anabolic steroids and male infertility

S andro C . Esteves, MD., PhD.Director, ANDROFERT

Andrology & Human Reproduction C linic

C ampinas, BRAZIL

Anabolic S teroids and Male Infertility

IS O 9001:2008

Reproductive Andrology S urgery Workshop IIReproductive Medicine Unit - J ahra Hospital - Kuwait 2014

Facts about Anabolic S teroids

• >3 million users in the US A

– 2/3 non-competitive athletes (aesthetic)

Maravelias et al 2005; Taylor Hooton Foundation.org

ANDROFERTandrofert.com.br

ANDROLOGY AND HUMAN REPRODUCTION C LINIC - REFERRAL C ENTER FOR MALE REPRODUCTIONS ESTEVES, 22014 DEC EMBER

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Source: worldwideweb

S ouza and Hallak, 2011



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Drug regimens

• Oral and injectable compounds combined in cycles lasting 4-12 weeks

• S tacking (small doses of multiple drugs)

– testosterone + nandrolone (mass-building)

– C ombinations with potent androgens preferred for dieting and body definition (low estrogenic activity)

– Post-cycle therapy using anti-estrogen + hC G to restart androgen production



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Effects• Increase in muscular activity (hypertrophy

of muscle fibers; increase in size)

• S ide effects:– Enlargement of prostate (5DHT androgenic

effect)

– T aromatization: gynecomastia

– Erectile dysfunction and low libido after discontinuation (low endogenous T)

– Hepatic/cardiotoxicity



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Exogenous testosterone: a preventable cause of male infertility

• Many doctors, including urologists and endocrinologists, prescribe testosterone to men at reproductive age

– 25% US urologists treated low T levels in male infertility with testosterone

– Prescription increased 170% in 5-year period

C rosnoe et al. 2013



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Infertility is a trigger to depression

• Decreased libido consequence, not causative

• Increasing T levels by exogenous T administration not a solution



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• Dose and duration-related effect

• Anabolic:androgenic ratio

• Weekly doses of 300 mg or higher

S ouza and Hallak, 2011



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Why AS cause infertility?

G nRH

FS H/LH Marked fall in ITT levels

Between the seminiferous tubules, Leydig cells produce

testosterone

S upraphysiological Tlevels > 1000 ng/dL



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• Adequate levels of ITT are essential for regulating spermatogenesis in combination with S ertoli cell stimulation with FS H

• ITT levels stimulate spermatogonia DNA synthesis and spermiogenesis

• ITT levels 100-fold higher than serum T

• S ertoli cells are major target for testosterone signaling (via AR)




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G nRH

FS H/LH

Azoospermia

Marked fall in ITT levels

Between the seminiferous tubules, Leydig cells produce

testosterone



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• Low FS H and LH (<1.2 mIU/L)

• Low total testosterone (<300 ng/dL)

• Hypotrophic testes

• Azoospermia

• S evere oligozoospermia

Adult-onset Hypogonadotropic hypogonadism



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Management

1. DiscontinuationRecovery in ~6 months (up to 25% persistent low sperm count/quality)

2. hC G -based therapy

3. C ombination of hC G -based therapy and FS H/HMG

Hormone level follow-up:– TT, estradiol, FS H, LH

– Avoid supraphysiological T and E levels



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ANDROFERTS ouza and Hallak, BJ UI 2011

C lassic treatment for male hypogonadism and infertility

Urinary hC G 1,000-2,000 UI IM injections; twice or t.i.w;

minimum 12 weeks

Rec-hC G : S C self-injection w/pre-filled

syringe, qw

Fraietta & Esteves C linics 2013

Adult onset hypo- hypo S pecific medical therapy



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Rec-hC G for male hypo-hypo

Baseline Posttreatment

Esteves & Papanikolaou Fertil S teril 2011

S eries of men with adult-onset HH;

Recombinant hC G (Ovitrelle 250 mcg)



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Anabolic steroids and male infertility Key Messages

AS , including T replacement therapy, highly prescribed

Negative effect on male fertility not well appreciated by doctors

C ounselling advisable and fertility restoration possible, especially in non-heavy users



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anabolic steroids and male infertility

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