Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 114

In Case History 2, the symptoms and biochemical findings are consistent with hypogonadism, which is secondary to the patient’s uncontrolled type 2 diabetes and a high BMI. The first step in the management will involve weight reduction, as adipose tissue produces cytokines and adipokines which lead to metabolic dysfunction and insulin resistance, which further contribute to a low total serum testosterone. A reduction in BMI will help with the control of diabetes, improve erectile dysfunction (ED) and testosterone levels [20]. Referral to a diabetologist is required to help achieve tight glycemic control which may improve the semen profile.

For diagnosis and treatment of hypogonadism, the recommendation from a panel of European and US testosterone experts are (a) to provide testosterone therapy if the total testosterone levels are < 8nmol/L and (b) in those with total testosterone of 8–12 nmol/L and hypogonadal symptoms consider a trial of testosterone therapy [21]. There is evidence that testosterone replacement therapy improves insulin sensitivity and glycemic control [22]. However, testosterone therapy adversely affects spermatogenesis and thus may not be an appropriate intervention in a man trying to achieve conception, especially if the sperm results are already poor pretreatment or if the couple is already planning for ART through ICSI.

ED, which is common in men with diabetes, could be because of hypogonadism or the vascular and neuropathic effects of diabetes. Men with ED may therefore respond to phosphodiesterase inhibitors.

Statins are hydroxymethylglutaryl‐CoA reductase inhibitors, which can potentially reduce testosterone levels by decreasing availability of cholesterol for testosterone biosynthesis. Studies have shown conflicting results of statin treatment on testosterone levels. However, there is evidence to suggest that in type 2 diabetes, statins lower testosterone levels [23]. Serum lipid profile should be repeated in this case and if normal, after appropriate counseling, statins can be withheld temporarily while the couple undergoing is ICSI treatment.