Male infertility

Male infertility

Male infertility i.e. difficulty in getting wife pregnancy due to defect in semen as decreased sperm count & low (Poor) motility or abnormal sperms occurs due to above causes. Treatment of low sperm count & motility are discussed below. Low sperm count or Low (Poor) motility Nil sperms (Azoospermia)

Low Sperm Motility (Ashtenospermia)

What is Low sperm motility: When sperm motility is less than normal i.e. less then 50% of sperms are actively motile is called Oligo-asthenia i.e. low sperm motility (when all the sperms are immotile are called astheno-spermia. This leads to difficulty in conceiving i.e. wife does not becomes pregnant. This is one of the common causes of male infertility. This is also one of the most common semen abnormalities.

How Testis Develops: In all male child testis is small. It remains small until the onset of genital development i.e. puberty which usually starts at age of 14 years. At this time L.H. & F.S.H. hormone is secreted from pituitary gland in brain. These hormone act as Germ cell & Sertoli cells in testis leading to there growth. This enlargement is size continues upto 18 years, ultimately reaching size of 12 to 25 ml. Other hormones which control testis size are growth hormone IGF-1 & others.

Cause of small Testis: There are many causes of small testis. These are as follows :-

Hypogonadotropic Hypogonadism: Hypogonadism, Hypothyroidism, Testosterone deficiency, hyperprolactinema, Hypogonadotropic hypogonadism (hypothalamic or pituitary deficiency) Hypogonadotropic states: Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalmic deficiency, pituitary hypoplasia, Trauma, post surgical, postoradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis) Autoimmune hypophysitis, drug-induced hyperprolactinemia, Untreated endocrinopathies , Glucorticoid excess, Hypopituitarism, Cushing disease, Addison disease.

Isolated gonadotropin deficiency (non acquired) : Pituitary , Hypothalamic Associated with multiple pituitary hormone deficiencies : Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngiomas, Rathke pouch cycts, hypothalamic tumors, pituitary adenomas), Following surgery, Following cranial irradiation, Following CNS chemotherapy, Following inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis), Associated with syndromes involving hypthalamic function, Laurence-Moon-Beidl sundrome Prader-Willi syndrome , Frohlich syndrome Isolated gonadotropic deficiency with or without anosmia, Fertile eunuch syndrone, Idiopathic hypopituitarism, CNS disorders : tumors, infections, pituitary agenesis or hypoplasia, hydrocephalus, Septooptic dysplasia, CNS radiation for leukemia or brain tumor, Prader-Willi and Laurence-Moon-Biedly Syndrome, Thalassemia major

(2) Hyperogonadotropic hypogonadism: –testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy, Primary testicular defect-disorders of testicular differentiation or inborn errors of testosterone synthesis, Klinefelter syndrome, Other X polysomies (i.e. XXXXY, XXXY) Rainbow syndrome,

3-Partial androgen insensitivity

(4) Growth Hormone Deficiency

Idiopathic small Testis: In many patients all the hormone growth factor & every thing else is normal ,still they have small testis with or without small pennis i.e. genitalia. This occurs due to Decreased capacity of testicular tissue to grow.This occurs due to defective development of the testis in utero so that its growing capacity decreases later in life

5 -Vanishing Testis Syndrome

(7) Dysmorphic Syndrome

(8) Post Mumps Orchitis.

Consequences of Small Testis :

When testis is small it denotes that testis is not fully developed thus it will not be having normal function also.

The two functions of fully developed testis are: (1) Production of normal amount of semen including sperms. So people with small testis has less i.e. decreased semen amount, subnormal sperms count or may be even nil sperms called Azoospermia. This leads to infertility.

(2) The second function of testis is to produce male hormone testosterone. This hormone then acts on various organ system of body like hair of face & body leading to development of beard & moustache, development of muscular body, increase in penile size, male pattern of behavior, having genital desire & power. Thus small testis meaning underdeveloped testis leads to less beard & moustache, less muscular body, feminine behavior, soft skin, infertility, impotency. Patient may have one symptom or more of above symptoms & signs.

Investigation & Diagnosis: For proper diagnosis of cause of small testis we do following tests. For diagnosis of cause of investigation following tests are required. These tests include

complete male hormone profile. This profile includes all the male hormone tests which affects testicular development , growth & other genital organ development as well as genital functions. Thyroid test serum prolactin SHBG Semen analysis ultrasound of testis Growth Hormone analysis DHT Level

Other tests depending on likelihood of other possibilities Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased may be low. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high.

other tests which may be required depending on likelihood of the any of above causes. In biochemistry liver function or kidney function tests are done. Dynamic test to judge functional capacity of testis whether testis has the capacity to function normally or not. In this test we inject single injection of gonadotropin as intramuscular injection then three day later the rise in concentration of male hormone is seen to asses whether testis has capacity to function normally or not. Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders, which lead to small pennis. Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of small pennis / thin pennis /underdeveloped pennis. Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable. MRI / CT SCAN head if suspecting hypogonadotropic hypogonadism. Serum inhibin is tested which tells that whether testis is functioning or not. Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis. Combined Pituitary hormone tests are performed when suspecting pituitary disorder. Molecular genetic studies done in some special cases. Serum estrogen increased whenever testicular function is decreased. Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased. Assessment of androgen receptor is done when needed, Dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests. Interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of small /or thin pennis is made. Once the cause is found then treatment becomes very easy with good results. If needed growth hormone & some other tests.

Treatment : After finding the cause appropriate treatment started in form hormone replacement therapy. The treatment s as follows:

1) Gonadotropin therapy is also very effective in testis enlargement. This is available as injections which has no side effects with very good results. After start of treatment testis starts enlarging in three months time. With in one year time testis enlarges to normal size. Its function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone. Once testosterone production normalizes, erection & genital desire becomes normal. Physical weakness disappears & mentally becomes more active & alert. All other symptoms also normalizes. Bone strength recovers.

Testosterone treatment is harmless if given by expert in hormone in proper doses.

2) Gonadotropin Releasing hormone therapy is effective in many cases of underdeveloped testis even when gonadotropin therapy has failed in normalizing testicular size & function.

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor Therapy

5) Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets, skin patch, skin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

What is Low sperm motility: When sperm motility is less than normal i.e. less then 50% of sperms are actively motile is called Oligo-asthenia i.e. low sperm motility (when all the sperms are immotile are called astheno-spermia. This leads to difficulty in conceiving i.e. wife does not becomes pregnant. This is one of the common causes of male infertility. This is also one of the most common semen abnormalities.

SMALL TESTIS How Testis Develops

Causes of small Testis

Investigations & Diagnosis

Treatment

Response of treatment

Side effects of treatment

How Testis Develops: In all male child testis is small. It remains small until the onset of genital development i.e. puberty which usually starts at age of 14 years. At this time L.H. & F.S.H. hormone is secreted from pituitary gland in brain. These hormone act as Germ cell & Sertoli cells in testis leading to there growth. This enlargement is size continues upto 18 years, ultimately reaching size of 12 to 25 ml. Other hormones which control testis size are growth hormone IGF-1 & others.

Cause of small Testis: There are many causes of small testis. These are as follows :-

1) Hypogonadotropic Hypogonadism: Hypogonadism, Hypothyroidism, Testosterone deficiency, hyperprolactinema, Hypogonadotropic hypogonadism (hypothalamic or pituitary deficiency) Hypogonadotropic states: Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalmic deficiency, pituitary hypoplasia, Trauma, post surgical, postoradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis) Autoimmune hypophysitis, drug-induced hyperprolactinemia, Untreated endocrinopathies , Glucorticoid excess, Hypopituitarism, Cushing disease, Addison disease.

Isolated gonadotropin deficiency (non acquired) : Pituitary , Hypothalamic

Associated with multiple pituitary hormone deficiencies : Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngiomas, Rathke pouch cycts, hypothalamic tumors, pituitary adenomas), Following surgery, Following cranial irradiation, Following CNS chemotherapy, Following inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis), Associated with syndromes involving hypthalamic function, Laurence-Moon-Beidl sundrome Prader-Willi syndrome , Frohlich syndrome Isolated gonadotropic deficiency with or without anosmia, Fertile eunuch syndrone, Idiopathic hypopituitarism, CNS disorders : tumors, infections, pituitary agenesis or hypoplasia, hydrocephalus, Septooptic dysplasia, CNS radiation for leukemia or brain tumor, Prader-Willi and Laurence-Moon-Biedly Syndrome, Thalassemia major

(2) Hyperogonadotropic hypogonadism:

testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy, Primary testicular defect-disorders of testicular differentiation or inborn errors of testosterone synthesis, Klinefelter syndrome, Other X polysomies (i.e. XXXXY, XXXY)

Rainbow syndrome,

(3) Partial androgen insensitiv

(5) Idiopathic small Testis: In many patients all the hormone growth factor & every thing else is normal ,still they have small testis with or without small pennis i.e. genitalia. This occurs due to Decreased capacity of testicular tissue to grow.This occurs due to defective development of the testis in utero so that its growing capacity decreases later in life

(6)Vanishing Testis Syndrome

(7) Dysmorphic Syndrome

(8) Post Mumps Orchitis.

Consequences of Small Testis :

When testis is small it denotes that testis is not fully developed thus it will not be having normal function also.

The two functions of fully developed testis are:

(1) Production of normal amount of semen including sperms. So people with small testis has less i.e. decreased semen amount, subnormal sperms count or may be even nil sperms called Azoospermia. This leads to infertility.

(2) The second function of testis is to produce male hormone testosterone. This hormone then acts on various organ system of body like hair of face & body leading to development of beard & moustache, development of muscular body, increase in penile size, male pattern of behavior, having genital desire & power. Thus small testis meaning underdeveloped testis leads to less beard & moustache, less muscular body, feminine behavior, soft skin, infertility, impotency. Patient may have one symptom or more of above symptoms & signs. Investigation & Diagnosis: For proper diagnosis of cause of small testis we do following tests.

For diagnosis of cause of investigation following tests are required. These tests include

complete male hormone profile. This profile includes all the male hormone tests which affects testicular development , growth & other genital organ development as well as genital functions.

Thyroid test

serum prolactin

SHBG

Semen analysis

ultrasound of testis

Growth Hormone analysis

DHT Level

Other tests depending on likelihood of other possibilities

Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased may be low. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high.

other tests which may be required depending on likelihood of the any of above causes.

Dynamic test to judge functional capacity of testis whether testis has the capacity to function normally or not. In this test we inject single injection of gonadotropin as intramuscular injection then three day later the rise in concentration of male hormone is seen to asses whether testis has capacity to function normally or not.

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders, which lead to small pennis.

Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of small pennis / thin pennis /underdeveloped pennis.

Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable. MRI / CT SCAN head if suspecting hypogonadotropic hypogonadism.

Serum inhibin is tested which tells that whether testis is functioning or not.

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis. Combined Pituitary hormone tests are performed when suspecting pituitary disorder.

Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function is decreased.

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor is done when needed,

Dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests.

Interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of small /or thin pennis is made. Once the cause is found then treatment becomes very easy with good results.

If needed growth hormone & some other tests.

Treatment : After finding the cause appropriate treatment started in form hormone replacement therapy. The treatment s as follows: 1) Gonadotropin therapy is also very effective in testis enlargement. This is available as injections which has no side effects with very good results. After start of treatment testis starts enlarging in three months time. With in one year time testis enlarges to normal size. Its function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone. Once testosterone production normalizes, erection & genital desire becomes normal. Physical weakness disappears & mentally becomes more active & alert. All other symptoms also normalizes. Bone strength recovers. Testosterone treatment is harmless if given by expert in hormone in proper doses.

2) Gonadotropin Releasing hormone therapy is effective in many cases of underdeveloped testis even when gonadotropin therapy has failed in normalizing testicular size & function.

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor Therapy

5) Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets, skin patch, skin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

1) Oral preparation that is available in capsule form. It need to be given one to three capsule daily.

These have no side effects.

2) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skin once a day. It is very effective & has no side effects.

3). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses. It is very effective & has no side effects.

4) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & bettergenital organ secondary genital character development. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective

5) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. 6) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

7) Long acting testosterone as testosterone bucilate given once in 4 months.

8) Testosterones implants are now available which once injected remain effective for up to six months.

Response: Once we start the treatment testis starts enlarging in size. After start of treatment testis starts enlarging in three months time. With in one year time testis enlarges to normal size. Its function also normalizes in most patients.

Side Effects: As this treatment consist of replacement of defective hormones. These hormones are given in physiological replacement doses as prescribed in our scientific text books. Thus this treatment does not have any side effects.

ABSENT GENITAL DEVELOPMENT (Delayed Puberty)

Absence of Genital development occurs due to male hormone deficiency, which can occur due to many of the below mentioned causes.

What is Normal Genital Development

Symptoms & features

Causes of Absent genital development

Investigations & Diagnosis

Treatment

Response of treatment

Side effects of treatment

What is Normal genital Development :Normally in boys the genital development stars at the age of thirteen to fourteen years. The absent genital development occurs due to male hormone deficiency. The sign & symptoms of testosterone & other male hormone deficiency are as follows:

Symptoms & features: These includes absent genital development or underdeveloped genital organ development like small genitals (genitalia) like small pennis, under developed testis, shrunken scrotum. Symptoms and signs of male hormone deficiency are less beard & moustache, poor development of body muscles, small pennis, under developed scrotum & testis, less aggressive behavior, feminine nature, poor in study, poor memory, poor performance in office or business, less confidence on his capabilities, less sperm (Oligospermia, Nil sperms), thin semen, female like voice can occur.

Decreased development of secondary genital characters like less beard & moustache, less body hair, soft skiin as found in girls, soft voice like females, less muscular development i.e. less manly body, decreased confidence on himself so that patient may feel less confidence on himself so that patient may feel less confident & even sometimes nervousness in talking to others. Sometimes even breast may enlarge due to less concentration of testosterone. Then body energy becomes less so that patient feel tired all the time. Decreased testosterone & other male hormone like DHEAS lead to decreased genital desire, less hardness of pennis i.e. dysfunction & other disorders. This also leads to less development of sperms leading to decreased sperm count & motility & even absent sperm. Due to less muscular development & less beard & moustache they look younger then their age & less mature look so that in workplace & among friends they are always treated like young so that they perform less well in career. There memory also may be less. Sometimes all above disorders can lead to severe anxiety & even frank depression may occur.

Causes of male absent or Inadequate Genital development:

Hypogonadotropic states:

Hypothalamic – pituita ovary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis) Autoimmune hypophysitis, Drugs (drug-induced hyperprolactinemia, genital steroids use)

Untreated endocrinopathies, Glucorticoid excess, Hypopituitarism, Isolated gonadotropin deficiency (non acquired): Pituitary, Hypothalamic Associated with multiple pituitary hormone deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngioma, Rathke pouch cysts, hypothalamic tumors, pituitary adenomas), , Laurence-Moon-Beidl syndrome Prader-Willi syndrome , Frohlich syndrome Hypergonadotropic hypogonadism : Klinefelter syndrome, Noonan syndrome, Viral orchitis, Cytotxic drugs, Testicular irradiation.

Testicular disorders (primary leydig cell dysfunction), Chromosomal (Klinefelter syndrome and variants, XX male gonadal dysgenesis), Defects in androgen biosynthesis, Orchitis (mumps, HIV, other viral, ) Myotonia dystrophica, Toxins (alcohol, opiates, fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic drugs, ketoconazole, cimetidine, spironolactone) Systemic illness (uremia, liver failure), End-organ resistance (impaired androgen action)

Androgen Receptor defects

5 alpha-Reductase deficiency.

Constitutional delayed growth puberty

Investigation & Diagnosis: For diagnosis of cause of investigation following tests are required. These tests includes:

Complete male hormone profile: This profile includes all the male hormone tests which affects testicular development, growth & other genital organ development as well as genital functions.

Thyroid test,

Semen analysis

SHBG

Ultrasound of testis, other tests which may be required depending on likelihood of the any of above causes.

Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased may be low. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high. In biochemistry tests liver function or kidney function may be abnormal. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of hypogonadism is made once the cause is found treatment becomes very simple.

Then we do testis functional capacity in this we inject single injection of gonadotropin as intramuscular injection then three day later the rise in concentration of serum total testosterone confirms whether testis has capacity to function normally or not.

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism. Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of hypogonadism Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable.

Serum inhibin is tested which tells that whether hypogonadism is temporary or permanent.

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis.

Combined Pituitary hormone tests is performed when suspecting pituitary disorder.

Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function decreased.

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor is due when needed, dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests.

Treatment: Treatment of absence of genital development includes cure of primary cause. Treatment may be given in the following form:

1) Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

a) Oral preparation that is available in capsule form. It need to be given one to three capsule daily. These have no side effects.

b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses. It is very effective & has no side effects.

d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better genital organ secondary genital character development. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very very effective.

e) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

g) Long acting testosterone as testosterone bucilate given once in 4 months.

h) Testosterones implants are now available which once injected remain effective for up to six months.

2) Gonadotropin therapy is also very effective in testis enlargement. This is available as injections which has no side effects with very good results. After start of treatment testis starts enlarging in three months time. With in one year time testis enlarges to normal size. Its function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone. Once testosterone production normalizes, enlargement of testis followed by rise in testosterone level occurs. This lead to development of beard & moustache, normal pennis size, sperm & semen normalizes & genital dysfunction if present is cured as erection & genital desire becomes normal.

Physical weakness disappears & mentally becomes more active & alert. All other symptoms also normalizes. Bone strength recovers.

Testosterone treatment is harmless if given by expert in hormone in proper doses. Thus almost all patient are cure in one-year time. 2) Gonadotropin Releasing hormone therapy is effective in many cases of underdeveloped testis even when gonadotropin therapy has failed in normalizing testicular size & function. It is effective when in cases of low L.H. & F.S.H..

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor, Mineral & Micronutrient Therapy

NOTE: Many times hypogonadism is temporary as in constiutional delayed growth & puberty, in many psychiatric disorders & in protein caloric malnutrition. In these cases after correct diagnosis we can permanently cure the hypogonadism in short time. In these patient with in one-year patient achieves normal development. When pituitary neoplasia is the cause then surgical treatment is required. When drugs are the culprit then stopping the offending drugs cure the problem.

In some long-term treatment with androgen as testosterone is required.

Side Effects: It has no side effects if given in proper disease and in patient’s when it is really indicated.

Less Beard & Moustaches

How hair grow on face & body

Causes of Less Beard & Moustaches

Consequences of less beard & moustache

Investigations & Diagnosis

Treatment

Why doctors don’t take this problem seriously

Response of treatment

Side effects of treatment

Testimonials

Videos on Treatment Procedures

Testimonials

Testimonials in English

Testimonials in Hindi

Testimonials in book format

(Click to enlarge and turn as pages to read)

(Note: Name & Place mentioned in the testimonials have been changed by the patient to hide the identity but treatment response mentioned by him/her is real.)

How hair grows on face & body: Every boy has same number of soft light colored hair on face in beard moustache area & other part of body. These are called vellus hair they are soft & light in colour , so that they are less easily visible. At the time of puberty i.e. beginning of genital development male hormone testosterone, adrenal hormone androstenidione, 17-oh Progesterone, DHEAS, Growth hormone, LH, FSH, DHT increases & SHBG decreases, THYROID Hormone also plays the role. These hormones changes lead to increased concentration of Free Testosterone, DHT & some more hormones. These hormones then act on the various sensors (called receptors) in the air roots of face & other parts of body. After the interaction of hormones & receptors certain changes occurs in the functioning of cells of hair roots so that hair starts growing in thickness & length, more black pigments (i.e. melanin) is produced so that hair becomes more dark also the blood supply in the hair root increases leading to more availability of growth factors to the hair roots resulting in faster, darker & stronger hair. These hormones growth factors are in high concentration during peak of secondary genital characters development i. e. puberty leading to persistent stimulation of hair growth for next two to three years i. e. up to completion of genital development. Thus in normal boys in two to three years full beard & moustache develops.

Causes of Less Beard & Moustaches: In boys the less beard & moustache can be due to following causes:

1) Male Hormone Deficiency: In which any of the male hormone as testosterone, androstenidione etc. may be low due to causes as hypothalamic disease, delayed and absent puberty, Kallman syndrome, idiopathic hypogoandotropic, hypogonadism, hypergonadotropic, hypogonadism, primary or secondary testicular failure, Klinefelter’s syndrome & testosterone biosynthetic defect ,Growth factor deficiency, systemic disesases etc.

2) Growth hormone deficiency due to hypopituiarism, pituitary disorders

3) Growth factor deficiency

4) Zinc Deficiency

5) Testosterone biosynthetic defects

6) Congenital adrenal hyperplasia

7) Absent development of hair roots

8) Alopecia universalis

9) Ninth Cause is resistance of hair roots to normal level of male hormones, in this disorder male hormone is normal in blood even then hair root do not grow because in hair root there is less male hormone receptor (i.e. sensor of male hormone) so that male hormone is unable to work & hair do not grow well. But when male hormone level is further increased by male hormone replacement treatment & certain more medicines are given so that male hormones becomes more effective on hair roots, then hair roots starts growing. Beard & moustaches then fully normalizes in six months to one-year time.

10) Absence of androgen receptors in hair roots.

11) Progeria

12)DRUGS: Cytotoxic Agents, Cyclophoamide, Vincristine, Ionising radiation, Azathioprine

13)Trichotelomania

14)Structural Defects Of Hair Shaft With Increased Fragility

15) Diffuse Nonscarring Alopecia

Investigations & Diagnosis: We take detail history to pinpoint the possible causes of this problem. After this we do certain blood tests to diagnose the possible cause of less facial hair in that particular patient. We do hormone tests , growth factors & other biochemistry all these tests are done by taking a single blood sample. Then there are tests to know whether male hormone is working on hair root or not i. e. to diagnose hair root resistance. At our diabetes & thyroid center we have most advance state of the art laboratory with all the modern facility for all above tests. After these tests we reach the final diagnosis.

Various tests needed are as follows:

complete male hormone profile: This profile includes all the male hormone tests which affects testosterone production & other genital functions.

- Serum testosterone is either below normal range or on the lower side of normal.

- Similarly free testosterone is either low or on lower side of normal.

- SHBG

- Adrenal Hormones

- Thyroid test

Other tests which may be required depending on likelihood of the any of above causes. Tests may show low testosterone. L.H. & F.S.H. may be decreased or may be normal. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of andropause is made, once the cause is found treatment becomes very simple.

One need to do detailed investigations for other causes of low testosterone so that one does not misses any serious underlying diseases.

Treatment: First of all we investigate the patient & find the cause of less beard & moustache. The treatment consists of hormone therapy which is given in form of oral tablets or injections or local application as androgen cream. By this treatment the deficient hormone is replaced & blood level of male hormones normalizes. When there is hormone resistance then we give certain medicine to increase the effectiveness of male hormone on hair roots leading to normal growth of beard & moustache. Then some additional drugs are given to increase the blood flow to hair roots. When more blood is available to the hair roots then more nutrients, vitamins, growth factors, & male hormone is delivered to the hairs then they start growing fast. These medicines are prescribed to the patient which can be bought from any good medical store. These medicines are available in all the good cities of India & other major cities of the world. These medicines have no side effects as these drug regimens are developed by many years of scientific studies by various research authorities & has not shown any side effects.

1.) Male Hormone Replacement: The various preparation of testosterone & route of administration are: a) Oral preparation that is available in capsule form. It needs to be given one to three capsules daily. These have no side effects. b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses. It is very effective & has no side effects.

d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better hair development on face. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective.

e) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement.

f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

g) Long acting testosterone as testosterone bucilate given once in 4 months.

h) Testosterones implants are now available which once injected remain effective for up to six months.

2) Medicines to increase blood supply to hair root (Oral & Local Gels): Medical treatment (i.e. prescription of various drugs to increase blood supply to hair root & their rejuvenation etc are given to correct the basic cause found on investigations. These drugs increase the blood supply to hair root so that they if the hair roots are already present they start growing as in normal persons(as they are present in most cases of less beard moustache but are not growing due to various reasons mentioned above). These drugs dilate peripheral small arteries of beard & moustache area so that blood flows into hair root increases. There are various drugs, which are effective to increase blood supply to hair root. The particular drug needed in particular patient depends on the cause of Hair fall. Some time two or more drugs may be needed to be used in resistant cases. These drugs have no side effects. They arte not costly also, the total cost of per month treatment is Rs 300/= per month.

3) G.H. Therapy

4) IGF Therapy

5) Medical Growth Factors Therapy

5) Minerals & other micronutrient therapy

6) Ant microbial therapy when needed

7) Hair Transplant

8) Gene Therapy

Why doctors don’t take this problem seriously: The problem of less beard & moustache is psychologically very painful for the patient who is suffering with this problem. It makes them feel less manly among the friends. Similarly due to younger looks they are not given big responsibility at workplace. Sometimes even the prospect of promotions decreases. All this creates lot of mental stress in the patients. Unluckily majority of doctors do not take this problem seriously, because they think it to be more of cosmetic problem. Many patients come to our center from different corner’s of Indian cities including many from abroad too, all patient complained to me that majority doctors got there male hormone tested & if it is normal they did not took this problem seriously & advised some vitamins & hormone if ever they gave it was not given in enough doses to overcome hormone resistance. Because most doctors do not take this problem seriously, thus do not read the scientific material available in detail due to lack of importance given by them. At our center because we are specialize in exclusive treatment of hormone disorders we take this problem as seriously as any other hormone disease investigate this problem properly, reach to the root cause of less beard moustache has not come in that particular patient the we start the treatment.

Response of treatment: At our center we have treated successfully thousands of patients from different states of India & other parts of world. After start of treatment hair roots start growing after three week. But because hair root is deep inside the skiin & subcutaneous fat, it takes approximately 3 months to see any significant hair growth on the skiin surface. In next three months almost all hair starts getting darker & thicker & coarser as happens in adult male. It takes full one year to develop adult like dark & dense beard & moustache.

Side effects of treatment: The treatment has no side effects because we give hormone & medicines in prescribed amount & these drugs are safe.

HYPOGONADISM (MALE HORMONE DEFICIENCY)

The absence of genital development in boys due to male genital hormone deficiency is called hypogonadism.

What is Hypogonadism

Symptoms & features

Causes of Hypogonadism

Investigations & Diagnosis

Treatment

Response of treatment

Side effects of treatment

What is Hypogonadism: When male hormone testosterone and other hormones are low leading to absence of normal genital development in the boy is called male hormone deficiency i.e. Hypogonadism. Thus hypogonadism is called when gonad i.e. testis is functioning less than normal or not functioning et all, leading to deficiency of male genital hormone which includes testosterone & few others & sometimes even absent sperm production.

Symptoms & features of male hormone deficiency are absent genital development or underdeveloped genital organ development like small genitals (genitalia) like small pennis, under developed testis, shrunken scrotum.

Decreased development of secondary genital characters like less beard & moustache, less body hair, soft skiin as found in girls, soft voice like females, less muscular development i.e. less manly body, decreased confidence on himself so that patient may feel less confidence on himself so that patient may feel less confident & even sometimes nervousness in talking to others. Sometimes even breast may enlarge due to less concentration of testosterone. Then body energy becomes less so that patient feel tired all the time. Decreased testosterone & other male hormone like DHEAS lead to decreased genitaldesire, less hardness of pennis i.e.dysfunction & other genital disorders. This also leads to less development of sperms leading to decreased sperm count & motility & even absent sperm. Due to less muscular development & less beard & moustache they look younger then their age & less mature look so that in workplace & among friends they are always treated like young so that they perform less well in career. There memory also may be less. Sometimes all above disorders can lead to severe anxiety & even frank depression may occur.

Sometimes they may have less aggressive behavior, feminine nature, poor in study, poor memory, poor performance in office or business, less confidence on his capabilities, less sperm (oligospermia, Nil sperms), thin semen, female like voice can occur. Patient may have one or more of the above mentioned features. Thus symptoms of hypogonadism are absence of development of male like features.

Causes of male hypogonadism (Inadequate genital development)

Hypogonadotropic states: Hypothalamic - pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalmic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis)Autoimmune hypophysitis, Drugs (drug-induced hyperprolactinemia, genital steroids use) Untreated endocrinopathies, Glucorticoid excess, Hypopituitarism,Isolated gonadotropin deficiency (non acquired) : Pituitary , HypothalamicAssociated with multiple pituitary hormone deficiencies : Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngiomas, Rathke pouch cycts, hypothalamic tumors, pituitary adenomas), Following surgery, Following cranial irradiation, Following CNS chemotherapy, Following inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis), Associated with syndromes involving hypthalamic function, Laurence-Moon-Beidl sundrome Prader-Willi syndrome , Frohlich syndrome

Genetic Mutuations : KALI (kakallmann), Gonadotropin-releasing hormone receptor (GnRHR), FSH3 isolalated FSH deficiency, PROP1 (pituitary deficiency), Hgenital1 (septo-optic dysplasia), DAX1

Isolated gonadotropic deficiency with or without anosmia, Fertile eunuch syndrone, Idiopathic hypopituitarism, CNS disorders : tumors, infections, pituitary agenesis or hypoplasia, hydrocephalus, Septooptic dysplasia, CNS radiation for leukemia or brain tumor, Prader-Willi and Laurence-Moon-Biedly Syndrome, Thalassemia major

Hypergonadotropic hypogonadism : Klinefelter syndrome, Noonan syndrome,

Infections: Viral orchitis, Mumps Orchitis, Leprotic Orchits

Drug Induced: Cytotxic drugs, Testicular irradiation. ), Drugs (cytotoxic drungs, ketoconazole, cimetidine, spironolactone) Developmental: Testicular disorders (primary leydig cell dysfunction),

Chromosomal Disorder: (Klinefelter syndrome and variants, XX male gonadal dysgenesis),

Defects in androgen biosynthesis

Myotonia dystrophica,

Toxins (alcohol, opiates, fungicides, insecticides, heavy metals, cotton seed oilSystemic illness (uremia, liver failure), End-organ resistance (impaired androgen action)

Androgen Receptor defects,

Postreceptor transduction abnormalities,

5 alpha-Reductase deficiency.

Constitutional delayed growth and puberty.

Investigation & Diagnosis :

Following tests are required to reach the correct diagnosis of cause of hypogonadism.

Complete male hormone profile: This profile includes all the male hormone tests which affects testicular development, growth & other genital organ development as well as genital functions.

Thyroid test,

Semen analysis

SHBG

Ultrasound of testis, other tests which may be required depending on likelihood of the any of above causes.

Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased may be low. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high. In biochemistry tests liver function or kidney function may be abnormal. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of hypogonadism is made once the cause is found treatment becomes very simple.

Then we do testis functional capacity in this we inject single injection of gonadotropin as intramuscular injection

then three day later the rise in concentration of serum total testosterone confirms whether testis has capacity to function normally or not.

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism.

Capacity of generation of active testosterone i.e. DHT is tested This DHT generation test is abnormal in some cases of hypogonadism.

Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable.

Serum inhibin is tested which tells that whether hypogonadism is temporary or permanent.

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis.

Combined Pituitary hormone tests is performed when suspecting pituitary disorder.

Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function decreased.

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor is due when needed, dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests.

Treatment : Treatment of hypogonadism includes cure of primary cause of hypogonadism.

In case of low L.H. & F.S.H. hormone treatment is given in form of Gonadotropin releasing hormone, Human chorionic gonadotropin, human menopausal gonadotropin or purified follicle stimulating when we start treatment with any of the above mentioned gonadotropins, enlargement of testis followed by rise in testosterone level occurs. This lead to development of beard & moustache, normal pennis size, sperm & semen normalizes & genital dysfunction is cured. Thus almost all patient are cure in one year time.

Many times hypogonadism is temporary as in constiutional delayed growth & puberty, in many psychiatric disorders & in protein caloric malnutrition. In these cases after correct diagnosis we can permanently cure the hypogonadism in short time. In these patient with in one-year patient achieves normal development.

When pituitary neoplasia is the cause then surgical treatment is required. When drugs are the culprit then stopping the offending drugs, cure the problem.

In some long term treatment with androgen as testosterone is required.

1) Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

a) Oral preparation that is available in capsule form. It need to be given one to three capsule daily.

These have no side effects. b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

c).Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses . It is very effective & has no side effects.

d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better genital organ secondary genital character development. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective.

e) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

g) Long acting testosterone as testosterone bucilate given once in 4 months.

h) Testosterones implants are now available which once injected remain effective for up to six months.

2) Gonadotropin therapy is also very effective in testis enlargement. This is available as injections which has no side effects with very good results. After start of treatment testis starts enlarging in three months time. With in one year time testis enlarges to normal size. Its function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone. Once testosterone production normalizes, enlargement of testis followed by rise in testosterone level occurs. This lead to development of beard & moustache, normal pennis size, sperm & semen normalizes & genital dysfunction if present is cured as erection & genital desire becomes normal. Physical weakness disappears & mentally becomes more active & alert. All other symptoms also normalizes. Bone strength recovers.

Testosterone treatment is harmless if given by expert in hormone in proper doses. Thus almost all patient are cure in one-year time.

2) Gonadotropin Releasing hormone therapy is effective in many cases of underdeveloped testis even when gonadotropin therapy has failed in normalizing testicular size & function. It is effective when in cases of low L.H. & F.S.H..

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor, Mineral & Micronutrient Therapy

Side Effects: It has no side effects if given in proper disease and in patient's when it is really indicated. This it is absolutely safe in young patients below 50 years.

TESTOSTERONE DEFICIENCY & TREATMENT

What are Male Hormones?

Causes of low Testosterone

Indications of treatment

Side Effects & Precautions

What are Male Hormones: Males have following male hormones namely testosterone, androstenidione, dehydrotestosterone & dehdroepiandrostenidione in the body. These male hormones are either produced from testis or adrenal glands.The testosterone is produced in testis by leydig cells. The secretion of testosterone is under control of L.H. & F.S.H. & Gonadotropin releasing hormones, Thyroid hormone & growth hormone. Additionally any significant & prolong diseases of other body organs also decreases the formation of various male hormones. After production from testis it circulates in blood in two forms, most of it remains bound to genital hormone binding globulin, which works as store for testosterone. Very small percentage of total testosterone remains free in blood circulation this free testosterone is active hormone. It binds with various tissues of the body as hair of face leading to development of beard & moustache, with pennis tissue leading to its enlargement of pennis & erection, with body muscles leading to enlargement of body muscle i. e. muscular body typical of men. It also works on genital centers in brain (hypothalamus) leading to normal genitaldesire. There are many conditions in which the protein which binds the testosterone (i.e. genital hormone binding globulin) concentration increases leading to increase in total testosterone concentration but free testosterone concentration decreases. Thus overall free testosterone decreases leading to less effect of testosterone on body. Testosterone also has many effects on testis functions leading to improvement in spermatogenesis. Thus there are many factors which may either decrease the testosterone production in the body or decrease its effectiveness. To complicate the matter further there are certain condition in which even if every aspects of testosterone is normal, there may be less male hormone receptor. Causes of Low Testosterone: The various causes for low testosterone are:

Hypogonadotropichypogonadism: (hypothalamic or pituitarydeficiencies)

Idiopathic GnRH deficiency, Kallman syndrome, Hypogonadism, Hypothyroidism, hyperprolactinemia, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postorradiation, Tumor (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis),Autoimmune hypophysitis, drug-induced hyperprolactinemia, Untreated endocrinopathies, Uncontrolled Diabetes mellitus, Chronic Glucorticoid excess, Hypopituitarism, Cushing disease, Addison diseases multiple pituitary hormone deficiencies, Idiopathic pan-hypopituitarism, Pituitary dysgenesis, Space-occupying lesions, cranial irradiation, CNS chemotherapy, inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis)

Hyperogonadotropic hypogonadism:

Testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy,Primary testicular defect-disorders of testicular differentiation or inborn errors of testosterone synthesis, Klinefelter syndrome, Other X polysomies (i.e. XXXXY, XXXY) Rainbow syndrome Andropause (for detail information read andropause webpage of this website) Delayed or Absent Puberty due to various cause (for detail information read Absent genital development webpage of this website) Investigation & Diagnosis: For diagnosis of cause of low testosterone following tests are required: Complete male hormone profile: This profile includes all the male hormone tests, which affects testicular development, growth & other genital organ development as well as genital functions.

Thyroid test

Semen analysis

SHBG

Ultrasound of testis

Biochemistry tests

Then we do test for functional capacity of testis in this we inject single injection of gonadotropin as intramuscular injection then we measure the rise in concentration of serum total testosterone. This test confirms whether testis has capacity to function normally or not.

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism. Gene tests for various genetic disorders

Capacity of generation of active testosterone end product i.e. DHT is tested. This DHT generation test is abnormal in some cases of hypogonadism.

Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable.

Serum inhibin is tested which tells that whether hypogonadism is temporary or permanent.

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis.

Combined Pituitary hormone tests are performed when suspecting pituitary disorder.

Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function decreased.

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor

Dynamic tests as HCG test

Response to antiestrogen & gonadotropin releasing hormone tests.

Other tests which may be required depending on likelihood on any of the above causes.

Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of low testosterone is made. Once the cause is found treatment becomes very simple.

Treatment of Testosterone deficiency: The various treatments for testosterone deficiency include:

Indications for male hormone testosterone therapy are testosterone replacement in male hormone deficiency cases, in males with less beard & moustache, delayed puberty & absent puberty & for enlargement of small pennis or micro pennis. It is also very effective in patients with low genital desire & erection problem. People also use these for improvement of body muscle & athletic performance, for gain in height but for this indication it should be used under specialist observation.Other uses are treatment of anemia, male osteoporosis, replacement in women with loss of desire for genital & replacement therapy in ageing males i.e. ADAM i.e. Androgen deficiency of ageing male. For weight & muscle gain in wasted conditions

1) Male Hormone Replacement: Treatment with male hormone testosterone is one of the modes of treatment of male hormone testosterone deficiency. It is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

a) Oral preparation that is available in capsule form. It needs to be given one to three capsules daily.

These have no side effects.

b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses . It is very effective & has no side effects.

d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better genital organ secondary genital character development. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very very effective.

e) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

g) Long acting testosterone as testosterone bucilate given once in 4 months.

h) Testosterones implants are now available which once injected remain effective for up to six months.

2) Gonadotropin therapy is also very effective in low testosterone. This has no side effects with very good results. After start of treatment testosterone level start rising in three months time. With in one year time testosterone value becomes normal in blood circulation. Testis function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone. Once testosterone production normalizes in turn it leads to better production of semen also. The normalization of testosterone values leads to reversal of all symptoms of testosterone deficiency. Thus all the symptoms normalizes. Bone strength recovers. Testosterone treatment is harmless if given by expert in hormone in proper doses. Thus almost all patient are cure in one-year time.

2) Gonadotropin Releasing hormone therapy is effective in many cases of testosterone deficiency even when gonadotropin therapy has failed in normalizing testicular function & testosterone level.

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor, Mineral & Micronutrient Therapy

NOTE: Many times testosterone deficiency is temporary. In these cases after correct diagnosis we can permanently cure the testosterone deficiency in short time. In these patient with in one-year patient achieves normal testosterone & testicular function. offending drugs cure the problem.

In some long-term treatment with androgen as testosterone is required.

Side Effects: It has no side effects if given in proper disease and in-patients when it is really indicated. This it is absolutely safe. Anabolic steroid drugs are those drugs, which are derived from male hormone & used for improving body muscles & weight. If they are given under supervision of hormone specialist they are safe. But many boys take it for developing body muscle or by sports person in wrong dosing or without any medical supervision. This should not be used without doctor’s supervision. Thus it should be taken under doctor’s supervision.

ANDROPAUSE

(Androgen Deficiency Of Aging Male (Adam))

What is Andropause?

Symptoms Investigations & Diagnosis

Treatment

Response of treatment

Andropause :Andropause is a condition in which male hormone testosterone & other male hormone Decreases with increasing age. This can occur any time after the age of thirty years though it is more common after the age of thirty years. Andropause is also called as androgen deficiency of aging men i.e. (ADAM). This is similar to menopause in women. In such people total testosterone & free testosterone decreases in concentration than what it used to be in young age. This decrease in testosterone concentration below the previous value may still may be in normal range (but in lower side). Thus in Andropause male hormone testosterone becomes lower then its previous value but still it can be in normal range. In approximately 30% people testosterone concentration falls below normal level.

Causes of decreased testosterone are decreased function of testis as well as decreased function of hypothalamic pituitary glands. Other causes may be intercurrent illness, less physical activity & use of some drugs which is quiet common in old age.

Symptoms: This low testosterone results in diminished libido & decreased erection power (i.e. decrease in penile hardness), increased weight specially on abdomen, reduced muscle mass & strength, bone weakness, increased risk of fractures’ Low mood, depressed mood, and anxiety. Sometimes even decreased sleep may occur so this is one of the important cause of disorder, low libido & easy fatigability & above mentioned problems . Other symptoms of decreased testosterone value are weakness, decreased desire to genital, irritability, depression, anxiety, less body hair, breast enlargement, poor genital performance. After detail investigation for other cause of male hormone deficiency. Testosterone replacement therapy is provided with gratifying results.

Investigation & Diagnosis :

Complete male hormone profile: This profile includes all the male hormone tests which affects testosterone production & other genital functions.

- Serum testosterone is either below normal range or on the lower side of normal. - Similarly free testosterone is either low or on lower side of normal.

- SHBG

Other tests which may be required depending on likelihood of the any of above causes. Tests may show low testosterone. L.H. & F.S.H. may be decreased or may be normal. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of andropause is made, once the cause is found treatment becomes very simple.

One need to do detailed investigations for other causes of low testosterone so that one does not misses any serious underlying diseases.

Treatment : Once the diagnosis of andropause is confirmed & other organic cause of low testosterone is excluded, then treatment as male hormone replacement started. Treatment with male hormone testosterone is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.Normally patient with andropause require very small doses of hormone as they have some production of their own. After start of treatment, erection & genital desire becomes normal. Physical weakness disappears & mentally becomes more active & alert. All other symptoms also normalizes. Bone strength recovers. Testosterone treatment is harmless if given by expert in hormone in proper doses. We monitor male hormone status regularly & maintain it normal range for that age.

The various preparation of testosterone & route of administration are:

1) Oral preparation that is available in capsule form. It need to be given one to three capsule daily. These have no side effects. 2) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

3). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses. It is very effective & has no side effects.

4) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better response in

Andropause. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective.

5) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement.

6) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

7) Long acting testosterone as testosterone bucilate given once in 4 months.

8) Testosterones implants are now available which once injected remain effective for up to six months. Gynecomastia (Breast Enlargement in Boys)

What is Gynecomastia?

Why Breast Enlargement Occurs?

Causes of Gynecomastia

Investigations & Diagnosis

Medicine & Hormone Therapy

Surgery for Breast Enlargement

Liposuction Therapy

Response of treatment

What is Gynecomastia? Breast enlargement in boys called gynecomastia (also known as gynecomazia). It may start any time from childhood to 35 years of age. It may start as small breast nodule then grow further to large size. It causes lot of embarrassment to boys. It leads to inferiority complex & lack of concentration in study or work. Sometimes breast enlargement may be associated with decreased development of secondary genital characters like less beard & moustache, less body hair, soft skiin as found in girls, soft voice like females, less muscular development i.e. less manly body. Due to all this patient may have decreased confidence on himself & may even sometimes may have nervousness in talking to others. The body energy may also become less so that patient feels tired all the time. There memory also may be less. Sometimes all above disorders can lead to severe anxiety & even frank depression may occur.

Why Breast Enlargement Occurs? All boys have very little undetectable breast tissue in childhood. In some boys due to any of below mentioned causes either male hormones decreases or female hormone as estradiol & other hormone either increase in amount or their effect increases in the body. These hormones changes lead to increased concentration of female hormones in the breast tissue. These hormones then act on the various sensors (called receptors) in the breast tissue. After the interaction of hormones & receptors certain changes occurs in the functioning of cells of breast tissue so that breast cells starts growing in thickness & size & more & more fat starts depositing in the breast . Thus breast size gradually starts increasing. Simultaneously it also increases the blood supply to breast tissue leading to more availability of growth factors to the breast tissue resulting in faster growth of breast tissue. These hormones & growth factors become particularly in high concentration during peak of secondary genital characters development i. e. puberty leading to persistent stimulation of breast tissue for next two to three years leading to further breast enlargement. In some boys breast size keeps on increasing for many years where as in other growth stops after few years.

Causes of Gynecomastia: Breast enlargement in male can occur due to any of the following causes as:

1) Deficiency of male hormones: It can be due to decreased production of male hormone (Testosterone & other male hormones) from testis either due to defect in testis or due to deficiency of trophic hormones from the pituitary gland.

a) Primary Testicular Disorder: Viral orchits, trauma, castration, granulomatous disease, varicocele, Congenital anorchia, Klinefelter syndrome, Noonan syndrome, Viral orchitis, Mumps Orchitis, Leprotic Orchits, other Testicular disorders, primary leydig cell dysfunction, XX male gonadal dysgenesis

b) Deficiency of Trophic Hormones: Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalmic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis), Autoimmune hypophysitis, Isolated gonadotropic deficiency with or without anosmia, Fertile eunuch syndrone, Idiopathic hypopituitarism, CNS disorders : tumors, infections, pituitary agenesis or hypoplasia, hydrocephalus, Septooptic dysplasia, CNS radiation for leukemia or brain tumor, Prader-Willi and Laurence-Moon-Biedly Syndrome, Thalassemia major c) Defects in androgen synthesis.

2) Excess female hormone production from Adrenal Glands: Increased female hormone estrogen in body due to excess production from testis, HCG-producing tumor , testicular tumor, True hermaphorditism, Estrogen-producing adrenal tumor, Increased production of female hormone in other body parts as in Adrenal disease, liver disease , thyrotoxicosis.

3) Excess female hormone production from testis: due to many disorders ovaries start producing more female hormones. This may occur due to Alcoholic Liver Disease, Hyperthyroidism, Obesity, Androgen-Insensitivity syndrome ,Familal aromatase excess

4) Idiopathic Gynecomastia: In this disorder breast tissue is more sensitive to even small amount of female hormone in the body . It can also due to abnormally increased sensitivity of breast tissue to tiny levels of female hormones so that they over-react & grow large. 5) Drug Induced: There are many drugs which when used wrongly may lead to enlargement of breast as phenothiazine, methyldopa, reserpine, trycyclic antidepressant, metochlopramide, estradiol, diethylstilbestrol, digitalis, HCG, clomiphene, ketoconazole, alkylating agents, spironolactone, cimetidine, aminoglutethimide, flutamide, cypoterone. Others : amiodarone, busulfan, captropril, ethionamide, isoniazid, D-penicillamine, phenytoin, diazepam, marijuana, heroin, omeprazole, rantidine, enalapril, niledipine, verapamil, Cytotxic drugs 6) Androgen Receptor defects: Defects in the structure or function of androgen receptors, Complete testicular feminization syndrome, Partial androgen insensitivity syndrome(Reifenstein syndrome)

7) Genetic i.e. hereditary causes

8) Postreceptor transduction abnormalities

9) Increase in peripheral aromatase activity

10) Physiological Pubertal Gynecomastia

Investigations & Diagnosis: We take detail history to pinpoint the possible causes of this problem. After this we do certain of below mentioned tests to diagnose the possible cause of breast enlargement in that particular patient. At our diabetes & thyroid center we have most advance state of the art laboratory with all the modern facility for all above tests. After these tests we reach the final diagnosis. Various tests needed are as follows:

Complete male hormone profile: This profile includes all the male hormone tests which controls all the male features & does not allows breast to enlarge.

Thyroid test Serum testosterone is either below normal range or on the lower side of normal. Similarly free testosterone is either low or on lower side of normal.

SHBG

Adrenal Hormones

Female hormone tests

HCG

Mammography

USG breast

USG of testis or abdomen or for some other part

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism. Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of hypogonadism. Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function decreased.

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor is due when needed, dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests.

Treatment: There are many drugs which cure gynecomazia in six months to one year time. All above drugs or procedures have no side effects. A) Drug treatment: various treatments are:

1) Antiestrogens as tamoxifen& clomiphene is very effective. These drugs block the effect of female hormone on the breast cells. After few week of treatment breast size starts shrinking. In many cases few month of therapy may completely cure the gynecomastia leading to absolutely flat chest.

2) Danazol also decreases the gynecomastia and is also very effective. The effects starts in three months & breast enlargement is cured in six months.

3) DHT gel local application: Local application of D.H.T. gel is new preparation for male hormone replacement. By binding to breast cell receptors it leads to shrinking & finally disappearance of breast enlargement. It is very effective for gynecomastia treatment & in most cases of cure of breast development in boys.

4) Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are:

a) Oral preparation that is available in capsule form. It needs to be given one to three capsules daily. These have no side effects. b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skiin once a day. It is very effective & has no side effects.

c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses.. It is very effective & has no side effects.

d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better effective. It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective.

e) Local application of D.H.T. gel available is a new preparation for male breast treatment.

f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given every 10 to 14 days. g) Long acting testosterone as testosterone bucilate given once in 4 months.

h) Testosterones implants are now available which once injected remain effective for up to six months.

5) Liposuction: In this technique with the help of needle all fat & breast tissue. In this no admission required. It is painless. Patient need to stay at the centre just for few hours.

6) Localized fat dissolving devices

B) Surgical treatment: is done by our surgeon. This procedure is called Reduction mammoplasty. This surgery is a minor surgery takes 15 to 30 minute under local anaesthesia.

Why doctors don’t take this problem seriously: The problem of breast enlargement is psychologically very painful for the patient who is suffering with this problem. It makes them feel less manly among the friends. This creates lot of mental stress in the patients. Unluckily majority of doctors do not take this problem seriously, because they think it to be more of cosmetic problem. Many patients come to our center from different corner’s of Indian cities including many from abroad too, all patient complained to us that majority doctors did not give much importance to their problem. Most doctors do not take this problem seriously, because they are not aware of the proper treatment of this case. At our center because we are specialize in exclusive treatment of breast enlargement & other hormone disorders, we take this problem as seriously as any other hormone disease.

Response of treatment: At our center we have treated successfully thousands of patients breast enlargement from different states of India & other parts of world. After start of treatment breast size starts decreasing in approximately 3 months time. In next six to nine months almost all breast size disappears in most patients.

Side effects of treatment: The treatment has no side effects.

Male Factor Infertility

Male factor infertility may result from low sperm count or low sperm motility, or decreased ability of the sperm to fertilize the egg or abnormal shape of sperms or lack of semen or inability of man to deposit the sperm into vagina due to erectile dysfunction or hypospadios. The leading cause of male infertility is low sperm count. Others may be low sperm motility, bad quality sperms, lack of semen, presence of pus cells in semen & inability to deposit semen into vagina either due to absent ejaculation or due to any sexual dysfunctions as erectile dysfunctions. In general, most cases of male infertility are due to low sperm count. There are many biologic and environmental factors that can lead to low sperm count. Here is a list of conditions that may cause low sperm count in men. Please click the links for detail information about causes, investigations & treatment options.

For knowing details about the various causes of infertility, diagnostic tests & its treatment, please click below mentioned disease links for more information.

Nil Sperms Low Sperm Motility

Pus in Semen

Anti-Sperm Antibody

Less Semen Formation

Absent Ejaculation

Dead Sperms

Abnormal Sperms

Immotile Sperms

What is Low sperm motility: When less than 50% sperms are motile then this condition is called oligoasthenia. When motility is less then chances of spontaneous pregnancy decreases (i.e. difficulty in conceiving i.e. wife does not becomes pregnant). This is one of the common causes of male factor infertility. This is also one of the most common semen abnormalities in men.

How sperms develop: When boy becomes of 14 years of age then L.H. & F.S.H. hormone secretion from pituitary increases. The rise in these hormones leads to proliferation of sperm forming cells (Germ Cells) in the testis. These germ cells start multiplying under the effect of above-mentioned pituitary genital hormones along with assistance of other hormones as testosterones, Growth hormones, Androstenidione, insulin like growth factor-I, Thyroids hormone, paracrine hormone & growth factors. Under the control of above-mentioned hormones germs cells divide & transformed into primary spermatocytes. Then further maturation of primary spermatocytes to spermatids & then finally into mature spermatozoa (i.e. normal sperms) occurs under the control of above-mentioned hormones. After few weeks of progressive maturation inside the testis these sperms become normally motile & develop the capacity to fertilize the ovum. This total sperm cycle from first stage to final stage of normal mature sperms is of three months. Any hindrance in the development of these spermatozoa will lead to less count of sperm & decreased motility, immotile or even dead sperms.

Causes of low sperm motility: The various causes of decreased motility are as follows:

1) Deficiency of central sperm producing hormones:

Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis) Autoimmune hypophysitis, Drugs (drug-induced hyperprolactinemia, genital steroids use)

Untreated endocrinopathies, Glucocorticoid excess, Hypopituitarism, Isolated gonadotropin deficiency (non acquired): Pituitary, Hypothalamic, Associated with multiple pituitary hormone deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions (craniopharyngioma, Rathke pouch cysts, hypothalamic tumors, pituitary adenomas), , Laurence-Moon-Beidl syndrome Prader-Willi syndrome , Frohlich syndrome, Hypergonadotropic hypogonadism : Klinefelter syndrome, Noonan syndrome, Viral orchitis, Cytotxic drugs, Testicular irradiation.

2) Testicular disorders (primary leydig cell dysfunction i.e. Hypoganadism), Chromosomal (Klinefelter syndrome and variants, XX male gonadal dysgenesis), Defects in androgen biosynthesis, Orchitis (mumps, HIV, other viral, ),Myotonia dystrophica, Toxins (alcohol, opiates, fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic drugs, ketoconazole, cimetidine, spironolactone), 3) Partial obstruction in outflow tract from testis to penile opening in epididymis or of vas deferens (cystic fibrosis, diethlstibesterol exposure) also called obstructive oligospermia.

4) Varicocele: varicocele is dilatation of scrotal vein in the scrotum that leads to rise in temperature of testis and raise testicular temperature, resulting in decreased sperm motility, less sperm production & death of whatever sperms are produced. 5) Drugs (e.g. spironolactone, ketoconazole, cyclophosphamide, estrogen administration, sulfasalazine) 6) Autoimmunity i.e. presence of Antisperm antibody. These Antisperm antibodies bind with sperms & either make them less motile, totally immotile or even dead which is called necrospermia.

7) Undescended testicle (cryptorchidism). Undescended testis is a condition when one or both testicles fail to descend from the abdomen into the lower part of scrotum during fetal development. Undescended testicles can lead to decreased sperm motility. Because the testicles temperature increase due to the higher internal body temperature compared to the temperature in the scrotum, sperm production may be affected.

8) Mosaic Klinefelter's syndrome. In this disorder of the genital chromosomes, of the man is abnormal. This causes abnormal development of the testicles, resulting in low sperm production or decreased sperm motility. Testosterone production may be low or normal. 9) Viral orchits as mumps or other viral infections.

10) Infections as tuberculosis, sarcoidosis involving testis or surrounding structures as epididymis.

11) Chronic systemic diseases as Liver diseases, Renal failure, Sickle cell disease, Celiac disease

12) Neurological disease as myotonic dystrophy

13) Development and structural defects as mild degree of Germinal cell hypo-plasia

14) Partial Androgen resistance

15) Mycoplasmal infection

16) Partial Immotile cilia syndrome v 17) Partial Spermatogenic arrest due to interruption of the complex process of germ cell diffrentation from spermatid level to the formation of mature spermatozoa results in decreased sperm count i.e. oligospermia. Its diagnosis is made by testicular biopsy. This is found in upto 30% of all cases of low sperm count patients.18) Heat Exposure to testis: as febrile illness or exposure to hot ambience induces a fall in sperm count or motility which is usually reversible.

19) Infection – as bacterial epididimo-orchitis, even in prostatis spermatogenic defect have been noted.

20) Hyper-thermia due to cryptorchidism

21) Chromosomal abnormality: has been found in many cases of low sperm count

22) Alcohol use, Cocaine or heavy marijuana use or Tobacco smoking may lower sperm count

23) Anti-sperm antibodies. In some people there occurs development of some abnormal blood proteins called anti-sperm antibodies which binds with sperm and make them either immotile or dead or decrease their count.

24) Infections. Infection of urogenital tract may affect sperm production. Repeated bouts of infections are one of the common causes associated with male infertility.

25) Klinefelter's syndrome. In this disorder of the genital chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production & what ever are produced are less motile. Testosterone production also may be lower.

26) Trauma to testis

27) Environmental toxins: as Pesticides and other chemicals in food or as ayurvedic medicines.

28) Genetic Factors: as idiopathic partial hypo-gonadotropic hypogonadism

Diagnosis of Cause of Low Sperm motility

For correct diagnosis of cause of low sperm count, we need detail history & physical examinations then certain relevant investigations are required.

History & Physical Examinations: First step in proper treatment is accurate diagnosis of cause of low sperm motility. So we first try to find out cause. We take detailed history, thorough drug counseling, and general physical examination, examination of testis, epididymis & testicular veins sperm carrying duct examinations. These examinations give idea about whether testis is normally developed or not & how is its function. After that depending on likelihood of particular, cause relevant tests are done. All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests done. The time taken in getting all the reports ready is 36 hours. So if you are from out of Delhi, you may come here for two days. Investigation & Diagnosis: For completes diagnosis of causes of decreased sperm motility & one or more of the following tests may be required as

1) Complete male hormone profile: This profile includes all the male hormone tests which control testicular development, functions including normal sperm Productions. The tests include L.H., F.S.H., Testosterones, prolactins, thyroids test, & other relevant hormone tests depending on history & examinations. 2) Antisperm antibody

3) USG or Doppler study of scrotum & testis

4) Semen culture sensitivity

5) Semen fructose

6) Immunobead test

7) Sperm Function Tests

8) Human Sperm-Zona Pellucida Binding Ratio

9) Human Sperm-Zona Pellucida Pentration test

10) Genetic Studies

11) FNAC Testis

12) Egg penetration test

13) Molecular genetic studies done in some special cases

14) Chromosome analysis i.e. Karyotype

15) Assessment of androgen receptor

16) Combined Pituitary hormone tests is performed when needed

17) MRI head if pituitary hormone defect suspected

18) Hemogram test for systemic diseases.

19) Sperm Function Tests

The hamster egg penetration assay (HEPA) and the hemizona assay (HZA) are sperm function tests which can help assess the ability of sperm to penetrate the egg. These tests will not definitively tell whether a pregnancy will occur, but an abnormal test result helps predict reduced fertilizing capability. These tests are performed only rarely today.

20) Semen Fructose

At our center facility for all the above tests are available.

Treatment: Once the cause of low sperm motility are found then with in three months of treatment sperm motility & motility becomes normal in more than 90% cases.

The various treatments are as follows:

Correction of the Cause: First of all we try to find out the primary cause of infertility by above mentioned investigations. Then we correct the basic defect i.e. correction of hormone disorder & other defects as varicocele surgery, stopping of alcohol & smoking, stopping of offending drug. We also give following treatment for permanent cure of low sperm motility & motility disorder. 1) Correction of Hormone deficiencies: Once the hormone disorder is found then it is corrected by any of the below medicines. Usually sperm motility normalizes in three month time with proper hormone treatment.

2) Gonadotropin Therapy: Gonadotropins are most potent natural stimulators of sperm production in the testis. Once we start gonadotropin therapy, these gonadotropins stimulates the sperm producing cells in testis. Under the stimulating influence of gonadotropins sperm forming cells start dividing & produce multiple normally motile sperms.Thus in more than 90% cases sperm production can be normalized in three to four months time. Gonadotropin therapy is most successful of all the treatment available till now for sperm motility & motility enhancement. Gonadotropin therapy is indicated & effective all cases of hypogonadotropic Hypogonadism& almost all case of low sperm motility & motility. In many cases of low sperm motility when all other treatment has failed even in those cases gonadotropin therapy is effective.

3) Repronex.

4) Bravelle

5) Ovidrel

6) Gonadotropin-releasing hormone (Gn-RH) analogs

7) Growth hormone therapy in many cases where somatrop deficiency is found.

8) Growth Factor, Mineral & Micronutrient Therapy

9) Free Radial Scavangers: These are drug to reduce the free damaging oxidative radical in the testis. For your information every minute lot of oxidant radicals are generated inside the testis which damages sperm forming cells. These special antioxidant drugs scavange these damaging oxidative free radicals thus leading to production of normal sperms by the testis. In many study these free radical scavengers have been found to be very-very effective in normalizing sperm motility.

10) Coenzyme ubique: These drugs improve the nutritional status of the testis. Thus testis as well as sperm forming cells get enough nutrient which helps in fast generation of sperms in good number with good motility & fertilizing capacity.

11) Carnititine supplimentation increases the production of sperm, with normalization of sperm motility in three months.

12) Fertyl: This drug is taken orally and it causes the pituitary gland to release more FSH and LH, which then stimulates the testis to produce more sperms.

13) Bromocriptine. This medication is for men who have elevated levels of prolactin.

14) Correction of thyroid hormone

15) Correction of congenital adrenal hyperplasia

16) Vitamins

17) Zinc

18) MethyPredinisolone

19) Antibiotics

20) Antiestrogens

21) Tamoxifen

22) Clomiphene

23) Hgh

24) Antimicrobials

25) Anti-inflammatory

26) AIH

27) ART'

28) Certain Newer Drugs has been found very effective

29) Treatment of antisperm antibody is achieved by steroid therapy, intrauterine insemination intra-cytoplasmic sperm injection (ICSI) 30) Surgery: Depending on the cause, surgery may be a treatment option for low sperm motility due to partial blockade of the tract from testis to the tip of pennis. Surgery is also the treatment of choice for significant varicocele. Similarly surgery may be one of the treatment options for many endocrine tumours.

31) Intra-uterine insemination: In certain patients motile sperms are selected by various methods & then transferred directly in uterine cavity leading to improved pregnancy rate.

32) Test tube baby is also delivered with our efforts by use of intra-cytoplasmic sperm injection (ICSI), then transfer of embryo to uterus of mother.

33) Treatment of general genital problems. Addressing or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.

34) Semen Bank: Facility for good quality sperm is semen bank in also available. At our center we have facility for all the testing & treatment facility required for low sperm motility to achieve pregnancy.

35) Assisted reproductive technology (ART)

ART has revolutionized the treatment of infertility. Each year thousands of babies are born in India as a result of ART. Medical advances have enabled many couples to have their own biological child.

The most common forms of ART include:

a) In vitro fertilization (IVF). This is the very effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended as a first-line therapy. It's also widely used for unexplained infertility, male factor infertility.

b) Electroejaculation. Electric stimulus brings about ejaculation to obtain semen.

c) Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.

d) Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.

35) Varicocele ligation

A varicocele is an abnormal tortuosity and dilation of veins of within the scrotum. It can be surgically treated - which might help fertility in some cases.

Response of treatment: When we start treatment, maturation of spermatocyte to mature spermatozoa start occurring in three to 4 weeks time and achievement of normal sperm motility in three months. Thus cure rate is achieved in more than 95% of patients in three months time. Side effects: This treatment is harmless because we prescribe well proven drugs which are prescribed in scientific literature. These medicines have to be purchased from medical store by patient himself.

Menopause Introduction: Menopause is called when period's stops permanently because of female hormone deficiency in females. It usually occurs between 40 to 50 year of age. But in some women it may occur at early age meaning menopause before the age of 40 year. Premature menopause occurs due to various causes of premature menopause (i.e. early menopause).

Early menopause is called when ovarian function stops i.e. menses stops before usual age.

The causes of premature menopause are idiopathic, anti-ovarian antibody, radiation or chemotherapy exposure, chromosomal defect, surgery, traumatic, viral infection of ovaries, estrogen synthesis defect, Ovarian dysgenesis, chromosomal defect, mumps oophoritis, surgical removal of ovaries, autoimmune diseases & idiopathic.

Symptoms of menopause are hot flushes, weakness, irritability, depression, insomnia (less sleep), body pain & less desire for genital, dryness of vagina during intercourse & absent orgasm or pain during intercourse & sometimes excess sweating. Patient may suffer sensation of heaviness in head, weakness, palpitation, fainting, vertigo& sometimes sensation of insect crawling over the skiin. Other symptoms which may be perceived by patient are anxiety, depression, fear, dryness (decreased lubrication) during coitus, decreased desire for genital& low enjoyment & absent orgasm.

Sometimes symptom may start 2 to 3 year before the actual menopause. This is called Perimenopause. In long term if not properly treated it may lead to bone fractures & deformity of back spine.

Hormone changes after menopause: oestradiol, oestrone, androstenidione,& testosterone decreases & LH,FSH increases.

Investigations & Diagnosis: it is diagnosed by high value of LH & FSH hormone & low value of female genital hormones.

Treatment: For hot flushes before or after menopause we give female hormone for short time, within two to six months hot flushes disappear.

1) Hormone Replacement therapy is prescription of female genitalhormone & other hormone for relief of menopausal symptoms & other consequences. Hormone replacement can be given as:

1) Synthetic or natural female hormone are replaced with immediate relief of all the symptoms without any side effects. It is available as oral tablets, skiin patch, dermal gels or vaginal creams. The various hormones used for this purpose have potency mild to strong. 2) Phytoestrogens: Natural source female hormones are also available hich have no side effect

3) Prohormones: many natural products are available which works as prhormones for female genitalhormones. They are devoid of any side effects.

3) Certain ayurvedic tablets are available which can cure these symptoms without side effects. 4) Progestogens

5)MedroxyprogesteroneDesgestrol

6) Megestrol

7) Norethisterone

8) Hydroxyprogesterone

9) Natural Progesterone

10) Norgestimate

11) Cyproterone Acetate

12) Tibolone

13) Androgen Replacement is also some times required when there is associated low genital desire or lack of enjoyment of genitalactivity.

14) Clonidine

16) For prevention of osteoporosis in female, various treatments given are hormones Ethnyl estradiol (Premarin), Tibolone & Raloxifene is prescribed along with biphosphonates, calcium & Vitamin D.

Defferential diagnosis of flushing

Physiologic flushing : Menopause, Ingestion of monosodium glutamate (Chinese restaurant syndrome), Ingestion of hot drings

Drugs : Alcohol (± disulfiram, metronidazome or chlorprppamise), Diltizen, Nifedipine, Nicrotinic acid, Levodopa, Bromocriptine,

Thyrotropin-releasing hormone, Amyl nitrate,

Neoplastic disorders, Carcinoid syndrome, VIPoma syndrome, Medullary carcinoma of the thyroid, Systemic mastocytosis, Basophilic chronic myelocytic leukemia, Renal cell carcinoma, Agnogenic flushing

Premature Menopause / Ovarian Failure

Premature Ovarian Failure is called when ovarian function stops before the age of 40 year age. Approximately 0.1% females suffer with this problem. Symptoms are absence of period along with some of the below mentioned symptoms. Those associated symptoms are hot flushes, weakness, irritability, depression, insomnia (less sleep), body pain & less desire for genital, dryness of vagina during intercourse & absent orgasm or pain during intercourse & sometimes excess sweating. Patient may suffer sensation of heaviness in head, weakness, palpitation, fainting, vertigo& sometimes sensation of insect crawling over the skiin

Causes of Premature Ovarian Failure:

Genetic Alterations or Tendencies :Structural alternations in or absence of an X chromosome, Trisomy X with our without mosaicism, Reduced germ cell number, Accelerated atresia of germs cell (?), In association with myotoria systrophica, Enzymatic defects, 17ß-Hydroxylase deficiency galactosemia

Defects in Gonadotropin Secretion or Action :Secretion of biologically inactive gonadotropin, a or ß subunit defects, FSH receptor (FSHR) mutations, Postreceptor defects (e.g. resistant ovary or savage syndrome)

Immune Dysfunction : Associated with other Autommune disorders, Isolated, Congenital thymic aplasia

Physical Insults : Chemotherapeutic (especially alklylating) agents, Ionisinz radiation, Viral agents, Cigarette smoking, Surgical exitirpation Idiopathic

For proper diagnosis all above causes investigated then treated accordingly.

(XII) Hormone replacement therapy in female prescribed when female hormone is deficient as after menopause or after surgical removal of ovaries. Symptoms of female hormone deficiency are hot flushes, anxiety, depression, fear, dryness (decreased lubrication) during coitus, decreased desire for genital & low enjoyment & absent orgasm.

Hormone replacement from out side is given as female genital hormone & other hormone for relief of menopausalsymptoms & other consequences.Hormone replacement can be given as:

1) synthetic or natural female genital hormone are replaced with immediate relief of all the symptoms without any side effects. It is available as oral tablets, skiin patch, dermal gels or vaginal creams. The various hormones used for this purpose have potency mild to strong.

2) Phytoestrogens: Natural source female hormones are also available which have no side effect

3) Prohormones: many natural products are available which works as prhormones for female genital hormones. They are devoid of any side effects.

3) Certain ayurvedic tablets are available which can cure these symptoms without side effects.

4) Progestogens

5) Medroxyprogesterone Desgestrol

6) Megestrol

7) Norethisterone

8) Hydroxyprogesterone

9) Natural Progesterone

10) Norgestimate

11) Cyproterone Acetate

12) Tibolone

13) Androgen Replacement is also some times required when there is associated low genital desire or lack of enjoyment of genitalactivity.

14) Clonidine

Monitoring for Side Effects: We do frequent Blood pressure & biochemical monitoring, mammography & other tests to see the good effects as well as any side effects.

(7I) Turner Syndrome is a chromosomal defect in females leading to short height, absent breast