1. Sandro C. Esteves, MD., PhD.
Director, ANDROFERT
Andrology& Human Reproduction Clinic
Campinas, BRAZIL
Anabolic Steroids and Male Infertility
ISO 9001:2008
Reproductive Andrology Surgery Workshop II
Reproductive Medicine Unit -JahraHospital -Kuwait 2014

2. Facts about Anabolic S teroids
• >3 million users in the USA
– 2/3 non-competitive athletes (aesthetic)
Maravelias et al 2005; Taylor Hooton Foundation.org
ANDROFERT
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4. ANDROFERT
androfert.com.br
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Source: worldwideweb

5. Souza and Hallak, 2011
ANDROFERT
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6. Drug regimens
•Oral and injectable compounds combined in cycles lasting 4-12 weeks
•Stacking (small doses of multiple drugs)
–testosterone + nandrolone(mass-building)
–Combinations with potent androgens preferred for dieting and body definition (low estrogenic activity)
–Post-cycle therapy using anti-estrogen + hCG to restart androgen production
ANDROFERT
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7. Effects
•Increase in muscular activity (hypertrophy of muscle fibers; increase in size)
•Side effects:
–Enlargement of prostate (5DHT androgenic effect)
–T aromatization: gynecomastia
–Erectile dysfunction and low libido after discontinuation (low endogenous T)
–Hepatic/cardiotoxicity
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8. Exogenous testosterone: a preventable cause of male infertility
•Many doctors, including urologists and endocrinologists, prescribe testosterone to men at reproductive age
–25% US urologists treated low T levels in male infertility with testosterone
–Prescription increased 170% in 5-year period
Crosnoeet al. 2013
ANDROFERT
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9. Infertility is a trigger to depression
•Decreased libido consequence, not causative
•Increasing T levels by exogenous T administration not a solution
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10. •Dose and duration-related effect
•Anabolic:androgenicratio
•Weekly doses of 300 mg or higher
Souza and Hallak, 2011
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11. Why AS cause infertility?
GnRH
FSH/LH
Markedfallin ITT levels
Between the seminiferous tubules, Leydigcells produce testosterone
SupraphysiologicalTlevels> 1000 ng/dL
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12. •Adequate levels of ITT are essential for regulating spermatogenesis in combination with Sertoli cell stimulation with FSH
•ITT levels stimulate spermatogonia DNA synthesis and spermiogenesis
•ITT levels 100-fold higher than serum T
•Sertoli cells are major target for testosterone signaling (via AR)
Why AS cause infertility?
ANDROFERT
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13. Why AS cause infertility?
GnRH
FSH/LH
Azoospermia
Markedfallin ITT levels
Between the seminiferous tubules, Leydigcells produce testosterone
ANDROFERT
androfert.com.br
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14. •Low FSH and LH (<1.2 mIU/L)
•Low total testosterone (<300 ng/dL)
•Hypotrophictestes
•Azoospermia
•Severe oligozoospermia
Adult-onset Hypogonadotropic hypogonadism
ANDROFERT
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15. Management
1.Discontinuation
Recovery in ~6 months (up to 25% persistent low sperm count/quality)
2.hCG-based therapy
3.Combination of hCG-based therapy and FSH/HMG
Hormone level follow-up:
–TT, estradiol, FSH, LH
–Avoid supraphysiologicalT and E levels
ANDROFERT
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16. ANDROFERT
androfert.com.br
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17. ANDROFERT
androfert.com.br
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Souza and Hallak, BJUI 2011

18. Classic treatment for male hypogonadismand infertility
Urinary hCG1,000-2,000 UI IM injections; twice or t.i.w;
minimum 12 weeks
Rec-hCG: SC self- injection w/pre-filled syringe, qw
Fraietta& EstevesClinics 2013
Adult onset hypo-hypo
Specific medical therapy
ANDROFERT
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19. Rec-hCGfor male hypo-hypo
Baseline
Posttreatment
Esteves & PapanikolaouFertilSteril2011
Series of men with adult-onset HH;
Recombinant hCG(Ovitrelle250 mcg)
ANDROFERT
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20. Anabolic steroids and male infertility Key Messages
AS, including T replacement therapy, highly prescribed
Negative effect on male fertility not well appreciated by doctors
Counsellingadvisable and fertility restoration possible, especially in non- heavy users
ANDROFERT
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21. Thank You
obrigado
شكرا