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treatment in a patient with IHH include induction and maintenance of secondary
sexual characteristics and to improve the fertility prospects. For induction of sec-
ondary sexual characteristics, testosterone therapy is initiated with a low dose of
testosterone esters (testosterone enanthate 50–100 mg) intramuscularly every
month which is gradually built up to 200–250 mg every fortnightly over a period
of 2–3 years. Improvement in libido, mood, and quality of life is observed over a
period of 3–6 months, whereas increase in body hair, muscle mass and strength,
and deepening of voice take longer time over a period of 1–2 years. Serum testos-
terone should be measured midway between the two injections after 3 months of
initiation of treatment to assess the adequacy of therapy; however, it may also be
required to measure serum testosterone just prior to the next injection to decide
about the dosing interval. The adverse effects associated with testosterone therapy
include gynecomastia, aggressive behaviour, priapism, mood swings, acne, and
androgenic alopecia. hCG has also been tried for the induction of puberty which is
associated with stable level of serum testosterone, minimal fluctuation in hypogo-
nadal symptoms, and initiation of spermatogenesis; however, frequent injections
and cost preclude its routine use in clinical practice. In addition, limited data is
available regarding the use of gonadotropins as a primary therapy in induction of
secondary sexual characteristics. The index patient was initiated with 100 mg tes-
tosterone every monthly for 3 months, and later the dose frequency was increased
to fortnightly. At 6 months of follow-up, his serum testosterone was 5 nmol/L and
he had improvement in generalized well-being. The dose was further increased to
150 mg fortnightly. Gonadotropin therapy is indicated when fertility is desired.
hCG is initiated at a dose of 1,000–2,000 IU twice or thrice a week with monthly
monitoring of serum testosterone to achieve and sustain testosterone in eugonadal
range. If the target is not achieved the doses can be increased up to 5,000 IU thrice
a week. Once the serum testosterone level is maintained >9 nmol/L, semen analy-
sis should be performed at monthly interval. If spermatogenesis is not initiated
despite continuation of hCG for 6–12 months after achieving the serum testoster-
one in normal range, hMG should be added at a dose of 75 IU thrice weekly. If the
sperm count is still <1 million/ml, the doses of hMG should be increased to 150 IU
thrice weekly. The predictors of response to gonadotropin therapy include initial
larger testicular volume, prior history of gonadotropin therapy, and absence of
prior androgen therapy. Prior androgen therapy may be associated with less favor-
able outcome, because optimal concentration of intratesticular testosterone is not
achieved with exogenous testosterone therapy, as intratesticular testosterone is
required to inhibit the secretion of AMH from Sertoli cells, which in turn exerts the
suppressive effect on germ cell growth and proliferation. The overall response rate
to gonadotropin therapy in terms of spermatogenesis and fertility has been shown
to vary from 50 to 90 %.
7 Delayed Puberty