From hormonal failure to fatherhood: Natural conception after targeted endocrine treatment of secondary hypogonadism

Abstract

Background: Secondary hypogonadism is a potentially reversible cause of male infertility but may remain unrecognized during routine infertility evaluation. Appropriate endocrine assessment and targeted treatment of hypothalamic-pituitary-gonadal dysfunction may restore spermatogenesis and enable biological fatherhood.

Case summary: We report two men with secondary hypogonadism who achieved natural conception following individualized endocrine therapy. The first patient was a 19-year-old 46,XY man presenting with absent pubertal development, reduced libido, and severe testosterone deficiency (42.45 ng/dL) with inappropriately low-normal gonadotropin levels. Normal olfaction and pituitary magnetic resonance imaging supported the diagnosis of idiopathic isolated hypogonadotropic hypogonadism. Testosterone therapy was initially administered for pubertal induction and virilization. After fertility planning, testosterone was discontinued and fertility-directed treatment with human chorionic gonadotropin (hCG) and follicle-stimulating hormone (FSH) was initiated, resulting in improvement of sperm concentration from 3.2 million/mL to 54.7 million/mL and natural conception. The second patient presented during adolescence with Hardy grade C macroprolactinoma associated with visual impairment, delayed puberty, hypopituitarism, and marked hyperprolactinemia (14,400 ng/mL). Long-term cabergoline therapy with appropriate pituitary hormone replacement resulted in significant prolactin reduction and tumor regression. Subsequent fertility-directed hCG therapy restored reproductive function, resulting in two spontaneous conceptions and live births in 2020 and May 2026.

Conclusion: Secondary hypogonadism should be considered a treatable cause of male infertility. Individualized endocrine management, including gonadotropin therapy when fertility is desired, can restore spermatogenesis, facilitate natural conception, and reduce premature reliance on invasive assisted reproductive techniques.

[J Assoc Clin Endocrinol Diabetol Bangladesh, 2026;5(Suppl 1): S61]