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Relationship between abnormal hormone detection and infertility in Saudi men

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  • Save Clinical M edicine and Diagnostics 2013, 3(5): 111-114 DOI: 10.5923/j.cmd.20130305.03 The Correlation between the Abnormal Hormonal Assay and Infertility among Saudi Males Wesam Khan1,2,*, Anmar Nassir3,4, Abdulaziz Baazeem5,6, Fatmah Alsolami7,8 1Department of Urology, Publique des Hospitaux de Paris, Paris, France 2Faculty of M edicine, University of Tabuk, Saudi Arabia 3Faculty of M edicine, Umm Al-Qura University, Saudi Arabia 4KingAbdullah M edical City, Saudi Arabia 5Faculty of M edicine, Umm Al-Qura University, Department of Urology 6King Faisal Specialist Hospital, Saudi Arabia 7Faculty of Health, Queensland University of Technology, Brisbane, Australia 8College of Applied M edical Science, Nursing School, Umm Al-Qura University, Saudi Arabia Abstract Semen analysis and hormonal evaluations are prerequisite in the assessment of infertile men. The object ive of this study is to evaluate the hormonal parameters of in fertile men in Saudi Arabia, results fro m one centre. Materials and methods included clinical data and laboratory work fro m a sample of 235 infert ile Saudi men were reviewed. Results showed that hormonal evaluation revealed high level of FSH (57.4 %), norma l level of LH (61%), testosterone (67.7%) and prolactin (83%) in the study population. To conclude, further studies are required in order to determine causes of high prevalence of endocrine abnormalities in infe rtile men in Saudi Arabia. Keywords Infe rtile Men, Se men Analysis, Hormone Evaluation, Saudi Arabia 1. Introduction Infertility is defined as a failure o f adult couples to conceive after one year of regular, unprotected sexual intercourse. It is classified as primary or secondary according to the previous occurrence of pregnancy. Primary infert ility accounts for 15% of couples[1] and is defined as no previous pregnancy having occurred. Approximately 10% of couples experience secondary infertility, which happens after one or mo re pregnancies[1]. Fifty percent of all infert ility cases involve a male partner factor. According to the World Health Organization (WHO), factors associated with male infert ility include urogenital tract infect ions, increased scrotal temperature, congenital or acquired urogenital abnormalities, immunological factors, genetic abnormalities and endocrine disturbances[2] Hormonal abnormalities can be detected in as many as 92% of infert ile men[3]. The assessment of infert ility in males includes hormonal evaluation and semen analysis[1]. Vitality, mo rphology, motility, sperm concentration, pH and volume are important characteristics of seminal fluid. When the ejaculate reveals a sperm concentration below <15, million/ml, <5 million/ ml * Corresponding author: dr.khan_al (Wesam Khan) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved or absence of spermatozoa, these are defined as oligozoospermia, severe oligozoospermia or azoospermia respectively[1]. Ho wever, in clinical pract ice endocrine evaluation usually performed for infertile men with severe oligozoospermia and azoospermia[4]. Abnormal hormone production is an important underlying etiology of infert ile male. It can so metimes be corrected by hormonal replacement therapy[5]. The evaluation of essential hormones may include testosterone, prolactin, luteinising hormone (LH) and fo llicle-stimulat ing hormone (FSH)[3]. The aim o f this study was to evaluate the hormonal parameters of Saudi males diagnosed with in fertility at our centre in order to determine the correlation between abnormal hormonal profile and infe rtility a mong Saudi men. 2. Materials and Methods This is a ret rospective study of men who were investigated for infertility at the King Faisal Specialist Hospital and Research Center in Jeddah (KFSH). All the data and lab work of infert ile patients over a nine-year period (2000 – 2009) was collected, reviewed and analy zed. The demographical p rofile, including age and the hormonal levels, was reviewed. Hormonal assessment was requested according to abnormal sperm counts of azoospermia or severe oligozoospermia. Pat ient age, diagnosis and detailed semen parameters were collected fro m their files and also fro m laboratory records. The seminal fluid analysis was 112 Wesam Khan et al.: The Correlation between the Abnormal Hormonal Assay and Infertility among Saudi M ales measured according to the WHO criteria[2]. A minimu m of two separate samples were required before the diagnosis of abnormal semen analysis was made. Hormonal levels were determined using a non-competit ive (sandwich) ELISA, with Microwell Strip Reader (Model EL 301, Awareness Technology Inc, Palm City, FL, USA). The analy zed hormones were: FSH, LH, testosterone and prolactin. Hypogonadotropic hypogonadism was diagnosed when both the gonadotropins (FSH and LH) and testosterone levels were low. The diagnosis was hypergonadotropic hypogonadism when gonadotropins were elevated and testosterone was low. Partial androgen resistance was diagnosed when LH and testosterone levels were elevated, and the diagnosis was germinal epithelial failure when only FSH was elevated[2]. The info rmation obtained was collected and plotted onto a form already designed for the study. This was then entered into a database system for analysis using the Statistical Package for Social Sciences version 11.0 (SPSS Inc, Ch icago, IL, USA). 3. Results A total of 2,001 men were evaluated for infert ility during the study period, out of which 235 had hormonal assessments done for azoospermia or severe oligospermia workup. Out of these 235 patients, 216 (91.1%) had primary infert ility and the remain ing 19 (8%) reported secondary infert ility. The mean age was 37.03 years (range 23-70). The majority of patients were azoospermic. The details of age groups, types of infertility, and sperm count are shown in Table 1. The hormonal levels of the study population are shown in Table 2. Seven patients (3%) had a hormonal profile in keeping with hypogonadotropic hypogonadism, while the endocrinological diagnosis in 59 patients (25.10%) was hypergonadotropic hypogonadism. Correlation of the endocrinological d iagnosis between the various age groups and the type of infert ility is shown in Table 3. Table 1. Age, Type of infertility and Sperm Count Categories < 22 No. (%) (n =23 5) 4 (1.7) Age Group (Years) 25-50 222 (94.5) > 50 9 (3.8) Types of Infe rtility Primary Secon da ry 216 (91.9) 19 (8.1) Sperm Count (milli on /ml) Az oospe rmia Se ver oligozoospe rmia 163 (69.4) 72 (30.6) H orm one FS H LH Te stosterone Prolactin Table 2. Hormonal profile and endocrinological diagnosis Normal Hi gh Low no. no. no. (%) (%) (%) 91 135 9 (38.7) (57.4) (3.8) 143 85 7 (61) (36.2) (3) 159 0 (67.7) (0) 76 (32.3) 195 35 5 (83) (14.89) (2.1) Mean (Range) 12.48 (0.2-62.6) 8.12 (0.1-42.6) 12.75 (0.7-48.6) 12.78 (1.6-81.3) Table 3. Endocrinological diagnosis accordingto age group andtype of infertility and statistical correlation between endocrinological diagnosis andtype of in fert ility Endocrinological Diagnosis Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism Androgen resistance Germinal epithelial failure Age Group (years) <25 25-50 >50 0 6 1 1 56 2 0 20 1 1 28 3 Infertility type & Odds Ratio Primary 6 56 Secondary 1 3 20 1 30 2 Testicular failure 1 36 0 35 2 normal 1 76 2 69 10 Clinical M edicine and Diagnostics 2013, 3(5): 111-114 113 4. Discussion The prevalence of endocrine abnormalities found in infert ile Saudi men included in this study from one centre in Saudi Arabia is 10.8%. To our knowledge there is no other comparable results fro m the same population however these results are considered higher than the results presented by a Nigerian study which showed 7.3%[3]. The majority of infertile men in our study have been reported to have azoospermia 69.4%. This is due to the selected sample in th is study which included results for infert ile men with azoospermia and severe oligo zoospermia. However, the reasons for this high percentage are not clear and require further investigation. In the present study, 57.4% (135) of the study population had a high seru m FSH (Table 2). These findings are h igher to those noted in a study of one centre in Nigeria which reported that 13.3% of infertile men have abnormalities in FSH level[6]. However, when men with azoospermia are observed with a high seru m FSH, there could still be capacity for fertility, including the possibility of obstruction[7]. Patients might display azoospermia when their reproductive tract is obstructed (obstructive azoospermia) or when their production of spermatozoa is inadequate (non-obstructive azoospermia)[8, 9]. Non-obstructive azoospermia can also be due to germinal ep ithelial damage[10, 11] or genetic ab n o rmalities [ 12 ]. The vast majority of azoospermic and severely oligozoospermic in fertile Saudi men included in this study had normal levels of LH (61%), testosterone (67.7%) and prolactin (83%) (Tab le 2). Infert ile patients with Sertoli-cell only syndrome have been suggested to have a higher LH level[10]. Also, high prolactin levels, low testosterone, abnormal FSH levels and other hormonal abnormalities can be associated with abnormal levels of LH[10]. Mean testosterone levels have been reported to be lo wer in patients with o ligo zoospermia or azoospermia[10, 11]. However, these results are not supported by the data presented in this study. We found that 67.7% of the infert ile ma les have a normal testosterone level (Table 2). Therefore, further studies are needed to describe serum testosterone levels in the in fertile male population with azoospermia or severe oligozoospermia as well as to investigate the relation of different variations of prolactin, testosterone and FSH in infert ile men. In this study the number of males with primary in fertility occurred as 6 with hypogondaotopic hypogonadism, 56 with hypergondaotropic hypogonadism, 20 with androgen resistance, 30 with germinal epithelial failure and 35 testicular failure cases and these numbers of primary type infert ility were found to be h igher when co mpared to men with secondary type of infert ility (Tab le 3). There were 59 infert ile men in this study that were found to have hypergonadotropic hypogonadism and this result might suggest damage to the semin iferous tubules and the Leydig cells and is therefore significant. There may be success for these patients from sperm ret rieval and invitro fertilisation (IVF) using intracytoplasmic sperm in jection[3]. This condition is thought to be caused by genetic factors, infections or trauma, and is associated with azoospermia or impaired spermatogenesis[13]. These characteristics of primary testicular dysfunction were confirmed by the hormonal levels in the study sample. However, for Saudi infert ile men, the underlying et iology of testicular dysfunction and hypergonadotropic hypogonadism requires further evaluation. This emphasizes the need to investigate for other underlying etiolog ies of male infertility. 5. Conclusions Most azoospermic and severely oligozoospermic patients (69.4% and 30.6% respectively) referred to our centre had an endicronological p icture consistent with hypergonadotropic hypogonadism and testicular failu re. These subgroups of patients are notorious for being among the most challenging male infert ility patients to treat. Dedicated studies need to be performed in order to determine the cause of this high prevalence of patients with poor prognosis in the Saudi population. REFERENCES [1] Jungwirth, A., et al., Guidelines on M ale Infertility, 2012, European Association of Urology 2012. [2] Rowe, P.J., et al., WHO M anual for the Standardized Investigation, Diagnosis and M anagement of the Infertile M ale, 2000, Cambridge University Press. [3] Geidam, A.D., et al., Hormonal Profile of M en Investigated for Infertility at the University of M aiduguri in Northern Nigeria. Singapore M edical Journal, 2008. 49(7): p. 538-549. [4] Dohle, G.R., et al., Genetic risk factors in infertile men with severe oligozoospermia and azoospermia. Human reproduction (Oxford, England), 2002. 17(1): p. 13-16. [5] Nilsson, S., et al., Recovery of spermatozoa after rFSH/hCG treatment, and subsequent ICSI/IVF, in a male with testicula r atrophy due to severe congenital hypogonadotrophic hypogonadism. Archives of andrology, 2006. 52(2): p. 135-135. [6] Jimoh, A.A., et al., Semen Parameters and Hormone Profile of M en Investigated for Infertility at M idland Fertility Centre, Ilorin, Nigeria. Journal of Basic and Applied Sciences, 2012. 8: p. 110-113. [7] Hauser, R., et al., Fertility in Cases of Hypergonadotropic Azoospermia. Journal of Fertility and Sterility, 1995. 63(3): p. 631-636. [8] Schlegel, P.N., Causes of azoospermia and their management. Reproduction, Fertility and Development, 2004. 16(5): p. 561-572. [9] Abdel-M eguid, T.A., Predictors of sperm recovery and azoospermia relapse in men with nonobstructive 114 Wesam Khan et al.: The Correlation between the Abnormal Hormonal Assay and Infertility among Saudi M ales azoospermia after varicocele repair. The Journal of Urology, 2012. 187(1): p. 222-228. [10] Babu, R., et al., Evaluation of FSH, LH and Testosterone Levels in Different Subgroups of Infertile M ales. Indian Journal of Clinical Biochemistry, 2004. 19(1): p. 45-49. [11] Bergmann, M ., H. Behre, and E. Nieschlag, Serum FSH and Testicular M orphology in M ale Infertility. Journal of Clinical Endocrinology, 1994. 40: p. 133-136. [12] Hellani, A., et al., Y chromosome microdeletions in infertile men with idiopathic oligo- or azoospermia. Journal of Experimental & Clinical Assisted Reproduction, 2006. 3(1): p. 1-1. [13] Tzschach, A., et al., Hypergonadotropic hypogonadism in a patient with inv ins (2;4). International journal of andrology, 2009. 32(3): p. 226

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