Hypogonadotrophic hypogonadism (HH) is an uncommon cause of low testosterone and male infertility. Unlike conditions where the problem starts in the testicles (testes), HH is caused by a problem with the hormonal signals from the hypothalamus or pituitary gland. Depending on the cause, treatment may improve testosterone levels and symptoms, stimulate sperm production, or both. For some men with HH, fertility can be restored. Here’s what you need to know about hypogonadotrophic hypogonadism, symptoms of the condition and treatment options.
What is hypogonadotrophic hypogonadism?
Your brain and your testes work together to control testosterone levels and sperm production. The hypothalamus is a part of the brain that produces gonadotrophin-releasing hormone (GnRH). This signals the pituitary gland to produce and release into the bloodstream two other hormones: luteinising hormone (LH) and follicle-stimulating hormone (FSH). These hormones act on cells in the testes to promote testosterone and sperm production. With hypogonadotrophic hypogonadism, there isn’t enough stimulation from GnRH, LH and/or FSH. As a result, the testes may not make enough testosterone, sperm or both.
What causes hypogonadotropic hypogonadism?
HH can be congenital, meaning you are born with it, or acquired, meaning it develops later.
Congenital hypogonadotropic hypogonadism can be caused by genetic conditions that affect the development or function of the hypothalamus and pituitary gland. One example is Kallmann syndrome.
Acquired hypogonadotropic hypogonadism can have several causes, including conditions affecting the pituitary gland, such as a prolactinoma, as well as pituitary surgery or radiotherapy. Some medicines and the use of testosterone or anabolic steroids can also interfere with the hormonal signals that control testosterone and sperm production.
Illness, obesity and other health problems can also suppress the hormonal system without permanent damage to the hypothalamus or pituitary gland. These cases are sometimes described as functional hypogonadism. Identifying and treating an underlying or reversible cause of HH may be more appropriate than treatments like testosterone therapy.
What are the symptoms of hypogonadotropic hypogonadism?
Symptoms depend partly on when hypogonadotropic hypogonadism develops.
Some men first discover there may be a problem when they have difficulty having a child. HH can cause very low sperm counts or no sperm in the semen.
How is hypogonadotropic hypogonadism diagnosed?
Assessment usually involves your doctor checking your medical and reproductive history, performing a physical examination and ordering blood tests. If fertility is a concern, a semen analysis may be suggested.
Blood tests can include testosterone, LH and FSH. Low testosterone combined with low or inappropriately normal levels of LH can suggest a problem involving the hypothalamus or pituitary gland. Depending on your results and medical history, your health practitioner may investigate other pituitary hormones, including prolactin.
Once HH is diagnosed, working out why you have it is important. Australia’s clinical guidelines for the management of male infertility recommend determining whether HH is congenital or acquired using clinical and hormone assessment, and following up with imaging and, when appropriate and available, genetic testing.
This investigation can matter beyond fertility. In some cases, HH can be caused by an underlying condition that needs treatment in its own right.
How does hypogonadotropic hypogonadism affect fertility?
The hormones involved in HH are also essential for sperm production. If the testes do not receive enough stimulation from LH and FSH, sperm production can be very low or stop altogether.
HH is typically diagnosed during teenage years or early adulthood because puberty does not occur. Treatment to induce puberty is a priority to support sexual development, musculoskeletal development and psychosocial maturation and wellbeing. Testosterone treatment is safe and effective for the indication of puberty but does not support sperm production or fertility.
But having HH does not necessarily mean you can’t have biological children.
Male infertility caused by HH may be successfully treated because gonadotrophins can stimulate the testes to produce sperm. Natural fertility may be restored for some men with the condition. This is why getting the diagnosis right matters. Treatment for low testosterone is not necessarily the same as treatment for fertility.
How is hypogonadotropic hypogonadism treated?
Treatment depends on what is causing the condition, your symptoms and whether having children now or in the future is important to you.
Where there is an identifiable underlying cause of HH, treating that condition may be part of the approach. Some pituitary conditions, for example, require their own specific treatment.
If you have confirmed androgen deficiency and fertility is not a current priority, testosterone therapy may be used to restore testosterone levels and improve symptoms.
What treatment is used if you want to have children?
If you have hypogonadotropic hypogonadism and want to have children, discuss this with your health practitioner before treatment starts.
Taking testosterone suppresses the hormonal signals needed for sperm production. This means testosterone therapy can reduce or stop sperm production and should not be started in men who are currently trying, or planning soon, to have children.
Instead of taking testosterone, treatment can replace the hormonal stimulation that is missing.
Australia’s male infertility guidelines recommend using human chorionic gonadotrophin (hCG) and FSH to induce sperm production in men with HH. These hormones stimulate the testes in ways that support testosterone and sperm production. This treatment needs specialist supervision and monitoring. The exact approach depends on the cause of HH and how your testes respond.
Importantly, using hCG and FSH for confirmed HH is different from using these medicines for unexplained male infertility. They are not routinely recommended when infertility has no identified cause.
What can you expect with treatment?
The outlook depends on the cause of hypogonadotrophic hypogonadism and your individual circumstances.
If HH is caused by an underlying condition that can be treated or reversed, addressing that cause may improve hormone function. If there is an ongoing problem with the hypothalamus or pituitary gland, gonadotrophin treatment may be needed to replace the missing signals to drive sperm production.
When fertility is the goal, gonadotrophin treatment can stimulate sperm production. This does not take effect immediately and response varies between individuals, so treatment and fertility planning can take time. About 75% of men with HH who receive gonadotrophin treatment will eventually produce sperm. Even though the average sperm concentration in ejaculate for these men is lower than the range for males with proven fertility, natural conception is possible. Assisted reproduction using intracytoplasmic sperm injection is an option for men with HH who have trouble fathering children.
The important thing to know is that HH is a potentially treatable cause of male infertility. Finding the cause can change your treatment, your fertility options and what you can expect in the future.
People also ask
Is hypogonadotropic hypogonadism curable?
It depends on the cause. Some causes may be reversible or treatable. In most cases, an ongoing problem with the hypothalamus or pituitary gland means hormone treatment may be needed long term. Finding the cause helps your health practitioner work out the most appropriate treatment and explain what you can expect. HH is usually something that is managed long term rather than cured.
How long does fertility treatment for hypogonadotropic hypogonadism take?
Sperm production does not return immediately. Treatment can take months and the response varies between individuals. Your specialist will monitor your response and adjust treatment as needed.
Is hypogonadotrophic hypogonadism the same as low testosterone?
Not exactly. Hypogonadotropic hypogonadism is one cause of low testosterone. It occurs when the hypothalamus or pituitary gland does not provide enough hormonal stimulation to the testes. Low testosterone can also have other causes, including problems that start in the testes themselves.
