pact of T deﬁciency on the overall health of men was

recently examined in meta-analyses.

2–4

Hypogonad-

ism was found to be linked to cardiovascular mortality,

metabolic syndrome, osteoporosis, frailty, noninsulin

dependent diabetes and depression.

Treatment for hypogonadism typically includes

TRT, which results in satisfactory amelioration of

symptoms and normalization of serum T. However,

treatment with exogenous T decreases serum gonad-

otropins, impairs normal spermatogenesis and sup-

presses intratesticular T. Azoospermia develops in

up to 40% of patients on TRT and, as a result,

treatment of hypogonadal men desiring to reproduce

while on TRT remains a challenge.

However, recent

studies indicate that intratesticular T can be main-

tained during TRT with co-administration of low

dose HCG, suggesting that exogenous HCG in the

setting of TRT may also preserve spermatogenesis

in these men.

We hypothesized that HCG is protec-

tive and preserves spermatogenesis in patients un-

dergoing TRT.

MATERIALS AND METHODS

After obtaining institutional review board approval, we

retrospectively reviewed the medical records of hypogo-

nadal men who desired fertility preservation during TRT

and presented to a single andrology clinic at Baylor Col-

lege of Medicine between 2006 and 2010. We identiﬁed 26

men, who were included in the study. All men were

started on TRT using daily transdermal gels or weekly

intramuscular injections as well as simultaneously on in-

tramuscular HCG (500 IU) every other day. The hypogo-

nadism diagnosis was based on symptoms, including low

libido, erectile dysfunction, low energy, poor concentra-

tion, inadvertent weight gain and sleep disturbances as

well as serum T 300 ng/dl or less.

Baseline T, FT and E were assessed before the start of

TRT, as were baseline semen analyses. Men were followed

after TRT initiation approximately every 2 to 4 months.

The effects of treatment on serum hormone values and

serum parameters were assessed at followup. All serum

hormone evaluations were performed at the Laboratory

for Male Reproductive Research and Testing, Baylor Col-

lege of Medicine on a single Access® 2 assay system.

Data were analyzed using Excel® and SPSS®. The

study was powered to identify a 45% difference in any

semen parameter with an

error probability of 20% and a

total sample size of 24 patients required. Statistical com-

parisons between baseline and followup values were per-

formed using the Student t test after evaluating our data

set for parametricity using Q-Q plots and Kolmogorov-

Smirnov goodness of ﬁt testing. Statistical signiﬁcance

was considered at p

0.05.

RESULTS

A total of 31 consecutive hypogonadal men who de-

sired fertility preservation were identiﬁed for study

inclusion. In 26 of these men complete data were

available on semen parameters and serum hormone

quantitation before and after TRT. The average

SD age of our cohort was 35.9

9.5 years. Men were

followed a mean of 6.2

4.9 months and up to 18

months (

table 1

). Of the men 19 men were treated

with injectable T formulations, while 7 used trans-

dermal gels. All men received intramuscular HCG

(500 IU) every other day.

In the cohort mean serum hormone levels before

vs during treatment were T 207.2

99.2 vs 1,055.5

420.9 ng/dl (p

0.0001), FT 8.1

3.9 vs 20.4

13.5

ng/dl (p

0.02) and E 2.2

1.0 vs 3.7

2.6 ng/dl

0.11), supporting the efﬁcacy of TRT in these

men. Mean pretreatment semen parameters were

volume 2.9

1.4 ml, density 35.2

29.6 million per

ml, motility 49.0%

10.4%, FP 2.3

0.3 and TMS

count 84.6

82.4 million.

To ascertain the effects of exogenous TRT and

HCG on semen parameters the men were followed at

2 to 4-months intervals with semen parameters and

hormonal assessment compared to pretreatment pa-

rameters. A statistically signiﬁcant decrease in se-

men volume was observed at 1 to 2 months of fol-

lowup (p

0.04). This small difference was not

observed at any other followup point. Furthermore,

no statistically signiﬁcant differences were noted in

other semen parameters at any followup time

(

table 2

). No signiﬁcant differences were observed in

semen parameters between the injectable and trans-

dermal TRT groups (

table 3

). Taken together, these

data indicate that concomitant HCG therapy in the

setting of TRT is effective for preserving semen pa-

rameters.

Table 1.

Patient demographics

No. pts

Mean

SD age

35.9

9.5

Mean

SD followup (mos)

6.2

4.9

No. TRT formulation:

Transdermal

Injectable

19†

Mean

SD pre-TRT hormone levels (ng/dl):

207.2

99.2

8.1

3.9

2.2

Mean

SD pre-TRT semen parameters:

Semen vol (ml)

2.9

1.4

Sperm density (million/ml)

35.2

% Sperm motility

10.4

Forward progression

2.3

0.3

TMS (million)

84.6

82.4

Mean

SD post-TRT hormone levels (ng/dl):

1,055.5

420.9

20.4

13.5

3.7

2.6

* AndroGel® (5 gm daily) in 2 patients and Testim® (5 gm daily) in 5.

† Testosterone enanthate (200 mg weekly) in 2 patients and testosterone cypi-

onate (200 mg weekly) in 17.

HUMAN CHORIONIC GONADOTROPIN PRESERVES SPERMATOGENESIS

648