Treatment Of Patients With Hypogonadotropic Hypogonadism

In patients with hypogonadism of prepubertal onset, treatment is initiated with testosterone to induce pubertal development and to achieve normal virilization. Subsequently, spermatogenesis can be stimulated with GnRH or with gonadotropins, because exogenous testosterone will not initiate spermatogenesis (5,6) (see Fig. 1). This treatment approach is recommended, even if fertility is not initially desired, because sper-matogenesis, once driven to full maturation, can be readily restimulated when fertility is desired later in life (5,7). In patients with hypogonadism that began after puberty, treatment can be initiated either with testosterone for androgen substitution or with GnRH or gonadotropins if fertility is desired immediately. Because GnRH and gonadotropins are both costly, they are justified only when fertility is desired or in the initial phase of treatment, when spermatogenesis is to be stimulated to the point of sperm production. Treatment may be required for 2 or more years, until sperm appear in the ejaculate or a pregnancy has been induced. Once it is initiated, sperm production can often be maintained with human chorionic gonadotropin (hCG) alone (5,8,9) (see Fig. 2); therefore, we continue hCG treatment until delivery, because miscarriage could occur. Thereafter, if the couple does not want to conceive additional offspring immediately, testosterone therapy is resumed, because it is less costly and easier to administer.

Table 1

Therapeutic Options for Spermatogenesis Stimulation

Table 1

Therapeutic Options for Spermatogenesis Stimulation

Drug

Trade Name

Application

Dose

Pulsatile gonadotropin-

Factrel

Subcutaneous,

4-20 |ig per pulse

releasing hormone (GnRH)

Lutrepulse

external minipump

every 120 min

Human chorionic

Profasi

Subcutaneous or

1000-2500 IU twice

gonadotropin (hCG)

Pregnyl

intramuscular

per week (Monday

Novarel

and Friday)

In combination with

Human menopausal

Pergonal

Subcutaneous or

75-150 IU three times

gonadotropin (hMG)

Reponex

intramuscular

weekly (Monday,

Wednesday, and Friday)

Human urinary follicle-

Fertinex

Subcutaneous or

75-150 IU three times

stimulating hormone

intramuscular

weekly (Monday,

(FSH), highly purified

Wednesday, and Friday)

(uhFSH-HP)

Recombinant FSH (rFSH)

Follistim

Subcutaneous or

75-300 IU three times

Gonal F

intramuscular

weekly (Monday,

Wednesday, and Friday)

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