17 Infertility

Successful testicular sperm retrieval in adolescents with Klinefelter

syndrome treated with at least 1 year of topical testosterone and

aromatase inhibitor

Mehta A, Bolyakov A, Roosma J, et al (Weill Cornell Med College, NY)

Fertil Steril 100:970-974, 2013

Objective.dTo evaluate surgical sperm retrieval rates in adolescentswith Klinefelter syndrome and testosterone replacement therapy (TRT).

Design.dCase series.Setting.dAcademic medical center.Patient(s).dTen patients with Klinefelter syndrome, aged 14e22 years,

treated with testosterone replacement and aromatase inhibitor therapyfor a period of 1e5 years before surgical sperm retrieval.

Intervention(s).dMicrosurgical testis sperm extraction with cryopreser-vation of harvested tissue.

Main Outcome Measure(s).dPresence of spermatozoa within testistissue.

Result(s).dSuccessful sperm retrieval in 7/10 patients (70%).Conclusion(s).dUse of topical TRT did not appear to suppress sperma-

togenesis in adolescents with KS. It is uncertain whether sperm retrievalrates would be higher or lower without testosterone replacement in theseyoung males. Sperm cryopreservation should be discussed in all KS adoles-cents who are either receiving or considering initiating TRT.

:

Klinefelter syndrome (47 XXY) is often identified when a boy fails to progress

through puberty. Small testes are noted on physical examination, and serum

studies demonstrate low testosterone and elevated gonadotropins (luteinizing

hormone and follicle-stimulating hormone). Testosterone replacement (TRT)

allows age-appropriate pubertal development, increasing muscle mass and pres-

ervation of bone density. However, TRT may suppress testicular function and

decrease the chance of fertility. In prepubertal males, the authors use an aroma-

tase inhibitor in conjunction with TRT to decrease negative feedback on the

pituitary from estradiol. Historically, testicular biopsies in Klinefelter syndrome

do not show mature sperm. However, using the current protocol, the authors

retrieved and cryopreserved sperm in 7 of 10 adolescents. There are ethical and

logistical issues associated with obtaining a semen analysis and surgical sperm

219

retrieval in a boy who may not be concerned about future fertility. That being

said, this technique may allow fatherhood.

D. E. Coplen, MD

Testosterone use in the male infertility population: prescribing patterns

and effects on semen and hormonal parameters

Samplaski MK, Loai Y, Wong K, et al (Univ of Toronto, Ontario, Canada)

Fertil Steril 101:64-69, 2014

Objective.dTo analyze how frequently and why men presenting withinfertility take testosterone (T) and if negative effects of T on semenparameters are reversed following cessation.Design.dAnalysis of a prospectively collected database.Setting.dMale Infertility clinic.Patient(s).dMen presenting for fertility evaluation from 2008 to 2012.Intervention(s).dNone.Main Outcome Measure(s).dThe frequency and reason for T use in the

infertile male population, and semen and hormonal parameters while on Tand following discontinuation.Result(s).dA total of 59/4,400 men (1.3%) reported taking T. T was

prescribed by a variety of physicians, including endocrinologists (24%),general practitioners (17%), urologists (15%), gynecologists (5%), andreproductive endocrinologists (3%). Only one of the men admitted thathe had obtained T from an illicit source. More than 82% of men were pre-scribed T for the treatment of hypogonadism, but surprisingly, 12% (7/59)were prescribed T to treat their infertility. While on T, 88.4% of men wereazoospermic, but by 6 months after T cessation, 65% of the men withoutother known causes for azoospermia recovered spermatogenesis.Conclusion(s).dIn Canada, T was not commonly used by men present-

ing for fertility investigation (1.3%). Close to 2/3 of infertile men using Trecovered spermatogenesis within 6 months of T discontinuation.

:

Testosterone is commonly prescribed to treat hypogonadism but adversely

affects spermatogenesis by suppressing hypothalamic gonadotropin-releasing

hormone and pituitary follicle-stimulating hormone and luteinizing hormone

production. Given the physiology, it is surprising that some men in this study

were given testosterone supplementation to treat infertility. In men admitting

to receiving testosterone supplementation, the vast majority had azoospermia.

To screen for men unknowingly receiving testosterone or another androgen

in a nutritional supplement, the authors used a suppressed serum LH

(<0.1 IU/L). None of these 27 men admitted to testosterone usage, although

9 had central hypogonadotropic hypogonadism (Kallmann syndrome). Unfortu-

nately, there was no reversible pharmacotherapy in this subset of men. Sperma-

togenesis improved in most men after cessation of testosterone, but caution

220 / Urology