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intramuscular preparations of testosterone like enanthate, propionate, or cypi-
onate are preferred for induction of puberty because of the vast experience with
their use. Therapy is initiated at a dose of 50–100 mg monthly, and the dose is
gradually increased by 50 mg, every six months. Therapy is initiated at a low
dose to minimize the risk of priapism, aggressive behavior, and acne and to
prevent premature closure of epiphysis. Once a dose of 100–150 mg is reached,
the frequency of administration can be increased to fortnightly. The adult
replacement dose of testosterone is 200–250 mg intramuscularly every
2–3 weeks. After initiation of therapy, boys should be monitored for growth and
progression of pubertal development. Monitoring of serum testosterone levels
is not recommended during induction of puberty because of wide variation in
reference range of serum testosterone during pubertal development in healthy
boys. However, monitoring of serum testosterone should be performed once the
adult replacement dose is initiated, with a target to maintain serum testosterone
in the mid-normal adult range.- What are the merits and demerits of testosterone therapy?
Pubertal induction with testosterone is inexpensive and has the convenience of
monthly/fortnightly injections as compared to gonadotropins/GnRH. In addi-
tion, there is extensive experience of pubertal induction with intramuscular tes-
tosterone therapy as compared to other modalities. However, therapy with
testosterone only induces virilization and does not initiate spermatogenesis.
Further, testosterone therapy is associated with adverse effects like priapism,
acne, aggressive behavior, mood disorders, and gynecomastia. Therapy with
intramuscular preparations is associated with supraphysiological levels of
serum testosterone in the initial few days, followed by low levels before the
next injection, resulting in wide swings in the concentration of serum testoster-
one, which manifests as disturbing fluctuations in sexual function, energy level,
and mood.- How does intratesticular testosterone facilitate spermatogenesis?
In normal men, intratesticular testosterone concentration is 100- to 200- folds
higher than serum testosterone levels. High levels of intratesticular testosterone
directly promote the growth of seminiferous tubules in concert with FSH. In
addition, high concentration of intratesticular testosterone also results in inhibi-
tion of AMH from Sertoli cells, which has a suppressive effect on germ cell
growth and proliferation.- How to induce fertility in men with congenital IHH?
In a male with congenital IHH desiring fertility, testicular volume is the key
determinant of further management. In patients with a testicular volume
>4 ml, therapy with hCG should be initiated and serum testosterone should be7 Delayed Puberty