Male hypogonadism: an extended classification based on a developmental, endocrine physiology-based approach.

Normal testicular physiology results from the integrated function of the tubular and interstitial compartments. Serum markers of interstitial tissue function are testosterone and insulin-like factor 3 (INSL3), whereas tubular function can be assessed by sperm count, morphology and motility, and serum anti-Müllerian hormone (AMH) and inhibin B. The classical definition of male hypogonadism refers to testicular failure associated with androgen deficiency, without considering potential deficiencies in germ and Sertoli cells. Furthermore, the classical definition does not consider the fact that low basal serum testosterone cannot be equated to hypogonadism in childhood, because Leydig cells are normally quiescent. A broader clinical definition of hypogonadism that could be applied to male patients in different periods of life requires a comprehensive consideration of the physiology of the hypothalamic-pituitary-testicular axis and its disturbances along development. Here we propose an extended classification of male hypogonadism based on the pathophysiology of the hypothalamic-pituitary-testicular axis in different periods of life. The clinical and biochemical features of male hypogonadism vary according to the following: (i) the level of the hypothalamic-pituitary-testicular axis primarily affected: central, primary or combined; (ii) the testicular cell population initially impaired: whole testis dysfunction or dissociated testicular dysfunction, and: (iii) the period of life when the gonadal function begins to fail: foetal-onset or postnatal-onset. The evaluation of basal testicular function in infancy and childhood relies mainly on the assessment of Sertoli cell markers (AMH and inhibin B). Hypergonadotropism should not be considered a sine qua non condition for the diagnosis of primary hypogonadism in childhood. Finally, the lack of elevation of gonadotropins in adolescents or adults with primary gonadal failure is indicative of a combined hypogonadism involving the gonads and the hypothalamic-pituitary axis.

Early onset of primary hypogonadism revealed by serum anti-Müllerian hormone determination during infancy and childhood in trisomy 21.

Male patients with an extra sex chromosome or autosome are expected to present primary hypogonadism at puberty owing to meiotic germ-cell failure. Scarce information is available on trisomy 21, a frequent autosomal aneuploidy. Our objective was to assess whether trisomy 21 presents with pubertal-onset, germ-cell specific, primary hypogonadism in males, or whether the hypogonadism is established earlier and affects other testicular cell populations. We assessed the functional status of the pituitary-testicular axis, especially Sertoli cell function, in 117 boys with trisomy 21 (ages: 2months-20year). To compare with an adequate control population, we established reference levels for serum anti-Müllerian hormone (AMH) in 421 normal males, from birth to adulthood, using a recently developed ultrasensitive assay. In trisomy 21, AMH was lower than normal, indicating Sertoli cell dysfunction, from early infancy, independently of the existence of cryptorchidism. The overall prevalence rate of AMH below the 3rd percentile was 64.3% in infants with trisomy 21. Follicle-stimulating hormone was elevated in patients <6months and after pubertal onset. Testosterone was within the normal range, but luteinizing hormone was elevated in most patients <6months and after pubertal onset, indicating a mild Leydig cell dysfunction. We conclude that in trisomy 21, primary hypogonadism involves a combined dysfunction of Sertoli and Leydig cells, which can be observed independently of cryptorchidism soon after birth, thus prompting the search for new hypotheses to explain the pathophysiology of gonadal dysfunction in autosomal trisomy.

Bisphenol A effect on glutathione synthesis and recycling in testicular Sertoli cells.

BACKGROUND AND OBJECTIVE: Controversial effects of bisphenol A (BPA) have been reported on testicular function. These differences might reflect dissimilar exposure conditions. Dose responses to toxicants may be non-linear, e.g. U-shaped, with effects at low and at high levels of exposure and lower or inexistent effects at intermediate levels. Sertoli cells produce high levels of glutathione (GSH) as a cell defense mechanism. In this study, we addressed the question whether the exposure to different doses of BPA could influence Sertoli cell GSH synthesis and recycling. MATERIALS AND METHODS: Primary Sertoli cell cultures were exposed to various doses of BPA (0.5 nM-100 µM). Cell viability was measured as an outcome of toxic effect. GSH cell content was determined to evaluate cell response to toxicant exposure. Glutamate-cysteine ligase catalytic (GCLC) and modulatory (GCLM) subunit expression were assessed to estimate GSH synthesis, and GSH reductase (GR) expression to estimate GSH recycling. RESULTS: BPA 100 µM, but not lower doses, decreased cell viability. BPA 10 and 50 µM, but not lower doses, induced an increment in Sertoli cell GSH levels, due to a rapid upregulation of GCLC and GR and a slower upregulation of GCLM. CONCLUSIONS: High doses of BPA are deleterious for Sertoli cells. Intermediate doses do not affect Sertoli cell viability and increase cell content of GSH owing to increased GSH synthesis and recycling enzyme expression. Lower doses of BPA are not capable of eliciting a cell defense response. These observations may explain a non-linear dose response of Sertoli cells to BPA.

Predictive value of anatomical findings and karyotype analysis in the diagnosis of patients with disorders of sexual development.

We assessed the predictive value of anatomical findings and karyotype for establishing a diagnostic orientation in patients with disorders of sex development (DSD). We performed a retrospective chart analysis of 228 patients, grouped into 4 categories: 46,XX DSD, non-dysgenetic testicular DSD, dysgenetic testicular DSD and ovotesticular DSD. Degree of virilisation, presence of vagina, presence of palpable gonads, size of gonads and a plain karyotype was available for all cases. 46,XX DSD due to congenital adrenal hyperplasia counted for 59.2% of the cases, non-dysgenetic testicular DSD for 13.6%, dysgenetic testicular DSD for 21.5% and ovotesticular DSD for 5.7%. Excluding congenital adrenal hyperplasia (CAH), a karyotype with at least one 46,XX cell line had a high diagnostic efficiency for ovotesticular DSD. In these patients, anatomical findings were not as useful to predict the gonadal phenotype. The existence of a 45,X cell line predicted with very high efficiency dysgenetic testicular DSD. Genital palpation was only partially helpful to predict the existence of testicular tissue. Non-dysgenetic testicular DSD could be ruled out with high efficiency in patients with an abnormal karyotype. Anatomical findings were helpful in 46,XY patients: palpated masses predicted non-dysgenetic testes with high accuracy. In all cases assessment of gonadal volume was less useful.

Evaluation of gonadal function in 107 intersex patients by means of serum antimüllerian hormone measurement.

Fetal male sexual differentiation is driven by two testicular hormones: testosterone (synthesized by interstitial Leydig cells) and antimüllerian hormone (AMH; produced by Sertoli cells present in the seminiferous tubules). Intersex states result either from gonadal dysgenesis, in which both Leydig and Sertoli cell populations are affected, or from impaired secretion or action of either testosterone or AMH. Until now, only Leydig cell function has been assessed in children with ambiguous genitalia, by means of testosterone assay. To determine whether serum AMH would help in the diagnosis of intersex conditions, we assayed serum AMH levels in 107 patients with ambiguous genitalia of various etiologies. In XY patients, AMH was low when the intersex condition was caused by abnormal testicular determination (including pure and partial gonadal dysgenesis) but was normal or elevated in patients with impaired testosterone secretion, whereas serum testosterone was low in both groups. AMH was also elevated during the first year of life and at puberty in intersex states caused by androgen insensitivity. In 46,XX patients with a normal male phenotype or ambiguous genitalia, in whom the diagnosis of female pseudohermaphroditism had been excluded, serum AMH levels higher than 75 pmol/L were indicative of the presence of testicular tissue and correlated with the mass of functional testicular parenchyma. In conclusion, serum AMH determination is a powerful tool to assess Sertoli cell function in children with intersex states, and it helps to distinguish between defects of male sexual differentiation caused by abnormal testicular determination and those resulting from isolated impairment of testosterone secretion or action.

Antimüllerian hormone as a serum marker of granulosa cell tumorsof the ovary: comparative study with serum alpha-inhibin and estradiol.

OBJECTIVE: Our purpose was to evaluate serum antimüllerian hormone as a marker for granulosa cell tumors. STUDY DESIGN: Serum antimüllerian hormone concentrations were determined in 16 patients with an adult-type granulosa cell tumor; in female patients with ovarian adenocarcinoma, benign ovarian cysts, or extraovarian cancers; and in normal premenopausal and postmenopausal women. Serum antimüllerian hormone, alpha-inhibin, and estradiol levels were compared in 10 patients with a granulosa cell tumor during 6 to 47 months of follow-up. RESULTS: Serum antimüllerian hormone was undetectable in normal postmenopausal women and was <5 micrograms/L in premenopausal women. Normal serum levels were found in patients with ovarian cancers or cysts or with extraovarian cancers. Levels were between 6.8 and 117.9 microg/L in eight of nine patients with a progressive granulosa cell tumor. In the remaining case antimüllerian hormone, alpha-inhibin and estradiol concentrations were normal. Serum antimüllerian hormone and alpha-inhibin levels became elevated at least 11 months before the recurrence was clinically detectable. During clinical remission serum antimullerian hormone, beta-inhibin, and estradiol were normal in most cases. CONCLUSION: Serum antimüllerian hormone is a sensitive, specific, reliable marker of adult-type granulosa cell tumors and is useful to evaluate the efficacy of treatment and to detect recurrences early.

Morphometric study of the testicular interstitial tissue of the monkey Cebus apella during postnatal development.

The purpose of this study was to evaluate the developmental changes of the Leydig cells and their precursors during postnatal development in the monkey Cebus apella. Four groups of monkeys were studied: neonatal, infantile, early pubertal and late pubertal. Light microscopy, immunocytochemistry, electron microscopy and stereological studies were performed to determine cytologic and cytochemical characteristics, volume density, absolute volume and cell counts of Leydig cells. In the interstitial tissue two components were recognized: specific interstitium comprising mature and immature Leydig cells and differentiating Leydig cell precursors, and non-specific interstitium including connective tissue and blood vessels. Mature Leydig cells were polygonal with a round, euchromatic nucleus and abundant cytoplasm. Immature Leydig cells were more elongated and the nucleus showed more heterochromatin. Mature and immature Leydig cells showed either a pale- or a dark-stained cytoplasm. Pale Leydig cells showed abundant smooth endoplasmic reticulum (SER), mitochondria with tubular cristae and glycogen granules. The SER of dark Leydig cells consisted of abundant flat cisternae, only few glycogen inclusions and abundant lipid droplets. All Leydig cells were intensely reactive for 3beta-hydrohysteroid dehydrogenase (3beta-HSD). Some peritubular cells acquired nuclear and cytoplasmic characteristics that indicated that they were differentiating to Leydig cells, as evidenced by the strong 3beta-HSD positivity found in scattered elongated cells of the peritubular tissue. Absolute interstitial volume increased from birth to the end of puberty due to an increment in Leydig cells numbers and size. The mature and immature Leydig cell populations showed a different evolution during postnatal development. While immature Leydig cells increased 7-fold from the neonatal to the early pubertal period and increased at a lower rate during puberty, mature Leydig cells remained stable until early puberty and increased significantly during late pubertal development.

Correlation between skin potential response and psychopathology in patients with affective disorders.

The correlation between the degree of psychopathology (assessed by the Minnesota Multiphasic Personality Inventory, MMPI) and sympathetic function (assessed by the skin potential response to somatosensory stimuli) was evaluated in 209 patients with affective disorders. A number of skin potential parameters (skin potential levels, negative fluctuations of first derivative of skin potential, negative areas in phase plane analysis, differences between last and initial average potentials and between the last average potential for the preceding stimulus and initial average potentials for a given stimulus) were correlated with the psychopathology index, calculated as the average of clinically relevant MMPI scales. Categorical classification of patients having or not having abnormally high psychopathology index scores also supported the differences in skin potential response between both groups of patients. The results further indicate the existence of a correlation between severity of mood disorders and increased sympathetic reactivity.

Is infancy a quiescent period of testicular development? Histological, morphometric, and functional study of the seminiferous tubules of the cebus monkey from birth to the end of puberty.

The objective of this study was to describe the maturational changes observed in the seminiferous tubules of the monkey Cebus apella, a New World primate species, from birth to the end of puberty. Nineteen animals were subdivided into four groups: neonatal (1-40 days), infantile (4 months to 1 yr), early pubertal (1 yr, 8 months to 2 yr, 9 months), and late pubertal (4-8 yr). Volumetric determinations of different testicular components were made, tubule diameter and length were calculated, and spermatogenic cells, Sertoli cells, and androgen-binding protein secretion were quantified. Testicular and seminiferous tubule volumes increased significantly in the first 5 months of life and during puberty due to the combined increment in seminiferous tubule diameter and length. The total number of spermatogonia increased until late puberty to stabilize subsequently. Spermatocytes and spermatids appeared during puberty and increased dramatically until the end of this period. The germ cell ratios, indicative of spermatogenic efficiency, improved continuously in late puberty coincidentally with a reduction of spermatocyte degeneration. Sertoli cells proliferated in the neonatal and infantile periods, determining a longitudinal growth of the seminiferous tubules, but remained stable during puberty, when androgen-binding protein secretion increased significantly. The multiplication of germ cells is the main factor responsible for the increment in tubule diameter during puberty and determines the most noticeable postnatal modification of testicular volume. During late puberty, the reduction of spermatocyte degeneration leads to an increment in germ cell ratios and a progressive, but slow, improvement of spermatogenic efficiency, explaining why pubertal development of the testis occurs over such a prolonged period in this primate. This is in contrast to what happens in most laboratory animals and suggests that the Cebus is a useful model for studies of human male puberty.

Diurnal changes in cyclic nucleotide response to pineal indoles in murine mammary glands.

The aim of this study was to determine whether pineal indoles affect cyclic nucleotide levels in mammary gland slices of BALB/c adult mice. Melatonin at 0.1 nM-10 microM concentrations decreased cAMP and augmented cGMP concentration in murine mammary gland slices in the presence of a phosphodiesterase inhibitor (1 mM theophylline), an index of cyclic nucleotide synthesis. Melatonin-induced changes in cyclic nucleotide levels were significantly larger at the end of the light period (2000) than in the morning (at 1000). Indole-induced inhibition of cyclic AMP levels by mammary slices exhibited the following order of potency: 5-methoxytryptamine > melatonin > or = 6-hydroxymelatonin > serotonin, N-acetylserotonin > 5-hydroxytryptophol. The order of potency for indole-induced augmentation of cyclic GMP levels was: 5-methoxytryptamine > melatonin > 6-hydroxymelatonin > serotonin, N-acetylserotonin, 5-hydroxytryptophol. When melatonin or 5-methoxytryptamine (10 nM) were examined for their effects on cAMP and cGMP levels in mammary glands of mice killed at six different time intervals during the 24-hr cycle, the activity was maximal during night. The data demonstrate that 5-methoxytryptamine and melatonin decreased cAMP and increased cGMP levels in mammary gland slices. Methoxyindole-induced changes in cyclic nucleotide synthesis in murine mammary glands exhibit the time-dependency known to occur in several other melatonin-influenced responses.

Some neurovegetative correlates of Minnesota Multiphasic Personality Inventory (MMPI)

In 57 patients with psicovegetative disorders and abnormal MMPI, abnormality in MMPI scales indicating hypochondriasis, hysteria, gender deviant, paranoia, psychastenia, schizophrenia, hypomania or introversion was accompanied by increased plasma catecholamine levels and/or responses to hypoglycemia or by an increased cardiovascular reactivity. A high depression scale was associated with lower plasma catecholamine levels. Blunted plasma growth hormone responses to hypoglycemia were found in abnormal hypomania scale, and augmented responses of plasma cortisol in abnormal hysteria or schizophrenia scales. Paranoia and hypomania traits correlated with absence of morning-evening differences in blood cortisol levels. Electrodermal responses compatible with increased sympathetic activity correlated with high hysteria, gender, paranoia, schizophrenia or hypomania MMPI scales. This study indicates that most psychopathological traits in MMPI are accompanied by humoral and/or electrophysiological signs of abnormality of the autonomic nervous system.

Some neurovegetative correlates of Minnesota Multiphasic Personality Inventory (MMPI)

In 57 patients with psicovegetative disorders and abnormal MMPI, abnormality in MMPI scales indicating hypochondriasis, hysteria, gender deviant, paranoia, psychastenia, schizophrenia, hypomania or introversion was accompanied by increased plasma catecholamine levels and/or responses to hypoglycemia or by an increased cardiovascular reactivity. A high depression scale was associated with lower plasma catecholamine levels. Blunted plasma growth hormone responses to hypoglycemia were found in abnormal hypomania scale, and augmented responses of plasma cortisol in abnormal hysteria or schizophrenia scales. Paranoia and hypomania traits correlated with absence of morning-evening differences in blood cortisol levels. Electrodermal responses compatible with increased sympathetic activity correlated with high hysteria, gender, paranoia, schizophrenia or hypomania MMPI scales. This study indicates that most psychopathological traits in MMPI are accompanied by humoral and/or electrophysiological signs of abnormality of the autonomic nervous system.

Some neurovegetative correlates of Minnesota Multiphasic Personality Inventory (MMPI)

In 57 patients with psicovegetative disorders and abnormal MMPI, abnormality in MMPI scales indicating hypochondriasis, hysteria, gender deviant, paranoia, psychastenia, schizophrenia, hypomania or introversion was accompanied by increased plasma catecholamine levels and/or responses to hypoglycemia or by an increased cardiovascular reactivity. A high depression scale was associated with lower plasma catecholamine levels. Blunted plasma growth hormone responses to hypoglycemia were found in abnormal hypomania scale, and augmented responses of plasma cortisol in abnormal hysteria or schizophrenia scales. Paranoia and hypomania traits correlated with absence of morning-evening differences in blood cortisol levels. Electrodermal responses compatible with increased sympathetic activity correlated with high hysteria, gender, paranoia, schizophrenia or hypomania MMPI scales. This study indicates that most psychopathological traits in MMPI are accompanied by humoral and/or electrophysiological signs of abnormality of the autonomic nervous system.

Autonomic peripheral evoked potential (APEP): a non-invasive procedure to assess sympathetic responses in humans.

The present study describes skin potential responses during a sequence of extero-, intero- and proprioceptive stimuli in 73 normal human subjects. By plotting the first derivative of skin potential vs. skin potential changes for every stimulus (phase plane) a generally opposite behavior of positive and negative deflections (indicating sympathetic inhibition and activation, respectively) was found. By area subtraction in phase plane analysis, only olfactory stimulation or nasal hyperventilation exhibited a significantly negative (sympathetic activating) skin potential response. Frequency of positive (sympathetic inhibitory) fluctuations of first derivative of skin potential was significantly lower than basal after explosive sound, tactile discrimination, photomotor reflex, and nasal and oral hyperventilation. Frequency of negative (sympathetic activating) fluctuations augmented significantly (as compared to basal) after explosive sound, tactile discrimination, nasal or oral hyperventilation, upright position or trot. These results suggest that activation of the sympathetic nervous system involves a coordinated motor program comprising activation of certain areas, and inhibition (or lack of changes) in others, with different patterns of interrelated activation and inhibition depending upon stimulus.

Autonomic peripheral evoked potential (APEP): a non-invasive procedure to assess sympathetic responses in humans.

The present study describes skin potential responses during a sequence of extero-, intero- and proprioceptive stimuli in 73 normal human subjects. By plotting the first derivative of skin potential vs. skin potential changes for every stimulus (phase plane) a generally opposite behavior of positive and negative deflections (indicating sympathetic inhibition and activation, respectively) was found. By area subtraction in phase plane analysis, only olfactory stimulation or nasal hyperventilation exhibited a significantly negative (sympathetic activating) skin potential response. Frequency of positive (sympathetic inhibitory) fluctuations of first derivative of skin potential was significantly lower than basal after explosive sound, tactile discrimination, photomotor reflex, and nasal and oral hyperventilation. Frequency of negative (sympathetic activating) fluctuations augmented significantly (as compared to basal) after explosive sound, tactile discrimination, nasal or oral hyperventilation, upright position or trot. These results suggest that activation of the sympathetic nervous system involves a coordinated motor program comprising activation of certain areas, and inhibition (or lack of changes) in others, with different patterns of interrelated activation and inhibition depending upon stimulus.

Autonomic peripheral evoked potential (APEP): a non-invasive procedure to assess sympathetic responses in humans.

The present study describes skin potential responses during a sequence of extero-, intero- and proprioceptive stimuli in 73 normal human subjects. By plotting the first derivative of skin potential vs. skin potential changes for every stimulus (phase plane) a generally opposite behavior of positive and negative deflections (indicating sympathetic inhibition and activation, respectively) was found. By area subtraction in phase plane analysis, only olfactory stimulation or nasal hyperventilation exhibited a significantly negative (sympathetic activating) skin potential response. Frequency of positive (sympathetic inhibitory) fluctuations of first derivative of skin potential was significantly lower than basal after explosive sound, tactile discrimination, photomotor reflex, and nasal and oral hyperventilation. Frequency of negative (sympathetic activating) fluctuations augmented significantly (as compared to basal) after explosive sound, tactile discrimination, nasal or oral hyperventilation, upright position or trot. These results suggest that activation of the sympathetic nervous system involves a coordinated motor program comprising activation of certain areas, and inhibition (or lack of changes) in others, with different patterns of interrelated activation and inhibition depending upon stimulus.