ASIH may suffer from sexual dysfunction

(9)

, administration

of AIs in this population may still be considered, but proper

monitoring is advised.

Management of sexual dysfunction.

Erectile dysfunction

and decreased libido are common complaints of AAS users,

especially during the post-cycle period when endogenous T

levels are lowest. Adding to the complexity of evaluating

these patients, the types of AAS used may contribute uniquely

to the pathophysiology of AAS-induced sexual dysfunction.

Certain synthetic AASs, such as nandrolone, have a reputa-

tion for causing erectile dysfunction when used alone. This

effect is likely due to an unopposed progestin-like action of

the steroid along with the relatively lower androgenic activity

of its 5-alpha metabolite dihydronandrolone (compared with

dihydrotestosterone). By concurrently administering inject-

able T, AAS users attempt to mitigate the sexual side effect

pro

le of synthetic AASs such as nandrolone (

Table 2

More than 25% of users report using PDE5i either prophy-

lactically or as treatment for erectile dysfunction

(9, 17)

Several popular Internet AAS suppliers offer drugs such as

dapoxetine, bromocriptine, and cabergoline as well as

PDE5i. In addition, AAS users commonly purchase over the

counter herbal

‘‘

aphrodisiacs

’’

that have been previously

found to contain designer analogues of licensed PDE5i

(42)

Indeed,

for

AAS

users,

initial

therapy

for

erectile

dysfunction consists of PDE5i. Although controversial, the

restoration of a normal hormonal milieu may be important

for optimal response to oral PDE5i therapies.

Management of inferility and testicular atrophy.

AAS use

can be an important cause of male-factor infertility

(12)

Although several recent reviews have addressed the effects of

androgen consumption on male fertility

(6, 12, 29, 95, 96)

some clinicians remain unaware of the fact that the use of

exogenous androgens suppresses the HPG axis and, by

decreasing intratesticular T (ITT), results in infertility

(6, 97,

98)

. Because an adequate ITT concentration is necessary for

spermatogenesis

(52)

, it is not surprising that AAS users have

presented to fertility clinics with azoospermia or oligospermia

as well as sperm dysmorphia and dysmotility

(12, 95, 99)

return of ITT is the most important factor for restoration of

spermatogenesis, and therefore initial management of AAS-

induced infertility should parallel strategies for the correction

of the underlying hypogonadotropic hypogonadism

(29, 52)

A review of the literature suggests that most cases of

AAS-induced oligospermia or azoospermia are likely to

resolve spontaneously within 4

–

12 months after AAS discon-

tinuation

(29)

. Although some authors have argued for

reserving medical treatment for cases of azoospermia lasting

24 months

(100)

, SERMs and/or gonadotropins have been

successfully used after much shorter intervals of AAS cessa-

tion

(67,

101,

102)

Spermatogenesis

recovery

time,

however, with or without medical treatment, appears to be

highly variable and is dif

cult or impossible to predict for

an individual patient.

In a case series of four azoospermic men, Gazvani et al.

reported on the spontaneous return of sperm concentration

to normal levels over a variable period of 5

–

18 months after

AAS cessation

(100)

. Turek et al. reported a single case of

AAS-induced azoospermia successfully treated with hCG,

and pregnancy was achieved after 3 months of therapy

(102)

. Menon et al. reported a return to normal semen param-

eters after 3 months of treatment with hCG and hMG in a

patient who had been untreated and azoospermic for 1 year

after stopping AAS

(67)

As far as we know, cases of persistent azoospermia

despite exhaustive medical treatment have not been described

in the literature. Clearly, the management of AAS-induced

male infertility should begin with conservative or medical

management. Histopathologic abnormalities, such as sperm

maturation arrest, have been described in AAS users and an-

imal models

(102, 103)

, and although there are no published

data con

rming the success of sperm retrieval techniques

with subsequent IVF-ICSI for cases of AAS-induced

TABLE 2

An example (considerable variations exist) of a bodybuilder's 12-week AAS cycle followed by 4 weeks of post-cycle therapy.

Week

Testosterone

cypionate, mg/wk

Nandrolone

(Deca-Durabolin), mg/wk

Metadienone

(Dianabol), mg/d

hCG

(IU/2

–

3d)

Anastrazole

(Arimidex), mg/d

Clomiphene

citrate (Clomid)

Tamoxifen

(Nolvadex), mg/d

500

750

500

750

500

750

500

1000

500

1000

500

1000

500

1000

500

1000

500

0.25

1000

500

0.25

750

500

0.25

500

0.25

200

100

Note:

AAS

anabolic-androgenic steroid.

Rahnema. Anabolic steroid

–

induced hypogonadism. Fertil Steril 2014.

1276

VOL. 101 NO. 5 / MAY 2014

ORIGINAL ARTICLE: ANDROLOGY