3 mIU/ml in two cases, and 1.0 to 1.5 mIU/ml in all other cases. Examination of other hormones, including thyroid-stimulating hormone, thyroid hormones, prolactin (PRL), cortisol, and 1713-estradiol (E 2), revealed normal values. These reShargil Treatment of IHH in men with LH -RH

493

sults established the diagnosis of hypogonadotropic hypogonadism. The cumulative clinical data laboratory findings, and results of the stimulatio~ tests indicated that the lesion was located at the hypothalamic-pituitary axis. The diagnosis of IHH of the adult type was established. HORMONE RADIOIMMUNOASSAY

The following preliminary hormone examinations, baseline samples (before every stimulation test), and hormone determinations (at all stages of treatment) were performed twice (in two laboratories) with the use of radioimmunoassay (RIA). 17f>-Estradiol. Laboratory A: Direct E2 1251 solid-phase coated-tube RIA for E2 (ZER Science Based Industries Ltd., Jerusalem, Israel). Sensitivity: 12.5 pg/ml. Laboratory B: Immuno-E 2 10dine-125 kit, Pantex 047 (Pantex division of BioAnalysis Inc., Santa Monica, CA). Sensitivity: equivalent to 10 pg/ml in serum. Testosterone. 035, Immuno-T- 1251 kit, by Pantex (Pantex division of Bio-Analysis Inc.). Sensitivity: 5 pg/ml (both laboratories). Luteinizing Hormone. RIA kit, ref. LHK-PR, by CIS-Commissariat a l'Energie Atomique (Sorin Biomedica SpA, Rome, Italy). Sensitivity: 1 mlUi ml, Medical Research Council 68/40 (both laboratories). Follicle-Stimulating Hormone. RIA kit, ref. FSHK-PR, by CIS-Commissariat a l'Energie Atomique (Sorin Biomedica SpA). Sensitivity: 1 mlUlml, Medical Research Council 78/549 (both laboratories). Prolactin. Laboratory A: PRL-RIA kit by Amersham (Amersham International Ltd., Amersham, UK), covering the range 0 to 200 ng/ml ofPRL (0 to 4000 /-LIUlml, World Health Organization's 1st International Reference Preparation (IRP 1) 75/504 for PRL, standardized accordingly (1 ng PRL = 19 /-LIU PRL). Laboratory B: PRL-NHS with human serum calibrators, Coat-A-Count, solid-phase RIA (Diagnostic Products Corporation, Los Angeles, CA), standardized in terms of the World Health Organization's IRP1 75/504. STIMULATION TESTS

To establish the exact nature of the disease, we performed the following stimulation tests. The hCG test was done to reveal the responsiveness of Leydig cells to the injection of hCG (Pregnyl, Organon, Oss, The Netherlands), 1500 Ulday, for 3 494

Shargil Treatment of IHH in men with LH-RH

consecutive days. The CC test was performed by administering 100 mg CC/day for 6 days. Blood samples were drawn on the first, third, fifth, and seventh days of the test for LH and FSH measurements. This test was done to establish the responsiveness of the gonadotropin-secreting cells of the hypophysis and the degree ofhypothalamic immaturity (whether profound or moderate). For the GnRH test, a bolus intravenous injection of 100 /-Lg of LH-RH was given, and blood samples were drawn for LH and FSH estimations before the medication was injected and again 10, 20,30, and 40 minutes thereafter. METHODS OF LH-RH TREATMENT

The 18 group A patients received synthetic LHRH (Hoechst, Frankfurt AM, FRG) self-injected subcutaneously in two 500-/-Lg doses/day (1000 /-Lg/ day). They received the treatment for 6 to 10 months. The 12 group B patients received the LH-RH treatment for 5 to 7 months, by means of a portable pulsatile infusion pump. LH-RH, either Hoechst synthetic (Hoechst) or Serono's [(pyro)GLU -HIS-TRP-SER-TYR-G L Y -LEU -ARG-PROGLY-(NH 2)] (Serono Pharmacologic Institute, Rome, Italy), was infused via a subcutaneous canula, inserted into the anterior abdominal wall· the pump itself was carried on an ordinary belt suspended from a sling. The injection site was changed every 4 days. The patients were instructed on how to insert the canula themselves prepare the infusion solution, and handle th~ pump. The hormone was injected at 90-minute intervals for 24 hours, throughout the treatment period. The dose of LH-RH injected in each pulse was 25 ng/kg body weight. Some patients (not included here) had received ~ 20 nglkg with no positive results; other patients (also not included in the present study) received ~ 35 nglkg of LHRH with no effect on the results with the increased dosage. Therefore, the dose of 25 nglkg per pulse was determined to be the most suitable dose. LH and FSH serum circulating values were measured before LH-RH was administered at monthly intervals until treatment was stop~ed, . and again several months after cessation of therapy. The same schedule was used for T reassessments and sperm analysis (with ejaculates obtained after 5 days of abstinence). The clinical criteria were reassessed only at the end of the treatment, following the lines of the introductory questionnaire.

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Fertility and Sterility

RESULTS

Table 1. CC Test Patient

STIMULATION TESTS

The hCG test revealed a positive reaction of Leydig cells to the injection of 1500 U hCG/day, for 3 consecutive days, with a T level more than two times the initial T level. The mean baseline T level was 1.6 ± 0.8 ng/ml; it rose to 6.2 ± 1.3 ng/ml on the fourth day of the test, except in the two patients in the pulsatile-treated group, who proved to be failures. Figure 1 presents the highest and lowest responses of each group and a failure case. The administration of 100 mg CC/day for 6 days, resulted, in some patients, in LH levels three to four times the initial levels (from 1.9 ± 0.7 mIU/ml to 8.25 ± 0.75 mIU/mI) and FSH levels two to three times the initial levels (from 2.15 ± 0.35 mIU/ml to 5.25 ± 1.75 mIU/mI). level increases were lower (from practically no response or as low as 1.8 ng/ml after 6 days ofCC, up to 4.1 ng/ml, in the patient that had a preliminary level of 1.9 ng/mI). Full T level development requires a longer period of treatment with CC.

r

nl/ml

9.0 w

z

,,,

PREGNYL 1500/DAY/3 DAYS

u.

1 .... DAILY INJ.

a: 7.0

2'"

w

fI)

6.0

fI)

5.0 4.0

2.0 1.0 0

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2

3

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3.0

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100 mg CC/day administration Baseline 2 4 6

Aa Ib

2f

BK 3b

4' 5h

LHc FSH d T" LH FSH T

2.3 2.5 1.8 2.5 2.1 1.2

8.0 4.9 3.0 4.0 3.5 3.4

6.9 5.0 3.4 7.5 5.4 3.1

7.9 4.5 4.2 9.0 7.0 3.5

LH FSH T LH FSH T LH FSH T

1.2 2.0 0.9 1.5 1.8 0.7 1.6 1.0 1.4

6.0 2.6 2.0 3.0 3.2 1.4 2.4 1.0 1.0

5.7 3.9 2.1 6.4 4.3 1.4 1.6 1.3 1.1

8.4 4.2 2.5 7.5 3.5 3.0 2.0 1.1 1.5

aDaily intermittent LH-RH injections. bEarly highest responder of each group. cLH in mIUlml. dFSH in mIU/ml. "T in ng/ml. 'Early lowest responder of each group. 6Pulsatile LH-RH treatment. hFailure case.

Patients with less favorable results to the CC test or with no response to CC administration, hence the more profound cases of IHH, also failed at that stage to respond to LH-RH treatment (Table 1).

8.0

0

... ...0 ...w

Test

A full positive response to the bolus intravenous injection of 100 I-Lg LH-RH was achieved when initial LH levels rose many-fold in 20 to 40 minutes after injection (from 1.75 ± 0.55 mIU/ml to 12.9 ± 3.7 mIU/mI). On the other hand, FSH was found only double the initial level in such a short period. It was found later that the patients who had a lower LH response were treatment failures or weak responders to LH-RH treatment. For example, this was true of the group B two failure patients who had a very low response to the GnRH test. Figure 2 illustrates the highest and lowest responses to the test by treatment group, and one failure case. LH-RH TREATMENT

1

4

5

DAYS

Figure 1 hCG test. T levels after 3 days of 1500 U hCG injections per day. Cases 1 (-----) and 2 (~) represent the highest and lowest responders, respectively, of group A (intermittent daily injections of LH-RH). Cases 3 (- - .....) and 4 (.... - -) represent the highest and lowest responders, respectively, of group B (pulsatile treatment). (---) Failure case in group B. Vol. 47, No.3, March 1987

Group A: 18 Patients Treated with Daily LH~RH Injections Ten of these 18 patients reacted positively to therapy, as manifested by an LH level increase, from an initial value of 2.1 ± 0.4 mIU/ml to 23.2 Shargil Treatment of IHH in men with LH-RH

495

LH mlU/ml

18.0 18.0

,

FSH

LH·!tH 100meo/I.V.

mlU/ml

9.0 8.0

14.0

7.0

12.0

8.0

,

LH·RH 100mcg/t.V.

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C . . . 3} .. ------.

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C ••• 4 .............

10.0

5.0 2

8.0

4.0

8.0

3.0 Fe i1ur.

4.0 2.0

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2.0 1.0

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30

40 Minute.

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40 Minute.

Figure 2 LH and FSH in GnRH test. LH and FSH levels at 10-minute intervals, up to 40 minutes, after a bolus intravenous injection of 100 f,Lg LH-RH. Cases 1 and 2 represent the highest and lowest responses, respectively, for group A, and cases 3 and 4 the highest and lowest for group B. The failure case is from group B.

± 4.2 mIUlml, in 6 to 8 weeks. Some reduction of the response, followed by stabilization at a level of 16.0 ± 1.0 mIU/ml of serum LH, was achieved from the third month of LH-RH treatment until the end, 6 to 10 months after it was initiated. Figure 3 (cases 1 and 2) represents the highest and lowest initial responses in this group. FSH rose from an initial level of 2.3 ± 0.7 mIU/ml to 5.0 ± 0.7 mIUlml within 8 weeks and stabilized thereafter at a normal level of 4.0 ± 0.5 mIU/ml (Fig. 4, cases 1 and 2). Normal T levels were reached in 8 to 10 weeks (6.35 ± 2.05 ng/m}), with the highest levels attained after 3 to 4 months (7.9 ± 1.2 ng/m}) (Table 2, cases 1 and 2). Sperm counts (Table 2, cases 1 and 2) rose from 0 or severe oligospermia to at least 60 x 106/ml of viable spermatozoa (at least 3 mllejaculate, good motility after 4 hours, and < 20% abnormal forms) in > 3, especially> 4, months of therapy, in only 8 of the 10 so-called responders, based on hormonal criteria. The other two patients, who responded with normal gonadotropins and T levels, did not impregnate their wives, as was the case with the remaining eight nonresponding patients in that group (group A). Spermograms of the remaining six responders at the eighth month of treatment fell between the two extreme sample cases, between 110 x 106/ml and 90 x 106/ml spermatozoa. The two patients with increased hormone response who did not impregnate their wives showed a transitory elevation in sperm count to 1.5 and 7.2 x 106/ml, but these levels dropped thereafter to < 1 x 106/ml nonmotile 496

Shargil Treatment of IHH in men with LH -RH

immature spermatozoa. The failure cases never demonstrated any sign of progressive spermatogenesis.

Group B: 12 Patients Treated via Pulsatile Pump These patients reacted more dramatically to the LH-RH treatment, although a very low dose was used. The treatment succeeded in ten patients, all responders to the GnRH test and with a positive response to hCG and CC tests. The two failures were low responders to those tests, especially to the GnRH test. Ten men responded to treatment, with a rise ofLH from 2.1 ± 0.4 mIU! ml to as high as 37.0 ± 3.0 mIU/ml in 2 to 4 weeks (Fig. 3; cases 3 and 4 represent the highest and lowest responses), and were stable thereafter at a level of 21.5 ± 1.5 mIU/ml. FSH levels (Fig .. 4, cases 3 and 4) rose -from 1.8 ± 0.2 to 5.4 ± 1.3 mIU/ml in 2 to 3 weeks, rose further by 1.2 ± 0.6 mIUlml through the next 4 weeks, and stabilized thereafter at 3- to 4-week levels. It took 8 to 10 weeks for serum T levels to reach normal values (the same period as needed for those treated by daily injections), from 0.9 ± 0.2 ng/ml to 5.0 ± 1.4 ng/ml, and 1 month more to rise as high as 7.0 ± 0.8 ng/ml (Table 2, cases 3 and 4). Spermatogenesis progressed faster in those ten patients than in the patients treated with daily injections, and sperm counts reached at least 60 x 106/mlof viable spermatozoa (ejaculates of at least 3 ml, good motility after 4 hours, and < 15% pathologic LH mlu/ml

1} • • e".3} ...... .. e •••

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DAILY INJ.

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40 35

4

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PULSATILE ........

30 25

5

LH 2

3

4

5

6

7

8

9

10 MONTHS

Figure 3 LH levels at monthly intervals during LH-RH treatment. Cases 1 and 2 represent the early highest and lowest responses, respectively, in group A. Cases 3 and 4 represent the same for group B. The failure case is from group B. C, conception. The values at (n) m [month] are at 4 to 7 months after cessation of therapy.

Fertility and Sterility

FSH

/jPULSTILE

mlU/ml

8

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10 MONTHS

Figure 4 FSH levels at monthly intervals during LH-RH treatment. Cases 1 and 2 represent the early highest and early lowest responses for group A. Cases 3 and 4 represent the same for group B. The failure case is from group B. C, conception. The values at (n) m [month] are at 4 to 7 months after cessation of LH-RH therapy.

forms); in 3 to 5 months of therapy; their wives conceived in 4 to 6 months after the start of LHRH treatment (Table 2, cases 3 and 4). Spermograms (or sperm counts) of the other responders in group B were between the values for the two presenting cases (Table 2, cases 3 and 4), with the highest value at 6 months of therapy being 87 x 106/ml and the lowest being 68 x 106 /ml motile spermatozoa.

size (Prader scale) reached 15 to 22 ml. The penis achieved normal adult size, with full erections at each intercourse. Ejaculations were normal and regular, and the patients reported normal libido. Libido and potency were achieved after 2 to 4 weeks of therapy, long before androgens reached even near normal adult levels. The highest sperm count reached was 120 x 106 /ml of viable spermatozoa. The pubertal stage was 5 (Tanner), LH level was higher than norplal, FSH level was normal, and T level was within normal range. Four to 7 months after cessation of treatment, some of the parameters were reassessed (Table 3), with the following results: normal levels of LH (> 5.1 mIU/ml), FSH (> 3.5 mIU/ml), T (> 4.8 ng/ ml), and sperm count (> 60 x 106 /ml). Although, all of these parameters were lower than at. the. end of the treatment,. Tanner pubertal stage was still 5. For some of the patients (wishing a second pregnancy) further reassessments were performed; these showed a further regression of the results to levels below the lower limits of the normal range. Gradual reduction after cessation of treatment might be due to residual function of activated Leydig cells and/or of activated receptors of gonadotropin-secreting cells of the anterior hypophisis.

POST-LH-RH TREATMENT

At the end of the treatment, all successful cases achieved a sexually mature body configuration and shaving rates of every 1 or 2 days (serving as an indicator for facial hair growth). Testicular

OFFSPRING

Eight patients treated with daily injections achieved fatherhood. Two of them needed a second course of treatment before being able to im-

Table 2. T Levels and Sperm Counts During LH-RH Treatment Patient

Test

Baseline 1

Months of LH-RH treatment 3 5 7

9

Aa 1b

T" spd

2e

IV 3b

4e

T

SP T

SP T

SP 58

T

SP

1.4 2.5 2.1 0

2.0 23.0 3.3 2.5

8.1 47.0 7.4 36.0

8.5 62.0 8.9 79.0

8.1 105.0 8.8 92.0

0.8 0 0.9 0 1.8 0.5

1.7 1.0 2.5 3.4 2.8 0.8

6.7 55.0 5.9 40.0 4.0 0.7

7.8 68.0 7.6 87.0 2.4 0.8

3.0 0.6

8.5 115.0 8.2 93.0

aDaily intermittent LH-RH injections. bEarly highest responder of each group. err (ng/mI). dSp, sperm count (x 106/mI). eEarly lowest responder of each group. 'Pulsatile LH-RH treatment. 8F'ailure case. Vol. 47, No.3, March 1987

Shargil Treatment of IHH in men with LH -RH

497

Table 3. LH, FSH, and T Levels and Sperm Counts After Cessation of LH-RH Treatment Daily intermittent injections (5 to 5 Pulsatile treatment months after (6 to 7 months after LH-RH) LH·RH)

Test

LH (mID/mD FSH (mID/mD Sperm count ( x 106/mD T (ng/mD Pubertal stage (Tanner)

6.05 ± 0.95 3.6 ± 0.1 70.5 ± 8.5

11.35 ± 2.85 4.25 ± 0.75 74.0 ± 8.0

5.1 ± 0.3 5

6.15 ± 0.35 5

pregnate their wives a second time, because they had lower-than-normal levels of LH, FSH, and T and lower-than-normal sperm counts. They were treated again via pulsatile infusion pump, but only for a short period of 1 to 2 months, after which their wives conceived. Both women have already given birth for the second time. Of the ten responders to the pulsatile infusion pump LH-RH .treatment, all have impregnated their wives. Eight of these have already fathered children, and two women (of the other two men ofthose ten) are still pregnant. Two of the men in group B already have had a second short course (2 months) of pulsatile treatment, and their wives have become pregnant. All pregnancies and deliveries were uneventful, and repeated examinations of the infants have revealed no deviation from normal. Of the 18 deliveries, 12 infants were identified genetically with their fathers. Three children of the daily injected fathers and two of those treated with pulsatile LH-RH were matched and identified with the use of HLA typing, and four and three babies, respectively, with the use of A-B-O, CDE/cde, and M-N blood typing. Six infants are the children of strict orthodox Jews or Muslims, who did not permit genetic identification. GENERAL

There were no allergic reactions to the treatment, and no adverse effects. In no case was there any inflammation at the site of injection. We did not face the problem of thrombophlebitis, because in both groups the subcutaneous route was used. There were no ill effects, nor did the medication affect the functioning of other hormones; this was monitored throughout the treatment period. There were no dropouts. The daily injection schedule was acceptable, with either the patients or the wives making the 498

Shargil

Treatment of IHH in men with LH-RH

injections. Changing the site of injections prevented induration and similar problems. The pump was well tolerated, with no problems in handling, changing the canulae, or preparing the solution. Those who followed the daily injection regimen for the first course and the pulsatile pump for the second preferred the latter. The use of the pump did not cause disturbances to normal daily life or sexual relations. Some orthodox Jews who used the pump even performed the weekly ritual bath (Mikveh) without interrupting the rhythm of the pulsatile infusion. DISCUSSION

Although promising results have been reported8 with intermittent injections ofLH-RH and its analogs, this method has been criticized and called unreliable. lO In mQst instances, the criticism has been directed at LH-RH treatment with daily doses of 100 to 200 f.1g. No studies to date have appeared in favor of or against treatment with doses as high as 1000 f.1g/day, such as was used for our 18 group A patients. Whether such high doses overcome blocked receptors on pituitary secreting cells (the down-regulation phenomenon), cause intracellular Ca + + concentration changes, 5 thus modulating gonadotropin production, stimulate interstitially located Leydig cells,20 or cause intracellular biochemical changes,15, 20 is yet unknown and was not investigated in this present study. There are many possible explanations for the high failure rate in group A: inhibited and damaged steroidogenesis and spermatogenesis,15, 17 down-regulatory effects and disturbed feedback mechanisms,23 and loss of pituitary response to the hormone. In fact, 8 of the 18 patients treated with injections have" fathered offspring; and seven of the children were identified and matched with their fathers. Since the pulsatile infusion of LH-RH at a physiologic rate has been shown to stimulate gonadotropin secretion in both primates2-4 and humans,9, 17-19,23 and with our better understanding of the physiologic factors that regulate the biologic pacemaker,14 treatment of hypogonadotropic hypogonadism via a miniature portable pulsatile infusion pump became the preferred modality. The pump was set to deliver a low dose (25 ngikg) every 90 minutes. The efficacy of this therapeutic method is not uniform, with divergent results in different situations. 17 , 22, 23 The results Fertility and Sterility



,

.,I'

of this study suggest promising outcomes for the low-dose pulsatile delivery of LH-RH in well-selected patients who have incomplete IHH. Ten of the 12 group B patients, treated primarily via the pulsatile pump, impregnated their wives. Eight infants have already been born, and five of these were identified and matched genetically with their fathers. Two women were still pregnant at the conclusion of this study, as were another two women whose husbands were treated primarily with the pulsatile method, had previously fathered children, and later received a second 2month course ofthe same treatment. Another two women, whose husbands had received daily injections (group B), became pregnant again after their husbands were treated subsequently with a short course of the pulsatile treatment and have already given birth to their second child. The cause of failure among group A patients may also be responsible for the failure of the two patients in group B, who were treated by the pulsatile method. I believe the primary cause of failure in these two cases was poor selection. Both men had been treated in the past for long periods with large amounts of various gonadotropins, methyltestosterone, and testosterone propionate. One reported having been treated with an unidentified LH-RH analog (injected intramuscularly) for 3 years before referral to our clinic. Their failure to respond was not unexpected. The reduction of gonadotropin secretion, steroidogenesis, and spermatogenesis after cessation of therapy is gradual in these patients, and it may be several months before they return to pretreatment levels. 24 Furthermore, it appears that the first course of treatment has a priming effect, inasmuch as the duration of a second course, required for a second impregnation, was shorter. The two phenomena may be due to a residual function of the activated Leydig cells and/or activated receptors and stimulated secreting cells of the anterior hypophysis, still able to respond to minor hypothalamic and pituitary reactions to changing feedback stimuli, by the lowering levels of gonadal steroids. 25 It is noteworthy that potency and libido appeared 2 to 4 weeks after the start of LH-RH treatment, even before androgens reached nearnormal levels. This may be a further illustration of a direct stimulatory effect of LH-RH on Leydig cells and, perhaps, on mental components of sexual behavior,12, 14, 19, 20 not only androgen-mediated. Vol. 47, No.3, March 1987

The main problem is the selection of patients. I suggest that pulsatile LH-RH therapy be considered for incomplete-IHH patients with optimal response to hCG and GnRH tests, or to the modified GnRH test discussed below. The results with more profound IHH cases are poorer and the treatment period longer. It is assumed that our patient population was of a wide range, from near classic IHH to partial or moderate hypothalamic immaturity.24 These latter (milder) forms oflHH are difficult to differentiate from extreme cases of congenital delay of puberty.26 Taking into consideration bone age, chronologic age (;:3 24 years) and absence of eunuchoid stature (only poor masculine stature with decreased hair growth) elicited the conclusion that the responding patients were peripubertal (incomplete IHH), not prepu- . bertal,24 hence the term adult-type IHH. The nonresponders or poor responders were of a more profound hypothalamic immaturity and may need a much longer period of treatment (12 to 18 months, as is the case with some patients classified here as failures and some new patients).22, 23 The positive response to CC administration by the patients who responded quickly and well to the LH-RH treatment was also an indication for the incompleteness of the IHH. The aim of the CC test was to determine whether some gonadotropin-secreting cells of the anterior pituitary were preserved and able to react. Unfortunately, the CC test failed to supply the precise information; such failures may be attributable to immature receptors and dormant cells, as a result of deprivation of the tropic hypothalamic influence. For elucidation of the correct status of the gonadotropin-secreting cells, a long CC treatment period may be necessary, and even that may be insufficient, as is the case when differentiation between IHH and congenital delay of puberty is required. 26 Nonresponsiveness to a single bolus LH-RH injection is also not conclusive and may not reflect failure of gonadotrops, but rather indicate chronic deprivation of hypothalamic activity.24-26 Furthermore, one may speculate that examination of a patient population > 24 years of age and of Near Eastern and Mediterranean origin will prove many of them to be of the incomplete-IHH type, as was the case with these patients, and therefore also responders to CC test. After the hCG test has demonstrated gonadal activity, the GnRH test is the most important indicator for successful LH-RH treatment. Patients with a good response to that test are put on Shargil Treatment of IHH in men with LH-RH

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the pulsatile pump for treatment. Patients who demonstrate a low response to the bolus LH-RH injection now receive 4 to 5 days of treatment with pulsatile LH-RH, and then the GnRH test is repeated. 26 This is important in case selection, because low responders or nonresponders even to that manipulation have a poor prognosis for benefiting from LH-RH treatment. A full positive response is achieved when the initial LH level rises many-fold 40 minutes after the bolus LH-RH injection. The FSH level may only double the baseline level in 40 minutes; I20-minute samples are preferred for demonstrating a more pronounced FSH response to the LH-RH injection. 23 For doubtful cases, Morris and colleagues 23 suggest a I-month pulsatile LH-RH therapy trial, based on their finding that those who later produced an effective spermatogenic response to therapy had normal T concentrations after 1 month of treatment. According to these findings, a 3-month trial is suggested for such cases, to prove at least a direct preliminary spermatogenic response. The intermediate and incomplete types of IHH seem to respond better to LH-RH treatment. Candidates for LH-RH treatment preferably should not have had previous hormonal treatment that may interfere with correct diagnosis or evaluation of stimulation tests. In conclusion, according to the promising results presented here, the use of chronic pulsatile subcutaneous delivery of LH-RH is an effective treatment for restoring gonadotropin secretion and curing infertility in men with incomplete adult-type IHH, when their pituitary-gonadal axis is physically intact. The treatment is well tolerated and without operational difficulties. Because it approaches natural physiologic situation, this low-dose treatment is much less expensive and much more effective than intermittent daily injections. Further studies are needed to explore the nature of the nonresponding cases of pulsatile LH-RH infusion and to determine optimal model of treatment in related syndromes. Note. Since the completion of this study, all four women reported above to be pregnant, as well as one other woman, have given birth to healthy babies. Two of the five infants were genetically matched with their fathers. Another two men have impregnated their wives. Details will be published elsewhere.

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Acknowledgments. I wish to express my appreciation to many colleagues who have referred their patients for treatment. Special thanks go to the laboratory staff for their invaluable contribution to this research. I am indebted to the medical department of Hoechst Ltd., Frankfurt AM, FRG and their Israeli agent for the generous supply ofLH-RH and for technical support. Many thanks to Medix Israel Ltd., for the free use of their pumps, and to Medipharm Ltd. (sole agents for Serono SpA in Israel) for assistance in technical finalization of the manuscript.

REFERENCES 1. Schally AV, Arimura A, Baba Y, Nair RMG, Matsuo H, Redding TW, Debeljuk L, White WF: Isolation and properties of the FSH and LH-releasing hormone. Biochem Biophys Res Commun 43:393, 1971 2. Belchetz PE, Plant TM, Nakai Y, Koegh EJ, Knobi! E: Hypophyseal responses to continuous and intermittent delivery of hypothalamic gonadotropin releasing hormone. Science 202:631, 1978 3. Knobil E: The neuroendocrine control of the menstrual cycle. Recent Prog Horm Res 36:53, 1980 4. Knobi! E, Plant TM, Wildt L, Belchetz PE, Marshall G: Control of rhesus monkey menstrual cycle: permissive cycle of hypothalamic gonadotropin releasing hormone (GnRH). Science 207:1371, 1980 5. Naor Z, Clayton RN, Catt KJ: Characterization ofgonadotropin-releasing hormone receptors in cultured rat pituitary cells. Endocrinology 107:1144, 1980 6. Yashimoto Y, Moridera K, Imura H: Restoration of normal pituitary gonadotropin reserve by administration of luteinizing hormone-releasing hormone in patients with hypogonadotropic hypogonadism. N Engl J Med 292:242, 1975 7. Roth JC, Kelch RP, Kaplan SL, Grumbach MM: FSH and LH response to luteinizing hormone-releasing hormone factor in prepubertal children, adult males and patients with hypogonadotropic and hypergonadotropic hypogonadism. J Clin Endocrinol Metab 35:926, 1972 8. Mortimer CH, McNeilly AS, Fisher RA, Murray MAE, Besser GM: Gonadotropin-releasing hormone therapy in hypogonadal males with hypothalamic or pituitary dysfunction. Br Med J 4:617, 1974 9. Jacobson RI, Seyler LE, Tambotlane WV Jr, Gertner JM, Genel M: Pulsatile subcutaneous nocturnal administration of GnRH by portable infusion pump in hypogonadotropic hypogonadism: initiation of gonadotropin responsiveness. J Clin Endocrinol Metab 49:652, 1979 10. Laron Z, Dickerman Z, Ben-Zeev Z, Prager-Lewin R, Comaru-Schally AM, Schally AV: Long-term effect of DTrp6-luteinizing hormone-releasing hormone on testicular size and luteinizing hormone, follicle stimulating hormone and testosterone levels in hypothalamic hypogonadotropic males. Fertil Steri! 35:328, 1981 11. Carmel PW, Araki S, Ferin M: Pituitary stalk portal collection in rhesus monkeys: evidence for pulsatile release of gonadotropin releasing hormone (GnRH). Endocrinology 99:243, 1976

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12. Quigley ME, Sheehan KL, Casper RF, Yen SSC: Evidence for increased dopaminergic and opioid activity in patients with hypothalamic hypogonadotropic amenorrhea. J Clin Endocrinol Metab 50:949, 1980 13. Clyton RN: The role of pituitary gonadotropin releasing hormone receptors in the physiological regulation of gonadotropin secretion. Clin Sci Molec Med 64:1, 1983 14. Veldhuis JD, Rogol AD, Johnson ML, Dufau ML: Modulation of the pulsatile release of biological active luteinizing hormone by endogenous opiates. In Hormone Action and Testicular Function, Edited by KJ Catt, ML Dufau. Ann NY Acad Sci 438:485, 1984 15. Cooke BA, Dix CJ, Habberfield AD, Sullivan MHF: Control of steroidogenesis in Leydig cells: role of Ca + + and lioxygenase products in LH and LH-RH agonist action. In Hormone Action and Testicular Function, Edited by KJ Catt, ML Dufau. Ann NY Acad Sci 438:269, 1984 16. Reitano JF, Caminos-Torres R, Snyder PJ: Serum LH and FSH responses to repetitive administration of gonadotropin-releasing hormone in patients with idiopathic hypogonadotropic hypogonadism. J Clin Endocrinol Metab 41: 1035, 1975 17. Evans RM, Doelle GC, Alexander AN, Uderman HD, Rabin D: Gonadotropin and steroid secretory patterns during chronic treatment with a luteinizing hormonereleasing hormone agonist analogue in men. J Clin Endocrinol Metab 58:862, 1984 18. Valk TW, Corley KP, Kelch RP, Marshall JC: Hypogonadotropic hypogonadism: hormonal responses to low dose pulsatile administration of gonadotropin-releasing hormone. J Clin Endocrinol Metab 51:730, 1980

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19. Skarin G, Nillius SJ, Wibell L, Wide L: Chronic pulsatile low dose GnRH therapy for induction of testosterone production and spermatogenesis in a man with secondary hypogonadotropic hypogonadism. J Clin Endocrinol Metab 55:723, 1982 20. Rommerts FFG, Molenaar R, Themmen APN, van der Molen HJ: Regulation of steroidogenic activities in Leydig cells by LH and LH-RH agonist. In Hormonal Regulation of the Hypothalamo-Pituitary-Gonadal Axis, Edited by KW McKerns, Z Naor. New York, Plenum Press, 1984, p 423 21. Burger HG, Baker HWG: Therapeutic considerations and results of gonadotropin tre'atment in male hypogonadotropic hypogonadism. In Hormone Action and Testicular Function, Edited by KJ Catt, ML Dufau. Ann NY Acad Sci 438:447, 1984 22. Hoffman AR, Crowley WF Jr: Induction of puberty in men by long term pulsatile administration oflow-dose gonadotropin-releasing hormone. N Engl J Med 307:237, 1982 23. Morris DV, Adeniyi-Jones R, Wheeler M, Sonksen P, Jacobs HS: The treatment of hypogonadotropic hypogonad- . ism in men by the pulsatile infusion of luteinizing hormone-releasing hormone. Clin Endocrinol 21:189, 1984 24. Rabinowitz D, Spitz 1M: Isolated gonadotropin deficiency and related disorders. Israel J Med Sci 11:1011, 1975 25. Winters SJ, Troen P: Evidence for a role of endogenous estrogen in the hypothalamic control of gonadotropin secretion in men. J Clin Endocrinol Metab 61:842, 1985 26. Parlsch CJ, Hermanussen M, Sippell WG: Differentiation of male hypogonadism and constitutional delay ofpuberly by pulsatile administration of gonadotropin-releasing hormone. J Clin Endocrinol Metab 60:1196, 1985

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