If you read the exact text of his HCG challenge, he categorizes patients as low, mid-level or high-level responders and identifies a treatment regimen for each. So basically, he is saying, for example, if there is no testicle response to HCG, use exogenous testosterone, mid-level use HCG+T and high responders, only HCG. There isn't a perfect correlation sometimes. For example, if someone goes over 500iu/injection and can get a decent T level, he allows for titrating dosages accordingly. There can be other things going on in one's endocrine system and responses to HCG can improve over time. However, I bring all this up as the HCG challenge is more than just a test for primary vs. secondary...he is trying to assess how much a patient's own system can produce its own hormones.
Two questions for you:
1. I thought he only allowed for 250 IU 3X/week? Are you saying that he will do 500 IU or more 3X/week for monotherapy?
2. I searched and cannot find a paper actually written by him on the "HCG Challenge" or "HCG Stimulation Test"? Have you seen this anywhere?
Answers:
1) Actually, the starting dose is 500iu 3x/wk. In fact, he wrote that on a prescription slip when he corresponded with me initially. The text of his HCG challenge then states basically that mid-level responders can go up in dosage accordingly. He is reasonable with this and conservative, thus, the idea is to go up just enough to get to a good testosterone level. Of course, if someone responded well to such a low dose such as 250, that could be a workable dose. However, if someone responded to such a low dose, that would intuitively tell me they've got severe pituitary dysfunction (ie. low LH).
2) I'll have to dig this up for you later. It is in several places on the web. I'll get back to you on this.
EDIT: See below.
Chorionic Gonadotrophin Stimulation Test (males < 75 years old)*
Chorionic Gonadotrophin is presently available through most pharmacies
or distributors as Profasi, Pregnyl or generic Chorionic Gonadotrophin
10,000 units per 10 cc vial. Various stimulation tests have been
described, from high dose, short course testing to more normal
physiologic doses over a longer time period. I have found that a typical
treatment course for three weeks is best for determining those
individuals who will respond well to this type of treatment. It is
administered by injection 500 units (0.5 cc) SQ, Monday through Friday
for three weeks. Teach patient to self administer with 50 Unit Insulin
Syringes with 30 gauge needles in anterior thigh, seated with both hands
free to perform the injection. Measure: Testosterone, total and free,
plus E2 before starting CG and on the third Saturday AM after 3 weeks of
stimulation (salivary testing may be more accurate for adjusting doses).
Studies have shown that SQ is equal in efficacy to IM administration.
Results:
1. <20% rise suggests poor testicular reserve of leydig cell function
(primary hypo-gonadism or eu-gonadotrophic hypo-gonadism indicating
combined central and peripheral factors).
2. 20-50% increase indicates adequate reserve but slightly depressed
response, mostly central inhibition but possibly decreased testicular response as well.
3. > 50% increase suggests primarily centrally mediated depression of
testicular function.
Options for treatment vary both with the response to CG and patient
determined choices.
1. If there is an inadequate response (< 20%), then replacement with
testosterone will be indicated.
2. The area in between 20-50% will usually require CG boosting for a
period of time, plus natural boosting or "partial" replacement options.
I believe that full replacement with exogenous testosterone is always
the last option in borderline cases since improvement over time may
frequently occur as leydig cell regeneration may actually happen. Much
of this is age dependent. Up to age 60, boosting is almost always
successful. 60-75 is variable, but will usually be clear by the results
of the stimulation test. Also, disease related depression of
testosterone output might be reversible with adequate treatment of the
underlying process (depression, AMI, obesity, alcohol, deficiency, etc.)
This positive effect will not occur if suppressive therapy is instituted
in the form of full replacement.
3. If there is an adequate response, >50% rise in testosterone, there is
very good leydig cell reserve. Natural boosting or CG therapy will
probably be successful in restoring full testosterone output without
replacement, a better option over the long term and a more natural
restoration of biologic fluctuations for optimal response.
4. Chorionic Gonadotrophin can be self-administered and adjusted
according to response. In younger, high output responders (T >
1100ng/dl), CG can be given every third or fourth day at bedtime or in
the AM. This also minimizes estrogen conversion. In lower level
responders(600-800ng/dl), or those with a higher E2 output associated
with full dose CG, 300-500 units can be given Mon-Wed-Fri. At times,
sluggish responders may require a higher dose to achieve full
Testosterone response. In these cases, the diluent is lowered to 7.5cc
or even to 5 cc, which increases the CG concentration 1 ½ - 2 X. This
can be administered in variable doses 0.3 - 0.5cc given every 3rd day.
Check salivary levels on the day of the next injection, but before the
next injection to determine effectiveness and to adjust the dose
accordingly. Keep in mind that later as leydig cell restoration occurs,
a reduction in dose or frequency of administration may be later needed.
5. Monitor both Testosterone and E2 levels to assess response to
treatment after 2 - 3 weeks after change in dose of CG as well as
periodic intervals during chronic administration. Sublingual testing is
very easy and cost effective. It will also better reflect the true free
levels of both estrogens and testosterone. (Pharmasan Labs 888-342-7272
is very good)
6. Adjustment of dosage is a result of symptomatic response and hormone
level boosting. It is based on clinical judgement as much as actual
hormone levels. Remember that "Normal" ranges are for populations, not
individuals!
7. Except for reports of antibodies developing against CG (I have not
seen this), there are no adverse effects of chronic CG administration.
An additional benefit is the boosting of Growth Hormone output which has
also been reported, either as a direct effect of CG or as an effect of
increased levels of testosterone.
*Protocol adapted from "The Testosterone Syndrome" by Eugene Shippen, M.
D. (M Evans and Co, NY 1998).
