Since the purpose is two-fold: (1) check for testes function, and (2) restore testes function, I use 2,000 IU SC Q3D X 10. I check the TT after the 5-6 injection. If the level is satisfactory (350+), I begin SERM treatment as described elsewhere. The use of a single GnRH agonist injection is performed if there is no gonadotropin response. Nothing is written in stone (many variations), but bloodwork is ESSENTIAL.
hCG Stimulation Test
de Kretser DM, Burger HG, Hudson B, Keogh EJ.
The HCG stimulation test in men with testicular disorders. Clin Endocrinol (Oxf) 1975;4(6):591-6.
The HCG stimulation test in men with testicular di... [Clin Endocrinol (Oxf). 1975] - PubMed result
The rise in plasma testosterone levels following stimulation with human chorionic gonadotrophin (3000 i.u./day for 4 days) has been used as a test of interstitial cell function in normal men and men with testicular disorders. The large majority of patients with testicular disorders resulting in infertility, showed a subnormal testosterone response to stimulation. The most marked impairment was noted in those patients with the biopsy appearance of germinal cell arrest and Sertoli cell only syndrome.
Grant DB, Laurance BM, Atherden SM, Ryness J.
HCG stimulation test in children with abnormal sexual development. Arch Dis Child 1976;51(8):596-601.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1546104/pdf/archdisch00826-0034.pdf
Plasma testosterone was estimated by radioimmunoassay in 60 children with disorders of sexual development before and after stimulation with human chorionic gonadotrophin (HCG). In 21 children the testosterone levels
after 3 and 5 daily injections of 1000 units HCG were compared and good correlation was found between the paired results (r =0-93), suggesting that the 5-day HCG test has no advantage over the 3-day test. In 7 boys with apparently normal genital development the increments in plasma testosterone ranged from 2-0 to 8-5 nmol/1 after 3 injections of HCG. 10 boys with anorchia showed little response to HCG stimulation, but in patients with other disorders, such as micropenis (10), cryptorchidism (8), hermaphroditism (3), male pseudohermaphroditism (13), hypospadias (3), and sex chromosome anomalies (6), there was considerable variation in the plasma testosterone level after HCG. In 2 boys with suspected anorchia the results suggested that testes were present and this was confirmed at operation.
Yazici M, Sahin M, Bolu E, et al.
Prediction of testosterone response to human chorionic gonadotrophin in idiopathic hypogonadotropic hypogonadism patients. J Natl Med Assoc 2009;101(1):71-6.
http://www.nmanet.org/images/uploads/Publications/OC71.pdf
[Twenty-five of the men with IHH were tested with hCG (Pregnyl, Organon, Italy). Subjects were given 5000 IU intramuscularly on 3 alternate days.]
In clinical practice, the human chorionic gonadotrophin (hCG) stimulation test is widely used to evaluate testicular function. Inhibin B, a gonadal peptide regulating follice-stimulating hormone (FSH) secretion, is an established marker of Sertoli cell function and spermatogenesis in adults. The aim of this study was to determine whether basal inhibin B levels are able to predict testosterone response to hCG in idiopathic hypogonadotropic hypogonadism (IHH) patients and to evaluate the correlation between inhibin B and gonadotropins in these patients and controls. Inhibin B (n=15) and other hormones (n=29) were measured in 29 patients with IHH and 32 controls. Inhibin B (n=8) and testosterone levels (n=25) before and after hCG stimulation were measured in 25 male patients with IHH by an immunoassay specific for inhibin B. Basal inhibin B was compared to the testosterone increase after hCG. There was a significant increase in inhibin B (22.6 +/- 9.8 vs 45.07 +/- 13 pg/mL; p=.005), free testosterone (2.92 +/- 0.55 vs. 7.9 +/- 1.5 pg/mL; p=.002), and total testosterone (69.0 +/- 15.9 vs. 184.9 +/- 44.1 ng/mL; p = .013) levels 72 hours after hCG injection. Inhibin B and the hCG-induced free testosterone and total testosterone increment correlated strongly (r=0.802, P<.001; r=0.793, P<.001, respectively). We conclude that basal inhibin B predicts the testosterone response to hCG in IHH patients and therefore gives reliable information about Leydig cell reserve. Furthermore, inhibin B levels show negative correlation with luteinizing hormone (LH) in control patients and positive correlation with FSH and LH in IHH patients. LH may effect inhibin B secretion. Further studies are necessary to define the physiology of inhibin B in human males.
Petak SM, Nankin HR, Spark RF, Swerdloff RS, Rodriguez-Rigau LJ.
American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients--2002 update. Endocr Pract 2002;8(6):440-56. https://www.aace.com/sites/default/files/hypogonadism.pdf
[hCG Stimulation Test.—Various protocols are used for hCG stimulation testing. In general for postpubertal male patients, a single dose of hCG (5,000 IU intramuscularly) is administered, and pretherapy and 72-hour posttherapy testosterone measurements are done (some protocols use 1,000 to 4,000 IU of hCG or multiday dosing) (14).]
In these clinical practice guidelines, specific recommendations are made for determining the most effective methods of diagnosing and treating hypogonadism in adult male patients. The target populations for these guidelines include the following: (1) men with primary testicular failure requiring testosterone replacement (hypergonadotropic hypogonadism); (2) male patients with gonadotropin deficiency or dysfunction who may have received testosterone replacement therapy or treatment for infertility (hypogonadotropic hypogonadism); and (3) aging men with symptoms relating to testosterone deficiency who could benefit from testosterone replacement therapy. Initial hormonal evaluation generally consists of a testosterone determination, in conjunction with a free testosterone or sex hormone-binding globulin level, inpatients with clear symptoms and signs but normal-range total testosterone, follicle-stimulating hormone, luteinizing hormone, and prolactin levels. Other possible tests include semen analysis, pituitary imaging studies, genetic studies, bone densitometry, testicular ultrasonography,testicular biopsy, and specialized hormonal dynamic testing. Therapeutic options generally consist of testosterone replacement by injections, patches, or topically applied gel in hypergonadotropic patients and in hypogonadotropic patients not interested in fertility. In hypogonadotropic patients interested in fertility, gonadal stimulation option scan be considered, including human chorionic gonadotropin stimulation therapy with or without human menopausal gonadotropin (or follicle-stimulating hormone) or gonadotropin-releasing hormone pump therapy. These therapies may be combined with assisted reproductive technologies such as in vitro fertilization with intracytoplasmic sperm injection, which may allow pregnancy to occur with very low numbers of sperm.
