Question

CASE STUDY
A 29-year-old man comes to your clinic, stating that he and his healthy 32-year-old wife had been unable to conceive after more than 1 year. The patient had been seen by an outside physician a few months ago and had been diagnosed as having hypogonadism with a low sperm concentration of 2 million/ml (normal concentration ≥20 million/ml). At that time, he was started on testosterone therapy, testosterone enantate 200 mg intramuscularly every 2 weeks, for hypogonadism.
While the patient was on testosterone therapy, a repeat sperm collection showed a complete absence of sperm (indicating a sperm concentration <2 million/ml). He then presented for a second opinion and further treatment of male infertility. At the time of evaluation in your clinic, the patient had ceased testosterone therapy for 2 months.
The patient had gone through normal puberty co-incident with his peers and had never, to his knowledge, fathered a pregnancy. He had no history of testicular trauma, torsion, or infections. The patient denied alcohol, tobacco, marijuana or other illegal drug use, and was taking no prescription medications at the time of referral.
On physical examination, the patient had vital signs of:
Weight = 154 kg BMI of 54.5 kg/m2

Notable findings on examination were the presence of stage IV gynecomastia and subnormal testicular volumes of 12 cm3 on the right and 8 cm3 on the left. He had normal male-pattern hair distribution.

1) What are you initially thinking might be going on based on this information? What additional tests/protocols would you want to order to get more information? What more would you want to know from his medical history?

You order lab tests and find:

Parameters studied	normal range	results
Estradiol (pmol/I)	73-275	172
FSH (IU/I)	1-14	2
LH (IU/I)	1-14	<1
Total testosterone (nmol/)	7.7-27.3	5.3
Calculated free testosterone (pmol/I)	105-490	102
Prolactin (pmol)	0-609	652
IGF-1 (μg/l)	117-329	102
SHBG (nmol/I)	13.0-71.0	34.8
TSH (mlU/I)	0.4-0.5	3.31
Sperm concentration (spermatozoa/mL)	<20,000,000	<1,000,000

2) Based on all the information above, what do you suspect is the origin for his hypogonadism? Based on what you know, what treatments, both pharmaceutical and lifestyle, do you recommend for this patient? What will you be monitoring over time?

Answer 1

Answer 1:

Based on the information, it is suggest that the hypogonadism is caused by hypothyroidism, indicated by increased TSH, obesity.

An MRI brain can be done rule out the complaints of pituitary gland, a thyroid scan and serum T3 and T4 tests to evaluate thyroid gland functions.

From his medical history any kind of autoimmune disease, any radiation therapy history, iodine deficiency in diet, goitre, Hashimoto thyroiditis etc

Answer 2:

The main cause of hypogonadism here I can see is hypothyroidism. So the intake of thyroid hormone replacement or levothyroxin tablet may improve the condition. Apart from that additional investigations to be done to find out the hypothyroidism. Iodised salt in the diet may improve hypothyroidism due to iodine deficiency.

The lifestyle modifications like daily exercise and diet modifications may control obesity and good thyroid gland functions.

Regular weight checking, thyroid function test and sexual hormone studies are important to assess the progress of disease.