Document Type : Case Report
Authors
1 Reproductive Medicine Center in Qingdao University affiliated Yantai Yuhuangding Hospital, Shandong, China
2 Weifang Maternal and Child Health Hospital, Shandong, China
Abstract
Keywords
The data from WHO shows that male factors
account for 50% of infertility cases (
A 32-year-old male visited our hospital for
infertility for three years following four years
of marriage. In the last three years, the patient
had lower sexual desire and less intercourse, accompanied by a decreased volume of ejacula-
tion, shorter duration of erection (<2 minutes),
and weak penis before ejaculation. There were
no oppressive symptoms, such as headache,
dizziness, and visual disturbances. Physical examinations showed that his beard and pubic hair
were thin whereas his Adam’s apple, bilateral
testis and breasts were normal. Two seminal
reports of the patient before his operation supported the diagnosis of oligoasthenozoospermia
(
Comparison of pre- and post-operation semen analyses
Pertubation | Before operation | 3 months after operation | Reference range | ||
---|---|---|---|---|---|
NO.1 | NO. 2 | NO.1 | NO. 2 | ||
6 | 6 | 6 | 6 | 2~7 | |
0.5 | 0.4 | 4.0 | 4.5 | ≥1.5 | |
7.8 | 8.0 | 7.5 | 7.5 | ≥7.2 | |
11.1 | 10.9 | 36.6 | 31.3 | ≥15 | |
8 | 5 | 42 | 45 | ≥32 | |
Comparison of pre- and post-operation sex hormones
Pertubation | Twice before operation(interval days:7) | After operation | Reference range | |
---|---|---|---|---|
NO.1 | NO. 2 | |||
0.22 | 0.24 | 3.74 | 2.8~8.0 | |
<5.00 | <5.00 | 21.96 | 7.7~42.5 | |
17.73 | 10.01 | 19.64 | 4.6~21.4 | |
4.06 | 4.44 | 3.67 | 1.5~12.4 | |
1.88 | 2.03 | 2.68 | 1.7~8.6 | |
The levels of FSH, LH, prolactin (PRL), cortisol, thyroid stimulating hormone (TSH) and
growth hormone (GH) were normal. Although
the levels of T and E2
were obviously lower than
the minimum reference values, they showed significant improvement after the patient received
hCG (
hCG test (5000U im) results
Before | After | |
---|---|---|
0.24 | 5.93 | |
<5 | 33.31 | |
The results of the GnRH stimulation test manifested
a low response of the serum LH and FSH levels after
the administration of 0.1 mg GnRH (
The results of the pituitary stimulation test.
Cornal (A) and sagittal (B) MRI sections revealed ahuge well-enhanced mass in the sella turcica.
The examination relating to the fertility of his spouse, who had been pregnant before their marriage, did not reveal any problems. Thus, the clinical diagnosis was as follows: secondary infertility, erectile dysfunction, oligoasthenospermia and pituitary adenoma. After the initial treatment, he was advised to undergo specific treatment in The Department of Neurosurgery. The neurosurgical removal of his pituitary adenoma was performed by the trans-sphenoidal route with protection of the healthy pituitary tissues. The result of the postoperative pathology was pituitary adenoma (Fig 3A). Immunostaining showed that only β-FSH was positive (Fig 3B) whereas PRL, LH, TSH, GH and ACTH were negative.
The histologic findings were compatible with pituitary adenoma (A. HE×100). The focus of the tumor cells were positive for β-FSH immunostaining (B. ×400).
The patient recovered and had a normal sexual
life after the operation. His semen improved and
became normal three months after the operation
(
Coronal (A) T2WI showed pituitary gland was shifted to the left side. Sagittal (B) TIWI demonstrated that de- creased signal intensity in sella bottom coincided with post- operative changes
Pituitary adenomas, as one of the most common
intracranial tumors, can be divided into two categories, clinically functional adenomas and nonfunctional adenomas. Functional adenomas mainly include GH-secreting adenomas (GHomas),
TSH-secreting adenomas (TSHoams), prolactinsecreting adenomas (PRLomas), ACTH-secreting
adenomas (ACTHomas), LH-secreting adenomas
(LHomas) and FSH-secreting adenomas (FSHo-
mas). Compared with other pituitary adenomas,
GHomas and PRLomas are clinically frequent,
however the remainder are rare. The rest of the
pituitary adenomas are mostly clinically non-functioning. Most clinically non-functioning pituitary
adenomas are gonadotrope-derived, while, in most
cases, these adenomas secrete low levels of FSH,
LH or only the biologically inert alpha- or betasubunits of these hormones. Therefore, most pituitary adenomas are endocrinologically silent and
patients commonly present with different symptoms such as impaired vision, headache or hypopituitarism. The diagnosis of a pituitary adenoma is
mainly based on the clinical manifestations of the
patients, endocrine test results and imaging examinations. It should be particularly emphasized that
the majority of clinically non-functional adenomas
are confirmed to be positive for gonadotropin subunits by immunohistochemical staining (
For the patient in this report, the blood FSH/LH
level was within the normal range, and the blood
testosterone (T)/estradiol (E2) level was below the
lower limit of the reference range. Generally, it
was believed that for patients with FSH-secreting
pituitary adenomas, the levels of FSH should be
increased. However, the FSH level was not elevated in our patient, which could be explained
by the increasing degradation of the FSH secreted
by the pituitary adenoma cells, which resulted in
no change in the FSH level (
In men, androgen is very important in every phase of life. Testosterone, more than 95% of which is derived from the testes, is by far the most important and abundant androgen in the blood. During the embryonal stage, testosterone determines the differentiation of the sexual organs; during puberty, testosterone furthers the development toward the adult male phenotype, which is then maintained along with the important anabolic functions. Double hydrogen testosterone (DHT) is the main androgen acting on the epididymis, vas deferens, seminal vesicles and prostate, originating from testosterone through 5α-reductase. These tissues are particularly dependent on continuous androgen activity. In the epididymis, seminal vesicles and vas deferens, a lack of testosterone can result in the regression of secretory epithelia, eventually leading to aspermia. The frequency and presence of sexual fantasies, morning erection, frequency of copulation and sexual activity are related to blood testosterone concentrations. Conversely, androgen deficiency is often accompanied by a loss of libido and sexual inactivity. Although axillary hair and the lower part of the pubic hair start growing even in the presence of low androgen concentrations, much higher androgen levels are necessary for the growth of the beard and upper part of the pubic hair.
All of these features were related to the low testosterone levels in the patient’s blood: his beard and pubic hair were thin, and he had persistent hypophrodisia and erectile dysfunction before the operation.
The primary functions of the testis, androgen
production and gamete development, are regulated
by the brain, e.g., hypothalamus and hypophysis
via GnRH and the gonadotropins. Importantly,
the hypothalamo-hypophyseal circuit is subject
to negative feedback regulation mediated by testicular factors. The site of androgen production in
the testis is the Leydig cell. Both its synthesis and
secretion are under the regulation of pituitary LH
and local factors (
In this report, the primary symptom was sexual
and reproductive dysfunction without neurological
symptoms and visual field defects. Additionally, the
FSH level was normal in the blood, but the T level
was low. Usui had reported one 40 year-old male
with a giant FSH-secreting pituitary adenoma who
was admitted to the hospital for vision disorders for
two years (
The pituitary FSH-secreting adenomas can be dis- covered in different ages of males. The levels of serum FSH differ significantly and the first diagnosed symptoms can be diverse, such as, headache, dizziness, vision field defect or reproductive dysfunction. The different symptoms of adenomas may be related to the size of the lump and its effect on the normal pituitary tissue and adjacent organs. Further study is needed to determine whether additional factors are involved.
The standard therapy for gonadotropin-secreting
macroadenomas (diameter ≥1 cm) is trans-sphenoidal
surgery. Because of the generally slow growth of microadenomas (diameter <1 cm), observation accompanied by regular endocrinological monitoring and
MRI appears justified in the absence of clinical symptoms. No effective drug therapy for gonadotropin-secreting tumors has yet been established; radiotherapy
is only indicated in special cases, such as residual or
recurrent tumors after trans-sphenoidal surgery (