PEDIATRIC UROLOGY

Neoadjuvant gonadotropin-releasing hormone therapy before surgery and effect on fertility index in unilateral undescended testes: a prospective randomized trial
Jallouli M, Rebai T, Abid N, Bendhaou M, Kassis M, Mhiri R
Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
Urology. 2009; 73: 1251-4

• Objectives: To investigate, in a prospectively randomized trial, whether preoperative gonadotropin-releasing hormone (GnRH) therapy improves the fertility index in primary cryptorchidism. Cryptorchidism is a common condition with a high risk of infertility. Treatment with GnRH appears to improve fertility later in life by inducing germ cell maturation.
• Methods: A total of 24 boys, 12-123 months old (median 34.5), with 24 undescended testes were prospectively assigned to 2 groups during a 24-month period. The patients were randomized to receive either orchiopexy alone (n = 12) or orchiopexy combined with neoadjuvant GnRH therapy (n = 12) as a nasal spray for 4 weeks at 1.2 mg/d. In both groups, testicular biopsies were performed at orchiopexy, and the histopathologic fertility index was determined.
• Results: The mean fertility index in the group treated with GnRH before surgery was significantly greater (0.88 +/- 0.31) than in the group without hormonal stimulation (0.49 +/- 0.52; P = .02). No significant correlation was found between the fertility index in the GnRH group and the patient’s age.
  Conclusions: The results of our study have shown that neoadjuvant GnRH treatment improves the fertility index in prepubertal cryptorchidism and, consequently, should improve fertility in adulthood.

• Editorial Comment
  Twenty-four boys were prospectively randomized to either undergo unilateral orchiopexy alone versus 1.2 mg of intranasal GnRH daily for 4 weeks prior to orchiopexy. Patients ranged from 12-123 months and biopsies were done during the orchiopexy procedure to evaluate the outcome of the hormone pretreatment. Their results showed an increased fertility index with more Ad spermatogonia per tubule in the hormone-treated group than the orchiopexy alone group. The statistically significant fertility index could only be observed in patients over three years of age.
  Infertility in cryptorchid patients has long been a concern, which has led to surgery in younger age groups and consideration of hormone treatments. The major issue with all fertility studies in pediatric patients is that it takes 20-30 years follow up to evaluate the true outcome. Histology does not necessarily predict semen quality or fertility and this study has the same concern. It is interesting in this study that the older patients seem to have better outcomes with their pretreatment than younger patients, which is not intuitive. One of the other problems hampering the adoption of this pretreatment is that the GnRH analogs are not available in all countries (United States). I expect the best advice is to keep an eye on studies such as this for their impact in the future but it is likely to take a very long time before outcomes can be documented and a unified treatment plan adopted.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu