with a history of AAS regretted their decision to use AAS

and what factors drove these feelings (Buckley

et al.

1988; Kanayama

et al.

, 2001; Evans, 2004; Parkinson &

Evans, 2006; Cohen

et al.

, 2007). Most men who under-

stood the effects that AAS would have on their fertility

did not experience regret; however, those who regretted

AAS use were signiFcantly more likely to not have com-

prehended the negative impact on fertility. In contrast,

the rates of actual fertility issues were equal in men who

regretted AAS use and those who did not.

Given the illicit nature of AAS, information regarding

their usage patterns is difFcult to identify in the context

of the medical literature. The only study to date that has

examined feelings of regret with regard to AAS use was

conducted in 1995; however, it was focused on profes-

sional athletes who used AAS for competitive reasons

(Silvester, 1995). In that study by Silvester (1995) from

the cohort of 22 competitive shot-put/discus athletes

studied, only 9.1% (

2) noted that they regretted their

prior AAS use. ±urthermore, a total of 86% believed there

were no long-term physical health problems, with only

one patient (4.5%) stating that AAS caused a permanent

reduction in the size of his testicles (Silvester, 1995).

Indeed, the majority of the patients in the Silvester

(1995) perceived their health problems to be a nuisance,

rather than a severe or debilitating condition. While the

population in the current study is different, the frequency

at which patients reported regret is similar.

When considering the long-term impact of AAS on

health, the current study examined whether the well-

known side effects of altered cholesterol values and

increased levels of aggression, acne and ²uid retention

were a reason for regret (±ig. 1). While no differences

were found, a possible limitation to our anonymous sur-

vey approach was that it was not possible to ascertain the

exact medical history of our study participants. As such,

we relied on patient self-report rather than actual medical

records. ±urthermore, given the anonymous nature of the

survey, we were unable to ascertain the reliability of the

survey or to correlate serum levels to patient responses.

Given that AAS users have previously been shown to

experience poor parental relationships (Skarberg & Eng-

strom, 2007), and partner/spousal anxiety and depression

results in emotional distress (Van den Broek

et al.

, 2013),

we sought to analyse whether spousal awareness and the

resultant relationship consequences had any in²uence on

AAS-induced regret. In our population, the majority of

spouses and partners were aware of their partners AAS

use; with most mentioning that it had no effect on their

relationship (±ig. 1). Similarly, mood affective disorders

have been recognised as a complication of AAS use with

case reports describing everything from unspeciFed mood

disturbances (Lindstrom

et al.

, 1990) as well as hypomania,

mania, irritability and feelings of power and invincibility

(Rashid

et al.

, 2007). In our study population, spousal

communication does not appear to be an issue, and while

we were unable to capture any psychiatric disorders,

mood disturbances were similar between men with and

without regret.

Unfortunately, as most men begin AAS at a young age

and are presumed to obtain the medication from illicit

sources, they are not educated regarding the possible nega-

tive outcomes that come with their use. AAS suppress LH

and ±SH leading to acute hypogonadotropic hypogona-

dism (Coward

et al.

, 2013). In a subset of men, this ana-

bolic-steroid-induced hypogonadism (ASIH) can result in

long-term or permanent inhibition of their hypothalamic

–

pituitary axis (Jarow & Lipshultz, 1990; Pirola

et al.

, 2010;

Boregowda

et al.

, 2011). ±urthermore, the exogenously

elevated serum testosterone levels obtained from AAS

results in oligospermia and azoospermia (Dohle

et al.

2003). A primary Fnding of our study was that regretful

prior AAS users did not understand the possibility that

ASIH could result and future fertility could be hampered

(±ig. 2). Indeed, those men with regret were less likely to

have understood the potential negative impacts on both

long-term testosterone levels (

0.06) and fertility

(

0.029) than men without regret.

The Fndings in the current study are important when

dealing with hypogonadal patients with ASIH seeking

TST. As a proportion of patients may be hypogonadal due

to ASIH (Coward

et al.

, 2013), asking about AAS is

important. ±urthermore, it is valuable for men with ASIH

to understand the impact that exogenous AAS may have

had on their fertility. In these men with a previous history

of AAS who present with infertility and hypogonadism,

multiple pharmacological treatments are available, includ-

ing exogenous testosterone, human chorionic gonadotro-

pin (hCG), human menopausal gonadotropin (hMG),

recombinant ±SH and clomiphene citrate (Martikainen

et al.

, 1986; Gill, 1998; Menon, 2003; Ioannidou-Kadis

et al.

, 2006; Hsieh

et al.

, 2013; Rahnema

et al.

, 2014).

Acknowledgements

JRK and RR are NIH K12 Scholars supported by a Male

Reproductive Health Research Career (MHRH) Develop-

ment Physician-Scientist Award (HD073917-01) from the

Eunice Kennedy Shriver National Institute of Child

Health and Human Development (NICHD) Program.

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