Intratesticular, Seminal and

Serum Testosterone in Sexual

and Reproductive Disorders

BY: PROF. DR.MOHAMED SAAD MAHMOUD

PROFESSOR OF ENDOCRINOLOGY AND DIABETOLOGY

FACULTY OF MEDICINE, AIN SHAMS UNIVERSITY, CAIRO, EGYPT

Mohamed Saad Hamed MahmoudManal M. AbuShady Endocrinology unit.

Hassan Shalaby Internal Medicine3, MUST. Sanaa Eissa Hamed2

Biochemistry department

Ain Shams University

INTRODUCTION

Hypothalamic GnRH regulates the production of the pituitary gonadotropins, LH and FSH.

GnRH is released in discrete pulses approximately every 2 hours, resulting in corresponding pulses of LH and FSH. These dynamic hormone pulses account in part for …….

the wide variations in LH and testosterone, even within the same individual. LH acts primarily on the Leydig cells to stimulate testosterone synthesis.

The regulatory control of androgen synthesis is mediated by testosterone and estrogen feedback on both the hypothalamus and the pituitary (1).

Testosterone is essential for the initiation and maintainence of spermatogenesis within the testes. Intratesticular testosterone (ITT) mediates its effects by binding to the androgen receptor, which is found in Leydig cells (2).

Although endocrine factors are an essential etiological factor in erectile dysfunction accounting for 2–5% of patients. The role of androgens in the regulation of erection is not clearly defined (3).

A certain critical level of blood androgens is required for the maintenance of normal sexual desire, nocturnal penile tumescence (NPT) and non visual stimuli penile erection.

A certain concentration of androgens is also required for initiation, maintenance of spermatogenesis and for maximum stimulation of growth and function of the prostate and seminal vesicles.

The amount of androgens required for these latter effects is greater than that needed for maintenance of libido. Thus, states of androgen deficiency manifested by desire disorders are always associated with some decrease in seminal volume (4).

Hypogonadism has been shown to reduce the frequency of sexual thoughts and intercourse. Low testosterone levels also decrease the frequency, volume, and quality of ejaculation (5).

Normal levels of testosterone appear to be important for erectile function, particularly in older males. Androgen replacement therapy can improve depressed erectile function when it is secondary to hypogonadism; however,

it is not useful for ED when endogenous testosterone levels are normal. Increased prolactin may decrease libido by suppressing gonadotropin releasing hormone (GnRH), and it also leads to decreased testosterone levels (6).

The measurement of circulating testosterone is clinically relevant in the investigation of androgen disorders in humans. In men, testosterone analysis is used to evaluate the endocrine activity of the testis.

In association with gonadotropin determination, the circulating testosterone concentration provides information concerning the origin of testicular dysfunction (7).

In blood, testosterone is bound to protein, specifically to sex hormone binding globulin (SHBG). Only approximately 2% of testosterone is unbound and available as free testosterone for biological activity (8).

Since generally total testosterone is well correlated with free testosterone, separate determination of free testosterone is only necessary in certain cases. As an example, hyperthyroidism and antiepileptic and other drugs and conditions cause an increase in

SHBG levels and thereby increased testosterone concentration in serum, without a parallel increase of the biologically active free testosterone fraction. In extreme obesity low testosterone levels are measured; however, in combination with low SHBG values;

accordingly, the free testosterone fraction remains normal, although in the low-normal range (8).

Normal range of total testosterone 9 - 30 ng/ml (0.3123 -1.0410 nmol/liter) and for free testosterone 2.8 - 8 ng/ml (0.09716 - 0.2776 nmol/liter).

Seminal fluid is a complex milieu surrounding spermatozoa. In addition to many components, seminal fluid contains also hormonal steroids. So far, the studies were focused mostly to androgen (9). Seminal testosterone levels may predict whether normal spermatogenesis is occurring within the seminiferous tubules.

Semen samples are usually collected by masturbation after 2–5 days of sexual abstinence (10). In the normal plasma levels of testosterone, seminal levels range from 23 to 148 ng/100 ml (0.7981- 5.1356 nmol/liter) (11).

Intratesticular testosterone (ITT) concentration was approximately 80-fold higher than that of serum testosterone. Normal intratesticular testosterone (ITT) levels range from 1095 – 1253 nmol/liter (31556.19 – 36109.51 ng/100 ml ) (12).

Testicular fluid aspiration allows for repeated measurements of intratesticular hormones with a minimally invasive procedure that is safe and effective (13).

AIM OF THE WORK

Our aim was to study whether there is a concentration gradient of serum testosterone, seminal testosterone and intra-testicular testosterone in men with either impotence or infertility.

SUBJECT AND METHODS

This work included 25 cases with sexual or reproductive disorders and 10 subjects as control, attending Ain Shams endocrinology clinic.

Inclusion criteria of selected patients:

Male patients above age of 25 years were included. Thirteen patients had impotence and twelve had infertility. Patients with infertility had azospermia or marked oligospermia.

Patients with renal disease, chronic liver disease, hemochromatosis, sickle cell disease, ethanol abuse, and anabolic steroid intake were excluded.Serum total and free testosterone, LH, FSH and prolactin were measured by chemiluminescent assay technique.

Semen samples were collected by masturbation after 2–5 days of sexual abstinence and stored in medical collection containers and left for 30 minutes in room temperature to liquefy then put in refrigerator at -20 degree Celsius. Testosterone is stable in serum at refrigerated temperature of 4°C for at least 4 weeks,

while being stable at -20°C for at least 12 months. At time of processing, samples were put in wasserman tubes and were centrifuged. Testosterone was measured by chemiluminescent assay technique using automatic multianalyzer.

Intratesticular testosterone :Testicular fluid samples were taken by percutaneous fine needle aspiration. Subjects were placed in the supine position and draped with sterile cloth. The skin over the spermatic cord was cleansed with alcohol on both sides. 2% lidocaine was injected for local anesthesia.

After adequate anesthesia was established, 5-mL syringe was inserted percutaneously into the testis. Negative pressure was created in the syringe. The needle was held in place and gentle pressure applied to the testis until an adequate amount of testicular fluid was withdrawn into the tube.

Samples collected in eppendorf tubes with 100µ saline and stored in refrigerator at -20 °C. At time of processing, samples were put in Wasserman tubes and were centrifuged. Testosterone was measured by chemiluminescent assay technique using automatic multianalyzer.

Statistical AnalysisData were collected, revised, verified then edited on personalcomputer (P.C.) the data were then analyzed using statistical

package for special sciences (SPSS) version (18) statistical testsused in this thesis.• Description of quantitative variables as median and interquartile range.• Chi-square test was used to compare qualitative variablesbetween groups.

- Kruskal–Wallis one-way analysis of variance used to compare more than two groups in non parametric quantitative data.- Pearson’s correlation coefficient (r) test was used for correlating data. Correlation coefficient (r) 0.1 - 0.3 weak correlation, 0.4 - 0.6 moderate correlation, and > 0.7 strong correlation.

• Mann Whitney test was used to compare quantitative variables, in non parametric data. A p value of p<0.05 was taken as significant.

RESULTS

Data characteristics of all groups are summarized in (table 1).Testicular, seminal and serum (total & free) testosterone levels were significantly lower in the two patient groups when compared with the control one (p < 0.01).

  Varabiles 

Groups

Impotence N=12 Infertility N=13 control N=10

Median IQR

Median IQR

Median IQR

Age(in years) 33 33 38 30 30 36 36 34 45

BMI kg/m2 25 24.5 27 26 25.4 28 25.1 24.8 25.2

Seminal Testosterone ng/100ml 0.38 0.35 0.4 0.39 0.37 0.43 28.9 27.7 30.4

Testicular Testosterone ng/100ml 122 121 131 76.3 66.8 140.1

31976.8

31746.1

33466.44

Free T ng/ml 2.4 1.8 3.6 4.6 1.7 7.4 18.58 17.44 20.2

Total Serum Testosterone ng/ml 0.7 0.3 1.2 2.8 2.7 5.9 6.66 6.56 7.1

FSH mlu/ml 21.8 19.5 26.3 12.67 12.4 15.3 8.99 8.7 9.86

LH mlu/ml 18.7 13.6 26.2 7.8 7.4 9.6 8.2 7.9 8.9

Prolactin ng/ml 17 16.4 18.3 15.2 14.7 16.32 9.7 8.9 10.1

However, there was no significant difference between the 2 patient groups. There was no significant difference regarding FSH, LH, prolactin, age and BMI (table 2).

We found that there was significant positive moderate correlation between serum total testosterone and seminal testosterone. On the other hand, there were statistically insignificant positive correlation between serum total testosterone and both ITT and free testosterone (r= 0.301, p >0.19). (Table 3).

Table (3): correlations between total serum testosterone with seminal testosterone, testicular testosterone and free testosterone.

Spearman's rhoMedian Median Value

Total Serum Testosterone

ng/ml

4.53 Seminal Testosterone

ng/ 100ml

0.42 R 0.550*

Sig. (2-tailed)

0.012

N 20

Testicular Testosterone

ng/ 100ml

126.5 R 0.301

Sig. (2-tailed)

0.198

N 20

Free Testosterone

ng/ml

6.5 R 0.252

Sig. (2-tailed)

0.284

N 20

  *. Correlation is significant at the 0.05 level (2-tailed)

There was significant negative correlation between total serum testosterone and FSH, LH and prolactin (Table 4).

Table (4): correlations between total serum testosterone with FSH, LH and prolactin.**. Correlation is significant at the 0.01 level (2-tailed).*. Correlation is significant at the 0.05 level (2-tailed)

Spearman's rhoMedian Median Value

Total Serum Testosterone

ng/ml

4.53 FSHmlu/ml

11.49 R -0.749-**

Sig. (2-tailed)

0.001

N 20

LHmlu/ml

8.45 R -0.690-**

Sig. (2-tailed)

0.001

N 20

Prolactinng/ml

13.45 R -0.679-**

Sig. (2-tailed)

0.001

N 20

 

 

Neither BMI nor age showed any significant correlation with serum total testosterone, seminal testosterone, ITT, free testosterone, FSH, LH or prolactin.

DISCUSSION

In our study, we found that there was significant positive moderate correlation between serum total testosterone and seminal testosterone in all groups (r = 0.55, p < 0.012).

This is consistent with Ibrahim et al; 1983 who stated that significant positive correlations were found between peripheral blood testosterone and semen testosterone in normal men (14).

We found that there was statistically insignificant positive correlation between serum total testosterone and ITT. This is on contrary with Coviello et al; 2005 who stated that a significant intra-testicular fluid to serum T gradient was observed in his study of young normal men at baseline group (12).

Also, Roth et al; 2010 who stated that serum testosterone correlated highly with ITT in normal men (15).

Our assessment was carried out on: sexually unhealthy men.

In the present study there was insignificant positive weak correlation between serum total testosterone and free testosterone (r= 0.25, p >0.28).This is in agreement with Sannikka et al; 1983 who stated that the correlation of serum levels of total testosterone with free was weak (r = 0.63 ) but again in normals (16).

We also found a significant negative correlation between serum total testosterone and both FSH, LH. This is in agreement with Shimon et al; 2006 who stated that LH and FSH levels were inversely correlated with normalization of the testosterone level in individual patients (17).

Our results showed significant negative moderate correlation between prolactin and total serum testosterone. Alternatively, Daly et al; 2005 who stated that there were no significant relationships between prolactin and total testosterone in normal people (18).

In the present study, we found also that there were no significant correlations between body mass index or age with seminal testosterone, testicular testosterone, free testosterone, total serum testosterone, FSH, LH and prolactin.

. These results were in line with Yeap et al; 2007 who stated that increasing age, body mass index and LH are independently associated with lower free testosterone (19). Also, Sofikerim et al; 2007 stated that no significant correlation was found between testosterone, free testosterone and age or between age and LH concentration (20).

On the other hand Boyce et al; 2004 found that serum testosterone declined significantly with increasing age and BMI (21). Also, Stanciu et al; 2010 who stated that there was no relationship between body mass index and free testosterone but there was a significant inverse correlation

between body mass index and LH and FSH and there was a significant negative correlation between age and serum free testosterone and significant positive correlations between age and serum LH and FSH (22).

CONCLUSION&

RECOMMENDATION

CONSIDERATIONS:

-SMALL NUMBER OF PATIENTS-NO COMPARISON WITH OTHERS

IN MALE PAIENTS WITH EITHER INFERTILITY OR IMPOTENCE:

SERUM TESTOSTERONE IS NOT WELL CORRELATED WITH TESTICULAR TESTOSTERONE.

HOWEVER, IT IS OF BETTER CORRELATION WITH THAT OF SEMINAL FLUID.

THEREFORE, THE RECOMMENDATION OF:

-WIDE SCALE STUDY.-FINDING PREVIOUS STUDIES TO COMPARE WITH. -DETERINATION OF GENITAL TRACT TESTOSTERONE LEVELS-TRY TO HAVE AN EQUATION TO DETERMINE TESTICULAR LEVELS OF TESTOSTERONE MATHMATICALLY THROUGH e.g. RELATIONS BETWEEN PROSTATIC , SERUM …ect

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