Pituitary-testicular axis in men with p-thalassaemia major

Human Reproduction vol 11 no 9 pp 1900-1904, 1996

Pituitary-testicular axis in men with p-thalassaemia major

J.Papadimas1'5, E.Mandala2, G.Pados3, B.Kokkas4, G.Georgiadis1, B.Tarlatzis1, J.Bontis3, Z.Sinakos2 and S.Mantalenakis1 '1st Department of Obstetrics and Gynaecology, 2Department of Internal Medicine, 32nd Department of Obstetncs and Gynaecology and 4Laboratory of Experimental Pharmacology, Aristotle University of Thessaloniki, 'Hippocration' General Hospital, 50 Papanastasiou Street, Thessaloniki 54639, Greece ^ o whom correspondence should be addressed

Delayed puberty and hypogonadism are frequently observed in patients with homozygous (J-thalassaemia. We evaluated the pituitary-testicular axis in 30 thalassaemic men, aged from 17 to 35 years who were regularly transfused and underwent chelation therapy, while emphasis was given to pituitary reserves of gonadotrophins and the correlation of hormones with serum ferritin (SF). The investigation included endocrinological examination, evaluation of serum basal levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), free testosterone and gonadotrophin-releasing hormone (GnRH) test and also spermiograms. According to the results, patients were divided into three groups: group A, which included 18 eugonadal patients with moderately elevated SF, group B which included six patients who had hypogonadotrophic hypogonadism and excessive elevation of SF, and group C, which included six patients characterized as intermediate, with regard to sexual maturation and SF levels. In conclusion, P-thalassaemia major leads to variable pituitary iron overload and thus hypophyseal damage. This endocrine disturbance is becoming less frequent nowadays with early and intensive chelation therapy. Key words: desferrioxamine/hypogonadotrophic hypogonadism/spermatogenesis/fi-thalassaemia major

Introduction Failure of pubertal growth, delay or absence of sexual development, infertility and sexual dysfunction due to hypogonadism are well recognized disturbances among male patients with P-thalassaemia major (De Sanctis et al, 1988; Wang et al, 1989; Danesi et al, 1992). These problems are attributed mainly to the damage caused by die deposition of haemosiderin in the pituitary gland (Bunn, 1987; Allegra et al., 1990; Balducci et al., 1990). The improved expectancy and quality of life in diese patients due to introduction of modern treatment with blood transfusions and chelating agents makes the desire for reproductive and sexual life more prominent. Nevertheless, 1900

hypogonadism with sexual dysfunction and problems of spermatogenesis are still frequent, since pituitary and testicular function cannot be fully preserved by long-term iron-chelating treatment (Borgna-Pignatti et al, 1985; Allegra et al, 1990; Wang et al, 1989). The purpose of this study was to evaluate the pituitarytesticular axis in 30 men with p-thalassaemia major with emphasis on die pituitary reserves concerning gonadotrophins and the correlations of hormone levels and spenniogram parameters with serum ferritin (SF) and haemoglobin (Hb). Materials and methods Thirty patients with P-thalassaemia major (Table I) and five normal controls were studied. The patients' ages ranged from 17 to 37 years (median: 20 years). All of the patients had blood transfusions at regular intervals (every 15-30 days) with their pretransfusional haemoglobin concentration between 8.0 and 12 g/dl (mean ± SD.

Table I. Clinical and laboratory characteristics of the 30 patients Patient (no.)

Age (years)

Hb(g/dl)

Serum fernun (ng/ml)

Pubertal development*

Testicular volume (ml) b

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

20 22 17 17 17 17 17 21 17 18 20 19 20 17 27 22 27 22 18 22 17 34 37 23 37 35 20 18 17 35

10 8 104 10 9 12 8 114 _ 12 10.5 10.8 10.6 8 10 10 9 118 106 _ 10 JS 10 9.7 9.5 10.7 _ _ 10 11.2 11.5 -

4000 1200 4100 _ 7000 9700 1800 4150 _ 2800 1866 4620 6000 950 3868 5000 3000 4950 _ 2700 3340 2570 3300 7300 _ _ 1399 5680 3580 -

I I I I

n n ra rv

2 2 9.5 10 2 15 13 4 5 20 21

V V V V V V V V V V V V V V V V V V

22 24 23 22 20 25 25 25 25 25 23 25 23 29 25 22 23 22

I I

n

in

9

•Pubertal development according to Tanner's staging. ''Combined volume of both testes (normal adult men > 2 4 ml). © European Society for Human Reproduction and Embryology

Pituitary—testicnlar axis in (J-thalassaemla major

Table IL Serum hormone levels in the 18 patients of group A Patients (no)

Age (years)

Tesucular volume (ml)

Serum basal hormones FSH (mlU/ml)

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

20 17 27 22 27 22 18 22 17 34 37 23 37 35 20 18 17 35

22 24 23 22 20 25 25 25 25 25 23 25 23 29 25 22 23 22

25 17 10 40 20 20 58 80 68 24 48 68 10 70 28 30 20 28

GnRH test LH (mlU/ml)

FT (pg/ml)

48 14 23 15 75 42 38 32 13.5 36 0 26 0 37 5 18 17 15 61 18 5 41

20 28 2.1 19 1.2 21 1.8 4.0 16 28 66 21 10 5 32 10 5 80 70 24

60 nun

30 min FSH

LH

FSH

LH

55 26.5 2.5 4.2 5.8 20 17 80 10 0 12.0 8.5 7.0 20.0 11 5 14 40 30 27

6.1 18 13 5.0 3.6 34 9.5 110 80 150 10 5 52 15 0 400 39 19 0 18 5.0

6.5 38 2.5 64 6.0 2.0 12.5 18.5 280 13 0 33 0 75 14 5 16 0 25 50 30 2.7

55 20 6.0 5.8 3.4 1.0 7.0 9.0 60 19 0 105 43 56 20 58 22 20 60

FSH = follicle stimulating hormone, LH = luteinizing hormone, FT = free testosterone, GnRH = gonadotrophin-releasing hormone

10 6 ± 0.9 g/dl) To minimize transfusional iron overload, desfernoxamine mesulate (Desferal, Ciba-Geigy, Sarono-Varese, Italy) was administered by s.c. infusion in a dose of 15-45 mg/kg body weight as home management and every 10-12 h per day. Mean (±SD) serum ferntin value for the group was 3809 ± 2077 ng/ml (range: 950-9700). Table I details the clinical and laboratory findings in these patients. Six of them were prepubertal (Tanner's stage I: cases 1-6), six patients had arrested puberty (Tanner's stage II-IV: cases 7-12) and 18 patients had a normal puberty (Tanner's Stage V: cases 13-30), 10 had undergone splenectomy (cases 1, 2, 6, 8, 10, 11, 14, 15, 26, 27), two patients had hepatitis B (cases 17 and 22), nine patients were positive to hepatitis C virus (anti-HCV positive cases 2, 8, 11, 13, 15, 23, 25, 26, 27) and none was found positive to KVantibodies (ann-HTV negative). One patient (case 2) had developed polyendocnnopathy syndrome (hypothyroidism, insulin-dependent diabetes melhtus, hypogonadism) and was controlled on appropriate treatment. All patients had morphometnc measurements at regular intervals. Sexual maturation was assessed with the cntena proposed by Tanner et aL (1966) and testicular volume was evaluated by the Prader orchidometer (Prader, 1966). Endocrine and sperm studies were performed in all patients' (I) a gonadotrophin-releasing hormone (GnRH) test, after obtaining basal blood samples for follicle stimulating hormone (FSH), luteinizing hormone (LH) and free testosterone (FT) evaluation. This test included the administration of 100 |xg GnRH (Relisorm: Serono, Rome, Italy) I.V and determination of FSH and LH levels at 30 min and 60 min. A minimum 2-fold increase of gonadotrophins at 30 min and 60 min in comparison to their values before GnRH administration was considered to be indicative of adequate pituitary responsiveness, and (n) a minimum of two or three spermiograms, at 3-6 month time intervals were obtained. Spermatozoa were collected by masturbation after 3—4 days of abstinence All samples were analysed for volume, sperm concentration, motility and morphologic features according to the World Health Organization (WHO) cnteria (1992) Semen was considered normal if sperm density was 3:20X106/ml, sperm motility (progressive: A + B) 2*50% or rapid progressive motility >25% (category A) withm the first hour and sperm morphology 5*30%.

Table III. Semen parameters in the 18 patients of group A Patients (no)

Volume (ml)

Concentration (X lOfyml)

Motility (1 h) (%)

Morphology (% normal)

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

33 25 32 22 _ 18 25 25 22 _ 26 18 37 24 42 49 -

211 32 217 445 — 35 70 55 40 _ 20 100 21.5 74.5 315 103 -

55 25 40 70 _ 50 40* 65 50 _ 35* 65 40* _ 30* 55 -

75 30 50 65 _ 30 60 30 _ 30 75 30 30 60 -

'Rapid progressive moulity

Hormone levels were measured by radioimmunoassay (Diagnostic Products Corporation, USA) The results are presented as mean ± standard deviation (SD), and the unpaired r-test was applied to analyse the data (P < 0.05 was chosen as the limit of significance).

Results On the basis of clinical findings (Tanner's staging), serum hormone concentrations and sperm quality evaluation, the 30 patients studied were further divided into three subgroups. Group A: 18 patients (patients 13-30) (60%) who had normal sexual development (Tanner's stage V), with normal secondary sex characteristics, normal testicular volume, as well as serum hormones and spenniogram parameters within normal limits (Tables II and HT). 1901

J.Papadimas tt al.

Table IV. Serum hormone levels in the six patients of group B Patients (no.)

Age (years)

Testicular volume (ml)

Serum basal hormones FSH (mlU/ral)


30 mm

FT(pg/ml)

FSH 1

2 3 4

5 6

20 22 17 17 17 17

20 20 95 10 2.0 1.5

10 1.0 4.0 2.5 40 05

20 20

3.2 1.4 1.7 7.5 0.4 0.4

1.6 1.0 18 10 16 04

41 70 62 12

60 mm LH

FSH

LH 1.8 1.0 9.0 1.7 2.1 3.0

21 1.0 6.0 1.2 1.8 03

20 35 13 52 51 15

Table V. Scrum hormone levels in the six patients of group C Patients (no )

Age (years)

Testicular volume (ml)

Serum basal hormones FSH (mTU/ml)

7 8 9 10 11 12

17 21 17 18 20 19

13 0 40 50 20 21 9.0

25 8.0 5.6 29 2.1 80


19 18 1.0 3.2 46 30

Table VL Semen parameters in the six patients of group C Volume (ml)

Concentration (X10*/ml)

Mouhty (1 h) (%)


7 8 9 10 11 12

0.5

113 _ 127.5 167 73

60

75

40 75 60

40

19 04 15 13 38 23

60 mm

FSH

LH

FSH

LH

45 20 41 41 13 25

21 5.4 2.0 18 25 45

31 1.8 408 25 1.0 24

15 2.8 2.1 11 22 39

Group A Group B Group C Controls

FSH (mlU/ml)

LH (mTU/ml)

FT(pg/ml)

47 23 99 5.6

3.8 1.2 2.2 6.9

28+14 7 1.2 + 1 13 + 86 378 + 199

+ 32 ±2 + 9 ± 45

+ + ± ±

27 0.5 0.7 5.2

60 65

Group B: six patients (20%) who were prepubertal (Tanner's stage I) with no development of secondary sex characteristics, small testicular volume, no erection or ejaculation, abnormally low basal FSH, LH and FT levels and no substantial increase in gonadotrophins after GnRH infusion (hypogonadotrophic hypogonadism) (Table IV). Group C: six patients (20%) had arrested puberty (Tanner's stage II-IV), with some degree of sexual development, low to low-normal testicular volume, abnormal spermiogram parameters and low to low-normal basal levels of serum FSH, LH, FT and GnRH response (arrested puberty) (Tables V and VI) The results of hormonal evaluation are as follows. Basal serum FSH levels (Table VH) in hypogonadal patients (group B) were low (2.3 ± 2 mlU/ml), but not significantly different from controls (5.6 ± 4.5 mlU/ml). In the remaining two groups, serum FSH levels were not significantly different from controls (4.7 ± 3.2 and 9.9 ± 9 mlU/ml respectively). Basal serum LH levels (Table VH) in hypogonadal patients (group B) were very low (1.2 ± 0.5 mlU/ml) and were significantly different (P < 0.05) from controls (6.9 ± 5.2 mRJ/ml). In the remaining two groups serum LH levels were also low 1902

30 mm

Table VXL Serum hormone levels m the three groups of patients and controls (mean ± SD)

Patients (no)

15 1.9 1.7

FT(pg/ml)

but not significantly different from controls (3.8 ± 2.7 and 2.2 ± 0.7 mlU/ml) respectively. Basal serum FT levels (Table VTI) in group B were very low (1.2 ± 1 mlU/ml). There was a significant difference (P < 0.001) compared to controls (37.8 ± 19.9 mTU/ml). In group A FT levels (28 ± 14.7 mlU/ml) were not significantly different from controls. Finally, in group C, FT levels (13±8.6 mlU/ml) were significantly lower (P < 0.05) than controls. FSH response to GnRH (Figure 1) was low in group A at 30 min and 60 min in comparison with controls but with no significant difference, whereas the corresponding response in group B was significantly lower (P < 0.01). Similarly, LH response to GnRH (Figure 2) was very low in groups A and B compared to controls (P < 0.01 and P < 0.001 respectively). The results of the clinical evaluation and semen analysis are as follows: Testicular volume (Table VHI) in group B was very low (2.8 ± 1.3 ml) compared to controls (22.2 ± 3.4 ml) (P < 0.001), whereas in group A it was normal (23.3 ± 1 . 8 ml) compared to controls (P = NS). Seminal volume (Table VHI) in group B was not measurable

Pituitary-testicular axis in p-thalassaemla major

(B)

I

F8H mponM tftm OnflH hfadfan

Figure 1. Follicle stimulating hormone (FSH) response to gonadotrophm-releasing hormone (GnRH) administration.

•

Hypogonadal(B)

Figure 2 Luteimzing hormone (LH) response to gonadotrophm-releasing hormone (GnRH) administration.

Table VOL Testicular volume and semen parameters in the three groups of patients and controls

Group A Group B Group C Controls

TesOcular volume (ml)

Seminal volume (ml)

Sperm concentration (XlfZ/ml)

Motihty (1 h) (%)


23 3 28 10.8 22.2

25 ± 1 3 0 09 ± 07 3.3 ± 0 7

1145 ± 112 0 72 7 ± 40 61 ± 22

47 3 ± 18 0 48 3 ± 20 61 ± 16

47 ± 20 0 57 ± 24 59 ± 7

± ± ± ±

1 8 13 1 8 34

due to absence of ejaculation, while in group A it was normal (2.5 ± 1.3 ml) compared to controls (3 3 ± 0.7 ml) (P > 0.1) and in group C very low (0.9 ± 0.7 ml) (P < 0.01). Sperm concentration (Table Vlil) in group B was not measurable, while in groups A and C it was normal (114.5 ± mxiOfyml and 72.7 ± 40xl0 6 /ml respectively) with no difference from controls (61 ± 22X106/ml) (P = NS). Sperm motility (Table Vlll) 1 h after ejaculation was normal in group A (47.3 ± 18%) and group C (48.3 ± 20%), with no difference from controls (61 ± 16%) (P = NS). Finally, normal morphology (Table VHP) was found in group A (47 ± 20%) and group C (57 ± 24%), with no difference from controls (59 ± 7%) (P = NS). Beside hormonal and sperm parameters there was a systematic study of serum ferntin and haemoglobin levels (at least

three values per year for 4 years) (Table I). Patients from group B (patients 1-6) had very high ferntin levels compared with patients from group A (patients 13-30) (P < 0.001). There was also a significant difference in mean ferntin levels between group A and C patients (P < 0.01), as well as B and C (P < 0.01). These results show that serum ferritin is a parameter which correlates with the hypophyseal damage. In contrast to ferntin, there was no significant difference in mean haemoglobin values between the three groups. In an attempt to induce (group B) or to improve (group C) pubertal development and to achieve spermatogenesis, we treated 12 thalassaemic patients (six with complete hypogonadotrophic hypogonadism and six with arrested puberty) with exogenous combined gonadotrophins (HMG 75 IU + HCG 1500 IU im. every 48 h). The evaluation of the 1903

J.Papadimas et al.

therapeutic results was performed every 3 months (testicular volume, secondary sex characteristics, spermiogram, serum FT) and showed clinical and laboratory improvement in all patients. One of them, who was the only married man in this group, showed a normal spermiogram after 4 months of combined treatment, and his wife became pregnant. Discussion It is well known that patients with P-thalassaemia major develop hypogonadotrophic hypogonadism with delayed puberty and infertility (Tanner et al, 1966; De Sanctis et al, 1988; Danesi et al, 1992). This hypogonadism is presumably due to pituitary haemosiderosis caused by chronic iron overload (Wang et al, 1989; Allegra et al, 1990; Seracchioli et al, 1994). These patients suffer from severe anaemia and are dependent on blood transfusion, which in turn is responsible for tissue haemosiderosis. Massive tissue iron deposition affects all organ systems, especially the cardiac, hepatic and endocrine systems (Bunn, 1987; Vannasaeng et al, 1991). Evaluation of the functional reserves of these systems is necessary to determine their ability to cope with the overload, which may result from treatment complications. The results of our study support those of previous reports (De Sanctis et al, 1988; Mordel et al, 1989; Danesi et al, 1992). Of the 30 patients studied, six (20%) showed hypogonadotrophic hypogonadism, 16 (60%) showed normal puberty, secondary sex characteristics and normal spermatogenesis and six patients (20%) showed arrested puberty. Previous studies (Prader, 1966; Wang et al, 1989) have indicated that as many as 63 to 68% of thalassaemic patients develop pubertal and spermatogenesic problems. We consider that improved modern haematological management, especially the use of early and intensive therapy, is the main reason for the decrease in these figures. Special emphasis is given to the avoidance of long periods of blood transfusions without a synchronous chelation therapy. Of all parameters studied, serum ferritin appears to correlate most highly with the presence of hypogonadism. An important question that needs to be addressed is whether spermatogenesis rather than induction of fertility should be considered the goal of treatment in these patients. Given the option of testosterone-induced virilization or gonadotrophininduced spermatogenesis plus virilization, we choose the latter in all our patients, even though this approach involves the administration of frequent injections for up to 1.5-2 years. Gonadotrophin treatment has the additional advantage of increasing testicular volume, a clinical sign not observed in hypogonadotrophic men treated with testosterone. Patients are delighted by their ability to produce spermatozoa and they are assured of the possibility of fathering a child. For all these reasons, we treat thalassaemic patients with gonadotrophins rather than androgen replacement therapy. In conclusion, p%thalassaemia leads to varying degrees of hypophyseal damage ranging from complete hypogonadotrophic hypogonadism to arrested puberty. This damage is due to chronic iron overload and leads to decreased pituitary responsiveness to GnRH. With the current scheme of hyper1904

transfusion together with early desferrioxamine therapy, an important percentage of thalassaemic patients develop normal puberty and spermatogenesis. References Allegra, A , Capra, M., Cuccia, L et aL (1990) Hypogonadism in betathalassemic adolescents- a characteristic pituitary-gonadal impairment The ineffectiveness of long-term iron chelating therapy Gynecol EndocnnoL, 4, 181-191 Balducci, R., Toscano, V, Finochi, G et aL (1990) Effect of hCG and hMG treatment in young thalassemic patients with hypogonadotropic hypogonadism. J Endocr Invest., 13, 1-7. Bunn, H.F. (1987). Disorders of hemoglobin In Isselbacber K., Adams, R., Braunwald, E. et al. (eds), Harrison's Principles of Internal Medicine McGraw-Hill, New York, USA, pp 1518-1527 Borgna-Pignata, C , De Stefano, P, Zonta, L et al. (1985) Growth and sexual maturation in thalassemia major J Pediatr, 106, 150-155 Danesi, L., Scacchi, M , De Martin, M. et aL (1992) Evaluation of hypothalamic—pituitary function m patients with thalassemia major /. EndocnnoL Invest, 15, 177-184 De Sanctis, V, Vullo, C , Katz, M et aL (1988) Spermatogenesis in thalassemia. FemL StenL, 50, 969-975 Mordel, N., Birkenfeld, A., Goldfarb, A. and Rachmilewitz, E. (1989) Successful full-term pregnancy in homozygous fl-malassemia major, case report and review of the literature. Obstet. GynecoL, 73, 837-840 Prader, A. (1966) Testicular size assessment and clinical importance. Triangle, 7, 240-245 Seracchioli, R., Porcu, F , Colombi, C. et aL (1994) Transfusion-dependent homozygous (J-thalassemia major successful twin pregnancy following tnvitro fertilization and tubal embryo transfer Hum. Reprod., 9, 1964—1965 Tanner, J , Whitehouse, R. and Takaishi, M. (1966) Standards from birth to maturity for height, weight, height velocity and weight velocity m British children. Arch. Dis Child., 41, 454-458. Vannasaeng, S., Fucharoen, S., Pootrakul, P. et aL (1991) Pituitary function m thalassemia patients and the effect of chelation therapy. Acta EndocnnoL, 124,23-30 Wang, C , Tso, S and Todd, D (1989) Hypogonadotropic hypogonadism in severe fi-thalassemia. Effects of chelation and pulsative gonadotropin releasing hormone therapy J. Clin. EndocnnoL MetaboL, 68, 511—516 World Health Organization (1992) WHO Laboratory Manual for the Examination of Human Semen and Sperm—Cervical Mucus Interaction. Cambridge University Press, Cambridge, UK. Received on April 24, 1995, accepted on May 8, 1996