Spermatogenesis improved by suppressing the high level of endogenous gonadotropins in idiopathic non-obstructive azoospermia: a case control pilot study

Abstract

Background: Elevated plasma gonadotropins were associated with desensitization of Sertoli and Leydig cells in the male testis. Testis spermatogenesis ability would be improved via inhibiting high endogenous gonadotropin in patients with severe oligozoospermia. Whether it would be beneficial for non-obstructive azoospermia (NOA) patients was still unclear.

Methods: Goserelin, a gonadotropin releasing hormone agonist (GnRHα) was used to suppress endogenous gonadotropin levels (gonadotropin reset) in the NOA patients, improving the sensitization of the Sertoli and Leydig cells. Then human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) were injected to stimulate them to ameliorate the ability of testicular spermatogenesis. The main outcome measure was the existence of spermatozoa in the semen or by testicular sperm extraction (TESE). Elevation of inhibin B and/or ameliorative expression pattern of ZO-1 was the secondary objective.

Results: A total of 35 NOA men who failed to retrieve sperm via TESE were enrolled. Among these, 10 patients without treatment were selected as control group and secondary TESE was performed 6 months later. Of the 25 treated men, inhibin B was elevated in 11 patients in the first 4 weeks (Response group), while only 5 patients had constant increase in the following 20 weeks (Response group 2). Of the 5 men, 2 men acquired sperm (Response group 2B), while 3 failed (Response group 2A). Immunofluorescence of mouse vasa homologue (MVH) and ZO-1 showed that both positive MVH signals and ZO-1 expression were significantly increased in the Response group 2, but only Response group 2B showed ameliorative ZO-1 distribution.

Conclusions: Gonadotropin reset, a new therapeutic protocol with GnRHα, was able to improve the ability of testicular spermatogenesis in the NOA patients through restoring the sensitivity of Sertoli and Leydig cells, which were reflected by elevated inhibin B and ameliorative ZO-1 expression and distribution.

Trial registration: ClinicalTrials.gov identifier: NCT02544191 .

Keywords: GnRHα; Gonadotropin reset; NOA.

Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the Research Ethics Committee of Nanjing Jinling Hospital and informed consent was obtained from all the participants.

Consent for publication

All authors provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Patients selection process. A total of 175 patients with azoopspermia in the male infertility clinic were enrolled. Among them, 13 with genetic abnormality, 8 with mumps virus infection history, 13 with varicocele, 33 who received medical treatment, 37 with small testes, 8 with acquired sperm, 8 with MA and 18 with SCOS were excluded. The rest 35 patients diagnosed with hypospermatogenesis (HP) were enrolled

Fig. 2

Histological analysis. The typical hematoxylin and eosin (H&E) staining of the testis specimens of the enrolled patients showed hypospermatogenesis (HP). The narrow arrow indicated the spermatocyte, the broad arrow indicated the elongated spermatid, and the medium arrow indicated the round spermatid. Scale bar, 200 μm

Fig. 3

Study protocol. Patients were given goserelin once every 4 weeks for 24 weeks. hCG was administrated with a dose of 2000 IU for once a week for 20 weeks. hMG was injected at a dose of 150 IU for twice a week for 16 weeks. Twenty four weeks later, all patients received the secondary TESE. Plasma hormone analysis was performed at the first TESE, week 4, week 8 and week 24 of the treatment

Fig. 4

Dynamic changes in plasma hormone levels. a-c The dynamic changes of FSH, LH, T levels through the whole treatment period were shown. d The dynamic change of inhibin B in the Response group (Response group 1 + 2). e The dynamic change of inhibin B in the Response group 2. f The level of inhibin B at baseline in the No response group and the Response group (Response group 1 + 2). Results were shown as mean ± SD. a-d*P < 0.05 compared with the value before the treatment (Pre); **P < 0.01 compared to the value before the treatment; ***P < 0.001 compared with the value before the treatment; ##P < 0.01 compared with value at week 4. ###P < 0.001 compared with value at week 4; e*P < 0.05 compared with the value before the treatment, **P < 0.01 compared to the value before the treatment, #P < 0.015 compared with value at week 8; f*P < 0.05 compared with No response group

Fig. 5

H&E staining of the testes before and after treatment. a The typical image of the testes specimens from OA patients. b The typical image in the first TESE. c-f The typical image of No response group, Response group 1, Response group 2A, Response 2B during the secondary TESE. Scale bar, 100 μm. Green color represented the Sertoli cells. The arrow indicated the mature sperm

Fig. 6

Immunofluorescence staining MVH and ZO-1 in the testis specimens. a The OA specimen were selected as positive control. b The typical images in the first TESE. c-f The typical images of patients in No response group, Response group 1, Response group 2A, Response group 2B during the secondary TESE. Scale bar, 100 μm. g Quantification of MVH-positive cells per tubule area in each group was then counted, 30 tubules from each group were calculated. h Relative mean fluorescence intensity of ZO-1 was calculated as total fluorescence intensity per tubule area, 30 tubules from each group were calculated. Results were shown as mean + SD. *P < 0.05, **P < 0.01, ***P < 0.001 compared with OA group; #P < 0.05, ##P < 0.01, ###P < 0.001 compared with NOA patients during the first TESE.