Lesson of the Week: Anabolic steroid abuse by body builders and male subfertility

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Abstract
Case reports Case 1—A couple (husband aged 29) requested in vitro fertilisation after primary subfertility for three years. Results of two semen analyses arranged by the general practitioner in early 1994 were normal (sperm densities 80x109 and 150x109/l). At presentation the husband was severely oligospermic (sperm densities nil and <100x106/l). His hobby was weightlifting and he admitted to taking oral steroids for two weeks 12 months earlier. Examination showed a normal muscular male physique with normal secondary sexual characteristics. However, follicle stimulating hormone and testosterone concentrations were very low, confirming steroid use. He admitted to taking a “protein health drink” which was made up by the gymnasium before training. Three months after stopping this drink his sperm density was 100x109/l. Case 2—A couple (husband aged 35) were referred for in vitro fertilisation with donor sperm. The husband owned a gymnasium and his hobby was body building. At the age of 24, six months after mumps without testicular involvement, a semen sample had shown azoospermia with maturation arrest on testicular biopsy. They were referred to a large tertiary referral unit. Knowing he was azoospermic from an apparent other cause, the husband had started and continued to take anabolic steroids without informing anyone. Azoospermia was confirmed and they received unsuccessful donor insemination. He stopped steroids at the age of 31 because of fear of the general side effects at that age. Four years later routine semen assessment before in vitro fertilisation showed normal sperm densities (90x109 and 59x109/l). For several years they had almost abstained from intercourse because they thought they had no chance of conceiving naturally. Case 3—A couple (husband aged 28) attended for investigation of secondary subfertility for 12 months. Each had a child from a previous relationship. The husband was azoospermic. He admitted to body building and regular use of oral testosterone from 1990 to September 1994. In an attempt to reverse the effects of the steroid “treatment” he was given human chorionic gonadotrophin injections by the supervisors of the gymnasium that he attended. His wife was unaware of the drug abuse. Five months after stopping steroids his sperm density was 30x109/l. Case 4—A couple (husband aged 27) had primary infertility for over two years. The husband had been a body builder since the age of 18 because of bullying. He had used steroids from the age of 21 but stopped 10 months before the consultation. Semen analysis results were: January 1995, 1.9x109/l (99% motile); June 1995, 11x109/l (16% motile); September 1995, 14x109/l (36% motile). He provided a detailed list of the oral and intramuscular drugs that he had used (needles being obtained from the needle exchange programme). These were: 1987 methandienone (Dianabol; six months); 1988 methandienone (Dianabol; four months), nandrolone (Deca-Durabovan), and intramuscular methyltestosterone (Testoviron; three to four weeks); 1990 oral mesterolone (Pro-Viron; two years) and oral stanozolol (Stromba); 1992 intramuscular methenolone (Primobolan; six months on, six months off) and oral nandrolone (Anabolin); 1993 oral methenolone (Primobolan; one year) and testosterone propionate (Testex; three months on, three months off for one year); 1994 intramuscular stanozolol (Stromba) and oral methandienone (Dianabol). He stopped the drugs in May 1994. Case 5—A couple (husband aged 28) presented with two years of primary infertility. The husband attended a gymnasium regularly for recreation and weight training. For five months before presentation he had taken steroids given to him by friends at the gymnasium. He doubled the dose that his friends suggested. His sperm count was 5x109/l with 80% motility. Pregnancy was achieved about six months after stopping steroids.