Induction of spermatogenesis in isolated hypogonadotrophic hypogonadism with gonadotrophins and early intervention with intracytoplasmic sperm injection

Idiopathic hypogonadotrophic hypogonadism (IHH) is a potentiallycorrectable cause of male infertility. However hormonal treatment isusually a slow process and artificial reproductive techniques such asintracytoplasmic sperm injection (ICSI) might be resorted to before fulltesticular response has been achieved. We report here an unusual variant ofIHH of post-pubertal onset in which early intervention with ICSI wasattempted. Our patient was 37 years old and presented with male infertilitydue to azoospermia and undetectable serum gonadotrophin concentrations. Hehad an apparently normal pubertal development, a testicular volume of 8 ml,normal pituitary-thyroid and pituitary-adrenal function, as well as normalcomputerized tomographic appearance of the sella region. A combination ofhuman chorionic gonadotrophin (HCG) and menopausal gonadotrophins (HMG) wasadministered. Spermatozoa were first detected in the semen after 3 monthsand reached a concentration of approximately 2x10(6)/ml after 9 months.ICSI was attempted at this point; the spermatozoa had good fertilizingability and three embryos were obtained and replaced. Unfortunately nopregnancy resulted. Treatment with 5000 IU HCG and 150 IU HMG three timesper week was continued and sperm counts rose rapidly thereafter to reach28.3x10(6)/ml after 16 months of injections. His wife conceived naturallyduring this period and the pregnancy is now in the second trimester. Thiscase illustrates the good prognosis of the rare patient with IHH ofpost-pubertal onset when treated with gonadotrophins, and suggests thatICSI procedures should be delayed until final testicular maturation isattained.