Stesura Seveso Archivio Italiano di Urologia e Andrologia 2015; 87, 3194 ORIGINAL PAPER The relationship between serum hormone levels (follicle-stimulating hormone, luteinizing hormone, total testosterone) and semen parameters Mehmet Zeynel Keskin 1, Salih Budak 1, Tuğba Zeyrek 2, Orçun Çelik 1, Oguz Mertoglu 1, Mehmet Yoldas 1, Yusuf Özlem !lbey 1 1 Tepecik Research and Education Hospital, Clinic of Urology, Izmir, Turkey; 2 Tepecik Research and Education Hospital, Assisted Reproductive Techniques Department, Clinic of Embryology, Izmir, Turkey. Objective: The aim of this study was to investigate the effect of serum gonadotropin and total testosterone levels on semen parameters. Materials and Methods: Three hundred and eighty-two patients that applied to a male infertility polyclinic were included in our study. Serum gonadotropin and total testos- terone levels and semen parameters of the patients were analyzed during the first visit to the clinic. The reference FSH value was 1.5-12.4 mIU/mL, that of LH was 1.7-8.6 mIU/mL and the reference value for total testosterone was 249-836 ng/dL. Results: While there was no statistically significant differ- ence between the patients with low gonadotropin levels and the controls regarding any of the semen parameters (p > 0.05), there was a strong statistically significant difference between the patients with high gonadotropin levels and the controls regarding sperm concentration (p = 0.000), total motility (p = 0.000), progressive motility (p = 0.000), and morphology (p = 0.000). There was a strong statistically sig- nificant difference between the patients with low testosterone levels and the controls regarding total motility (p = 0.012) and progressive motility (p = 0.010), and a weak statistically significant difference in morphology (p = 0.042). There was no statistically significant difference in semen volume or sperm concentration (p > 0.05). There was no statistically significant difference in any of the semen parameters between the patients with high testosterone levels and the controls (p > 0.05). Conclusions: Our findings especially regarding LH and T levels are not in agreement with previous reports. In this regard, there is a need for larger-scale and randomized tri- als to resolve this discrepancy. KEY WORDS: Gonadotropin; Semen; Testosterone. Submitted 5 January 2015; Accepted 31 March 2015 Summary No conflict of interest declared. to testicular obstruction (2) or abnormal hormone levels, leading to dysregulated sperm production. Follicle-stimulating hormone (FSH), luteinizing hor- mone (LH), and testosterone (T) are key hormones in fertility health. FSH and LH are types of ‘gonadotropins’ that are synthetized in the adenohypophysis of verte- brates due to the effect of gonadotropin-releasing hor- mone (GnRH). Production of gonadotropins is con- trolled by T, estradiol (E2), and inhibin B (3, 4). LH binds to receptors on Leydig cells, leading to increased release of intratesticular T. FSH binds directly to Sertoli cells, leading to secretion of many factors cru- cial for sperm development. As Leydig cells, Sertoli cells, and peritubular cells in the seminiferous tubules are important in spermatogenesis (5), the decrease in FSH and LH production results in reduced testicular function, and infertility. FSH and inhibin B are considered markers of spermato- genesis and Sertoli cell function (6-10). In previous stud- ies, a negative correlation was found between FSH levels and sperm concentration, while a positive correlation was found between inhibin B levels and sperm concen- tration (10-12). No relationship between semen parame- ters and LH and T levels was detected (10). The aim of this study was to investigate the relationship between semen parameters and serum gonadotropin and total T levels. MATERIALS AND METHODS Three hundred and eighty-two patients from the outpa- tient clinics of urology for male infertility problems at the Ege Maternity Hospital between August 2014 and December 2014 were included in the study. Initially, his- tory was taken and a physical examination carried out. Patients who had a characteristic that could affect semen parameters (drug, hypovolemic testis, varicocele, systemic diseases etc.) were excluded from the study. Semen analy- sis and serum hormone levels were evaluated in the remaining patients. Blood samples for determination of hormone levels were collected before 10:00 am. Hormone analysis was performed with a Roche Cobas and 601 HITACHI device by microparticle enzyme immunoassay. DOI: 10.4081/aiua.2015.3.194 INTRODUCTION The subfertility rate in couples of worldwide is 15% (1). Evaluation of spermatogenesis has an important role in diagnosis, and semen analysis is usually the initial test per- formed. If an abnormality is determined in patients after semen analysis, hormone levels may then be measured to determine the cause of subfertility. Subfertility may be due Keskon_Stesura Seveso 30/09/15 09:27 Pagina 194 195Archivio Italiano di Urologia e Andrologia 2015; 87, 3 The relationship between serum hormone levels (follicle-stimulating hormone, luteinizing hormone, total testosterone) and semen parameters Reference values for FSH levels were 1.5 to 12.4 mIU/mL, those of LH were 1.7 to 8.6 mIU/mL, and reference values of total T were 249 to 836 ng/dL. Semen samples were taken on the same day by manual masturbation, following the patient refraining from sex for 3-6 days. Samples were evaluated by the same embryologist in the Assisted Repro du ction Treatment Center Spermiogram Labora tory of the hospital. Semen samples were assessed according to the WHO 2010 cri- teria (13). The relationship between serum FSH, LH, total T levels and semen parameters was investigated using the IBM Statistical Package for the Social Sciences (SPSS) version 22.0 software. A value of p < 0.05 was taken to indicate statistical significance. RESULTS Upon analysis of semen parameters and hormone levels of the 382 patients included in the study, the mean FSH level was 7.91 mIU/mL and the mean LH level was 6.26 mIU/mL. The mean T level was 425.21 ng/dL, semen volume was 2.86 mL, sperm concentration was 26.4 × 106/mL, total motility 42%, progressive motility 29%, and morphology was found to be 2% (Table 1). Patients were divided into three groups according to FSH, LH, and T levels. Patients with a FSH level of 0-1.5 mIU mL were considered Group 1 (low) (n = 9), patients with a FSH level of 1.5-12.4 mIU/mL were considered Group 2 (nor- mal) (n = 320)), and those with a FSH level > 12.4 mIU/mL were considered Group 3 (high) (n = 53). Patients with a LH level of 0-1.7 mIU/mL were consid- ered Group 1 (low) (n = 4), patients with a LH level of 1.7-8.6 mIU/mL were con- sidered Group 2 (normal) (n = 321), and those with a LH level > 8.6 mIU/mL were considered Group 3 (high) (n = 57). Patients with a T level of 0-249 ng/dL were considered Group 1 (low) (n = 45), patients with a T level 249-836 ng/dL were considered Group 2 (normal) (n = 333), and those with a T level > 836 ng/dL comprised Group 3 (high) (n = 4). Upon classifying the patients into low, normal, and high hormone level groups, semen parameters were evaluated. Mean, standard deviation, and minimum and maximum values of volume, concentra- tion, total motility, progressive motility, and morphology of semen were assessed according to FSH (Table 2), LH (Table 3), and T (Table 4) levels. N Minimum Maximum Mean Std. Dev. FSH (mIU/mL) 382 0.11 46.00 7.91 8.45 LH (mIU/mL) 382 0.31 36.10 6.26 3.78 T (ng/dL) 382 1.94 1173.00 425.21 164.47 Volume (mL) 382 0.10 8.50 2.86 1.48 Total Motility (%) 382 0.00 90.00 41.90 26.39 Progressive Motility (%) 382 0.00 80.00 29.0393 21.79 Concentration (million/mL) 382 0.00 190.00 26.40 33.60 Morphology (%) 382 0 10 1.79 1.95 FSH group Volume Concentration Total Progressive Morphology (mL) (million/mL) motility (%) motility (%) (%) Low Mean 2.35 22.06 35.22 25.22 1.89 Std. Dev. 1.47 22.58 28.99 24.4 1.83 Minimum 0.20 0 0 0 0 Maximum 5 67 75 65 4 Normal Mean 2.89 30.78 46.60 32.34 2.07 Std. Dev. 1.48 34.72 23.39 20.45 1.97 Minimum 0.10 0 0 0 0 Maximum 8.50 190 85 75 10 High Mean 2.75 0.72 14.62 9.71 0.08 Std. Dev. 1.48 1.99 26.74 19.25 0.38 Minimum 0.30 0 0 0 0 Maximum 7 11.50 90 80 2 Table 1. Mean data of patients. Results of hormone levels and sperm characteristics of 382 patients included in the study. Minimum, maximum, mean, and standard deviation were determined for follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) levels, and volume, total motility, progressive motility, concentration, and morphology. Table 2. Values of semen parameters according to FSH level. Relationships between FSH levels and semen parameters. There was no statistically significant difference in semen parameters between the normal and low FSH groups (p>0.05), but there was a significant difference in all semen parameters (with the exception of volume, p = 0.272, p > 0.05) between the normal and high FSH groups (p = 0.000, p < 0.05). LH group Volume Concentration Total Progressive Morphology (mL) (million/mL) motility (%) motility (%) (%) Low Mean 2.05 4.30 30 15 1 Std. Dev. 2.10 7.80 26.77 17.79 2 Minimum 0 0 0 0 0 Maximum 5 16 55 35 4 Normal Mean 2.88 30.05 44.80 31.22 2.03 Std. Dev. 1.49 34.81 24.92 21.34 1.98 Minimum 0.10 0 0 0 0 Maximum 8.50 190 90 80 10 High Mean 2.80 7.43 26.40 17.71 0.49 Std. Dev. 1.40 16.57 29.15 20.93 1.10 Minimum 0.30 0 0 0 0 Maximum 7 61 75 60 4 Table 3. Values of semen parameters according to LH level. Relationships between LH levels and semen parameters. There was no statistically significant difference in any of the semen parameters between the normal and low LH groups (p > 0.05), but there were significant differences in all semen parameters (with the exception of volume, p = 0.908, p > 0.05) between the normal and high LH groups (p = 0.000, p < 0.05). Keskon_Stesura Seveso 30/09/15 09:27 Pagina 195 Archivio Italiano di Urologia e Andrologia 2015; 87, 3 M. Zeynel Keskin, S. Budak, T. Zeyrek, O. Çelik, O. Mertoglu, M. Yoldas, Y. Özlem !lbey 196 DISCUSSION FSH is synthesized in the anterior lobe of the hypophysis gland and stimulates Sertoli cells to release inhibin B. LH is also synthetized in the anterior lobe of the hypophysis gland and increases intratesticular T levels by acting on Leydig cells. Intratesticular T stimulates the Sertoli cells in a paracrine manner and increases spermatogenesis. Previous studies have examined the effects of FSH, LH, and T levels on semen parameters. In a study by Kumanov et al. in 2006, FSH and LH levels were found to be significantly negatively correlated with semen param- eters, while T levels were not correlated (14). The same study stated that inhibin B levels were a stronger indica- tor of infertility than FSH and LH levels (14). In a study by Subhan et al., serum hormone levels were compared between oligospermic and control groups. Serum LH and T levels were found to not be statistically different, but serum FSH levels were significantly higher in the oligospermic group compared to the control group (11). In a 2004 study of 1558 young Danish soldiers, Jensen et al. found significant correlations of FSH, LH and inhibin B with sperm concentration, motility and morphology (15). In another study in 2003, Uhler et al. reported sig- nificant correlations between FSH and inhibin B with concentration, motility and morphology. However, they found that LH and T levels did not correlate with those semen parameters (10). Meeker et al. (2007) reported in their study significant negative correlations of FSH, LH with concentration, motility and morphology; however, T levels were signif- icantly positively correlated only with motility (16). In studies comparing the diagnostic value of inhibin B and FSH for infertility, inhibin B has been found to be superior by most (9, 14, 17), although some favor FSH as a diagnostic marker of infertility (18, 19). Halder et al. (2005) found significant correlations of FSH and inhibin B with semen parame- ters, but not with LH and T. Moreover, inhibin B level was not found to assist the diagnosis of infertility (20). In our study, we investigated the statistical difference between normal and abnormal (low and high) hormone groups with semen parameters. We found no signifi- cant difference between the normal group and the low FSH/LH groups. However, we found significant differences in concentra- tion, total motility, progressive motility and morphology between the high FSH/LH groups and the controls. There was a strong significant difference between the low and normal T groups with regard to total motility (p = 0.012) and progressive motility (p = 0.010), and a weak statistically significant difference in morphology (p = 0.042). However, we found no significant difference in semen volume and sperm concentration (p > 0.05). There was no significant difference in any of the semen parameters between patients with high versus normal T levels (p > 0.05). In our study, we detected a sig- nificant negative correlation between gonadotropin lev- els and semen parameters (with the exception of vol- ume), a strong significant positive correlation between T levels and motility, a weakly significant correlation between T levels and morphology, and no correlations among semen volume, concentration, and T levels. CONCLUSIONS Many of these results are conflicting. The LH and T lev- els reported herein are not in agreement with the current literature. In most studies, although there was no associ- ation between semen parameters and T levels, our find- ings show a strong association between motility and T levels. Because of the limited research that has been conducted on the relationship between T levels and sperm motility, there is a need for larger, randomized studies. REFERENCES 1. Greep RO. The dual nature of anterior pituitary influence on the testis. Anatomical Records 1937; 67(Suppl.), 22. 2. Anderson RA, Sharpe RM. Regulation of inhibin production in the human male and its clinical applications. Int J Androl. 2000; 23:136-144. 3. Anawalt BD, Bebb RA, Matsumoto AM, et al. Serum inhibin B levels reflect Sertoli cell function in normal men and men with tes- ticular dysfunction. J Clin Endocrinol Metab. 1996; 81:3341-3345. 4. Sharlip ID, Jarow JP, Belker AM, et al. Best practice policies for male infertility. Fertil Steril. 2002; 77:873-882. 5. Behre HM, Yeung CH, Holstein AF, et al. Diagnosis of male infer- tility and hypogonadism. In Andrology 2001, Springer Berlin Heidelberg, pp.89-124. T group Volume Concentration Total Progressive Morphology (mL) (million/mL) motility (%) motility (%) (%) Low Mean 2.48 20.85 32.15 21.53 1.20 Std. Dev. 1.52 31.12 28.22 21.38 1.50 Minimum 0.20 0 0 .00 0 Maximum 6 130 85 75 6 Normal Mean 2.90 27.28 43.09 30.00 1.86 Std. Dev. 1.47 34.03 26 21.74 1.99 Minimum 0.10 0 0 0 0 Maximum 8.50 190 90 80 10 High Mean 3.75 16.02 52.50 33.25 2 Std. 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Correspondence Mehmet Zeynel Keskin, MD zeynel_akd@hotmail.com Salih Budak, MD Orçun Çelik, MD Oguz Mertoglu, MD Mehmet Yoldas, MD Yusuf Özlem Ilbey, MD Tepecik Research and Education Hospital, Clinic of Urology Güney Mahallesi, 1140/1 Sokak, No:1 Yenişehir- Konak- !zmir, Turkey Tugba Zeyrek, MD Tepecik Research and Education Hospital, Assisted Reproductive Techniques Department, Clinic of Embryology, Izmir, Turkey Keskon_Stesura Seveso 30/09/15 09:27 Pagina 197