Familial hypogonadotropic hypogonadism with alopecia.

In one family several male and female members had hypogonadism and frontoparietal alopecia, whereas other members with normal sexual development had normal scalp hair. Clinical and laboratory evaluation of three affected young men (two brothers and their cousin) revealed that the hypogonadism was the result of decreased serum concentrations of follicle stimulating and luteinizing hormones. There was no evidence of a deficiency of any other pituitary hormone. Long-term treatment of the three patients with human chorionic gonadotropin resulted in an increase in the serum testosterone concentration, the appearance of male secondary sex characteristics and an increase in the size of the external genitalia.     

Olfactory function in patients with hypogonadotropic hypogonadism: an all-or-none phenomenon?

Hypogonadotropic hypogonadism (HH) refers to an endocrine defectof hypothalamic origin resulting in gonadal hypoplasia and frequentlyassociated with anosmia or severely impaired olfactory function(Kallmann's syndrome). This apparently results from a disruptionin the migration of neurons from the olfactory placode to thebulb and hypothalamus early in development, and so providesa unique opportunity to investigate olfactory function in humansubjects with congenitally incomplete peripheral systems. Olfactoryperformance in 37 HH patients and 37 age-matched controls wascompared using a modified version of the Munich Olfaction Test.This test is based on the sniff-bottle method and includes testsof (i) odor quality discrimination, (ii) intensity discrimination,(iii) detection thresholds, and (iv) recognition, hedonic evaluationand identification ability. The patients could be divided intotwo distinct groups differing significantly on all four subtestsand showing no overlap in performance: 20 anosmics, conformingto Kallmann's syndrome, and 17 apparent normosmics whose performancewas slightly poorer, but not significantly different to thatof the controls. The unexpected failure to find a continuumof olfactory dysfunction now raises the question whether HHwith or without anosmia represents two syndromes with distinctetiologies, or rather reflects the ability of the olfactorysystem to function well despite morphological impairment.     

Normal sequence of the gonadotropin-releasing hormone gene in patients with idiopathic hypogonadotropic hypogonadism.

Idiopathic hypogonadotropic hypogonadism (IHH) results from absent or greatly diminished secretion of GnRH. Defects in the GnRH gene have been identified in an animal model of IHH and have been hypothesized as a possible basis for GnRH deficiency in humans. In this study, we used the polymerase chain reaction to clone and sequence the coding regions, promoter, and 3' untranslated tract of the GnRH genes from both alleles of four unrelated patients with IHH. One of the patients studied is a member of a kindred in which X-linked inheritance has been excluded by father-to-son transmission of the disease. No DNA sequence mutations were found. We conclude that most cases of IHH in humans do not involve mutations in the GnRH gene and are presumably caused by mutations at one or more other genetic loci that are required for normal function of GnRH-producing neurons.     

Assisted reproductive techniques with congenital hypogonadotropic hypogonadism patients: a systematic review and meta-analysis

Background

After hormonal replacement therapy (HRT) including androgen replacement or sequential therapy of estrogen and progesterone, The combination of human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) and pulsatile GnRH, is not sufficient to produce sufficient gametes in some patients with Congenital hypogonadotropic hypogonadism (CHH). A Systematic review and meta-analysis was performed to determine that assisted reproductive techniques (ART) can effectively treat different causes of infertility.

Methods

To determine the effect of ART on fertility of CHH patients and investigate whether outcomes are similar to infertility due to other causes, we conducted a systematic review and meta-analysis of retrospective trials.Clinical trials were systematically searched in Medline, Embase, and the Cochrane central register of controlled trials databases. The keywords and major terms covered “hypogonadotropic hypogonadism”, “kallmann syndrome”, “assisted reproductive techniques”, “intrauterine insemination”, “intracytoplasmic sperm injection”, “testicular sperm extraction”, “in vitro fertilization”, “embryo transplantation” and “intra-Fallopian transfer”.

Results

A total of 388 pregnancies occurred among 709 CHH patients who received ART (effectiveness 46, 95% confidence interval 0.39 to 0.53) in the 20 studies we included. The I² in trials assessing overall pregnancy rate (PR) per embryo transfer (ET) cycle was 73.06%. Similar results were observed in subgroup analysis by different gender. Regression indicates pregnancy rate decreases with increasing age. Fertilization, implantation and live birth rates (72, 36 and 40%) showed no significant differences as compared to infertility due to other causes.

Conclusions

Despite CHH patients usually being difficult to generate gametes, their actual chances of fertility are similar to subjects with other non-obstructive infertility. ART is a suitable option for CHH patients who do not conceive after long-term gonadotropin treatment.

     

Pulsatile gonadotropin-releasing hormone treatment of men with idiopathic hypogonadotropic hypogonadism

OBJECTIVES/METHODS: To induce testicular growth and spermatogenesis, 11 patients with idiopathic hypogonadotropic hypogonadism were treated with long-term subcutaneous pulsatile gonadotropin-releasing hormone (GnRH) administration. Three patients had a history of undescended testes. Patients who did not respond to therapy with a sufficient increase in serum testosterone or spermatogenesis were offered additional injections with hCG or, after discontinuation of GnRH, either combined therapy with hCG and hMG or recombinant FSH. RESULTS: During treatment testicular volume and serum levels of FSH, LH and testosterone increased. Semen analysis revealed the presence of spermatogenesis in 9 of the 11 patients (8 on GnRH alone and in 1 when hCG/hMG was subsequently instituted), and 7 pregnancies have resulted thus far. CONCLUSION: Pulsatile GnRH therapy is a well-tolerated and effective therapy for the induction of spermatogenesis in some men with idiopathic hypogonadotropic hypogonadism. It appears that a significant fraction of them should be treated for a minimum of 1-2 years to maximize testicular growth and achieve spermatogenesis. Cryptorchidism was a negative prognostic factor.     

Modulation of postinhibitory increase in plasma prolactin by domperidone in patients with prolactin secreting adenoma

To evaluate the PRL secretory mechanism in patients with PRL-secreting adenoma (PRL-oma), plasma PRL responses to dopamine (DA) were studied in these cases and in normal subjects. Plasma PRL values showed clear decreases during the infusion of DA (5 micrograms/kg/min for 90 min) in both 6 normal and 7 PRL-oma subjects (%decrease: 43.8 +/- 3.9% vs. 53.9 +/- 5.6%; NS) and postinhibitory increases after the termination. However, the postinhibitory increase occurred more promptly and markedly in PRL-oma patients than in normal subjects, i.e. the postinhibitory increase exceeded the basal level 45 min after the termination of DA infusion in PRL-oma patients, whereas the increase in normal subjects did not exceed the basal level even 90 min after the infusion. When domperidone was injected at the termination of DA infusion, the postinhibitory increases were significantly enhanced in either PRL-oma or normal subjects. The maximal increments in plasma PRL in the combination test of DA plus domperidone were significantly larger in PRL-oma patients, but were almost the same in normal controls, compared to the single domperidone test. In contrast, TRH did not modify the postinhibitory rises in 9 PRL-oma patients. These results indicate that the secretory properties and the sensitivities of lactotrophs to decreasing action of DA might be different between PRL-oma patients and normal controls. Further, the postinhibitory rebound phenomenon in PRL-oma patients is possibly determined by an overshoot of PRL storage concomitantly with a decreasing DA action.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sexual behavior of men with isolated hypogonadotropic hypogonadism or prepubertal anterior panhypopituitarism

Sexual behavior of men with secondary hypogonadism was studied. Seven of the thirteen subjects presented with hypogonadism secondary to isolated gonadotropin (Gn) deficit, whereas the other six had idiopathic prepubertal anterior panhypopituitarism. Testosterone (T) levels were low and did not differ between the two groups. All subjects were evaluated both during replacement therapy (Gn in the first group; Gn plus cortisone and thyroxine in the second group) and 2 months after withdrawal of Gn therapy. During and after withdrawal of Gn administration, men with isolated deficit of Gn retained sexual activity and nocturnal penile tumescence, although they were partially compromised compared with a control group; on the other hand, panhypopituitarics reported compromised sexual function during Gn treatment and no sexual function when Gn therapy was not given. We conclude that different lesions of the hypothalamus-pituitary axis were accompanied by varying degrees of sexual impairment in the two groups of men presenting both secondary hypogonadism and very low T levels.     

Lack of nocturnal blood pressure fall in elderly bedridden hypertensive patients with cerebrovascular disease

To prevent recurrence of cerebrovascular disease (CVD), adequate control of blood pressure (BP) is extremely important for the treatment of hypertensive CVD patients. As absence of the nocturnal fall of BP by the expected 10-20% from daytime levels is reported to exaggerate target organ injury, 24-h ambulatory blood pressure monitoring (ABPM) was conducted, especially to obtain data during nighttime sleep. Forty-eight elderly bedridden chronic phase CVD hypertensive patients (assessed 1-3 mo after CVD accident) participated. As a group, nocturnal BP was higher than diurnal BP, whereas nocturnal pulse rate was lower than diurnal pulse rate. The nocturnal BP fall was blunted in most (～90%) of the patients. These results suggest that to perform a rational drug treatment, it is essential to do 24-h ABPM before initiation of antihypertensive therapy in elderly bedridden hypertensive CVD patients.     

Reduced conversion of dehydroepiandrosterone into estrogens in women having hypogonadotropic hypogonadism associated with weight loss

The purpose of this study was to evaluate, without using radioisotopes, the peripheral contribution of dehydroepiandrosterone (D) to estrogens and to androstenedione (A) in patients with hypogonadotropic hypogonadism associated with weight loss (HH) and in normal menstruating women (N).Unlabelled D was infused for 48 h in 12 normal women and in 12 women affected by HH. Plasma levels of D, dehydroepiandrosterone sulfate (DS), A, estrone (e₁), estrone sulfate (E_1s) and estradiol (E₂) were measured before and after 48 h of infusion. Metabolic clearance rates of D (MCR_D), production rates of D (PR_D), and increases in plasma concentration of DS, A, E₁, E_1s and E₂, relative to the corresponding increase in plasma concentration of D, were determined. The baseline plasma levels of all steroids studied were found to be significantly lower in the patient group than in the control. The MCR_D in the normal and the HH groups were similar (1420 ± 340 1/day versus 1670 ± 569 1/day, P > 0.05). No significant difference was found in PR_D between the 2 groups (X ± SD 10.3 ± 5 versus 13.3 ± 5.5 mg/day, P > 0.05). Administration of D increased the levels of estrogen in the normal group but not in the HH group. The relative increase in plasma levels of DS resulting from infusion of D (Δ_CDS/Δ_CD) was found to be larger in the HH group than in the normal group (40.4 ± 17 versus 26.3 ± 11.8, P < 0.05). Furthermore, relative increases in plasma levels of A derived from infusion of D were larger in the HH group than in the normal group (0.0495 ± 0.0021 versus 0.192 ± 0.0071, P < 0.001).We conclude from these results that in the HH patients there is a blockage of the peripheral conversion of D to e₁ and E_1s and an enhancement of the peripheral conversions of D to DS and to A. These metabolic changes may account for the androgenization of the patients under study.     

A patient with hypogonadotropic hypogonadism successfully treated by long-term pulsatile administration of luteinizing hormone-releasing hormone

A male patient with hypogonadotropic hypogonadism has been treated by pulsatile administration lf luteinizing hormone-releasing hormone (LHRH) (20-25 micrograms, every 2 hours, sc) for 4 years 6 months. His plasma testosterone (T) concentration began to increase after 4 weeks of treatment and reached the normal range in week 5. He showed complete secondary sexual development after 1 year of treatment. His sperm count was normalized after 1 year of treatment. He was married after 29 months of therapy, and has a healthy male child. Blood type tests showed his paternity of the child. During the long duration of pulsatile LHRH therapy, his gonadotropin secretion has been stimulated by LHRH and his T level has been maintained with no observable side effects. There are no other reports of patients treated by pulsatile LHRH injection for such a long duration, but finding in this patient indicated that long-term pulsatile LHRH therapy is a useful and safe method for treatment of hypothalamic hypogonadotropic hypogonadism.     

Comparison between the meiotic activities in the male with hypogonadotropic hypogonadism and in the human fetal ovocytes

In the testicles of males with postpuberal hypogonadotropic hypogonadism, we have detected a preleptotene phase similar to that described in the human ovary. The two characteristic stages of this phase, contraction and despiralization, were noted. In this paper the origin and the significance of preleptotene in relation to the hormonal levels are discussed.     

Deletion of Otx2 in GnRH neurons results in a mouse model of hypogonadotropic hypogonadism

GnRH is the central regulator of reproductive function responding to central nervous system cues to control gonadotropin synthesis and secretion. GnRH neurons originate in the olfactory placode and migrate to the forebrain, in which they are found in a scattered distribution. Congenital idiopathic hypogonadotropic hypogonadism (CIHH) has been associated with mutations or deletions in a number of genes that participate in the development of GnRH neurons and expression of GnRH. Despite the critical role of GnRH in mammalian reproduction, a comprehensive understanding of the developmental factors that are responsible for regulating the establishment of mature GnRH neurons and the expression of GnRH is lacking. orthodenticle homeobox 2 (OTX2), a homeodomain protein required for the formation of the forebrain, has been shown to be expressed in GnRH neurons, up-regulated during GnRH neuronal development, and responsible for increased GnRH promoter activity in GnRH neuronal cell lines. Interestingly, mutations in Otx2 have been associated with human hypogonadotropic hypogonadism, but the mechanism by which Otx2 mutations cause CIHH is unknown. Here we show that deletion of Otx2 in GnRH neurons results in a significant decrease in GnRH neurons in the hypothalamus, a delay in pubertal onset, abnormal estrous cyclicity, and infertility. Taken together, these data provide in vivo evidence that Otx2 is critical for GnRH expression and reproductive competence.     

Induction of puberty in a patient with hypogonadotropic hypogonadism: effect of sequentially applied hCG and pulsatile GnRH administration

Pulsatile substitution with GnRH appears to be the therapy of choice in patients with Kallmann's syndrome, a well defined type of hypogonadotropic hypogonadism. We tried to simplify the treatment and to limit the subcutaneous GnRH therapy to the period absolutely necessary to induce spermatogenesis. Therefore we applied in sequence first hCG to stimulate testicular growth and second pulsatile GnRH application to induce spermatogenesis. We herein report that with this mode of therapy testicular growth from infantile to adult size and normal spermatogenesis could be achieved. We conclude that pulsatile GnRH application is a new effective therapy of hypogonadotropic hypogonadism which can be simplified considerably by pretreatment with hCG.