Pregnancy Outcome

hCG/hWIG in IHH/Kallmann syndrome

pulsatile GnRH in

IHH/Kallmann syndrome

hCG/hMG in pituitary insufficiency

hCG/hWIG in IHH/Kallmann syndrome

□ sperm positive

□ azoospermia

Fig. 4. Effectiveness of gonadotropin-releasing hormone (GnRH) or human chorionic gonadotropin (hCG)/human menopausal gonadotropin (hMG) treatment in patients with hypogonadotropic hypogonadism. (Data from ref. 117.)

nancy") increases with advancing female age even in otherwise normal women. Moreover, the time of coitus is important, because most conceptions occur on the day of ovulation and the 2 preceding days (44). If pregnancy fails to occur after 1 yr of regular unprotected intercourse, techniques of assisted reproduction may be employed.

On theoretical grounds, pulsatile GnRH treatment is more physiologic because it reproduces the normal pulsatile pattern of LH and FSH release from the pituitary in patients with GnRH deficiency. Interestingly, although GnRH must be administered in a pulsatile pattern, spermatogenesis can be induced and maintained if gonadotropins are given in a nonpulsatile pattern. A direct comparison between GnRH and hCG/hMG regimens revealed that during GnRH treatment a larger testis size was achieved and spermatogenesis was induced more rapidly compared with gonadotropin therapy (10). However, that study was not randomized, and the results could not be confirmed by others (7,45). In all three studies, there was no significant difference in efficacy of induction of spermatogenesis or the number of pregnancies (7,10,45) (see Fig. 4). The patients treated with gonadotropins had a significantly greater increase in estradiol levels than those treated with GnRH, leading to the development of gynecomastia in only the gonadotropin-treated patients (28%) (10).

From the data available, GnRH and hCG/hMG are probably of equal value in their efficiency to induce spermatogenesis in patients with hypogonadotropic hypogo-nadism. However, GnRH therapy requires good patient compliance and technical understanding because patients have to self-manage most of the technical component

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