Hypogonadism

This study utilized a community based participatory research framework. This approach has previously been put forth as a useful research model for empowering patients and overcoming health inequities [29 (link)]. As part of a European network focused on CHH (COST Action BM1105 [30 ]), partnerships with online patient community leaders (i.e. moderators of online patient support sites) were developed to contribute to the study design, recruitment, and conduct of the study. We recognized patients as experts and these partners were actively involved in generating ideas as well as providing feedback, comments, and criticism in an iterative process to refine the questions and improve the language and clarity of the survey and focus group questions. This descriptive, multivariate correlational needs assessment study employed a sequential mixed-methods design. This approach (QUANT-Qual) started with an online survey and statistical analysis of the quantitative data (Figure 1). Subsequently, patient focus groups were conducted and discussions were analyzed using a qualitative data analysis. The intention behind employing this mixed-methods approach was to provide a deeper exploration of the unmet health needs of CHH men than would be possible by either method in isolation.
Men were targeted for recruitment as CHH is rare and male cases are 2–5 times more common than female cases [10 (link),11 (link)]. Men 18–70 years of age diagnosed with CHH [31 (link)] were included in the study. A random sampling (40% of subjects) were contacted to confirm diagnosis and those outside of the age range or who had other causes of hypogonadism were excluded from analyses. The study was publicized online via a closed/private CHH social media group (Facebook), CHH forum (chat room), a clinical trials registry [32 ], and the COST Action website [30 ]. Focus groups were held in concert with patient-support meetings that were planned jointly by patient community leaders and study investigators.
First, the quantitative arm included an online survey to collect demographic information and to assess healthcare literacy, health information seeking patterns, interactions with healthcare system/providers, and self-reported adherence to treatment/healthcare (Additional file 1). To assess healthcare literacy we used a self-report method previously shown to correspond with lengthier gold standard literacy tests [33 (link),34 (link)]. Descriptive statistics, Chi square and Pearson product moment coefficients of correlation were performed on survey results. To evaluate the relative importance of the most frequently used sources of CHH information we performed Kruskall-Wallace one-way analysis of variance on ranks. SigmaStat (Systat Software Inc., San Jose, California, USA) was used for statistical analyses and a p < 0.05 was considered significant.
Second, the qualitative arm involved patient focus groups discussing issues and challenges related to living with CHH, patient-reported coping strategies and the acceptability of possible online interventions. Questions were derived from Pender’s Health Promotion Model [35 ] and developed with input from patient community leaders. Focus group transcripts were analyzed using NVivo10 (QSR International PSY Ltd., Melbourne Australia). Briefly, thematic analysis (coding) was conducted by two separate investigators (AD:DM) to identify categories of responses and themes emerging from the focus group discussions and discrepancies in coding as well as emergent categories were discussed until resolution was achieved. Iterative coding occurred until no further themes are identified, suggesting a saturation point has been reached. Additionally, connections between coded terms were mapped to examine connections within and between categories (i.e. whether or not certain themes appear together repeatedly) and those arising frequently and expansively were given particular emphasis [36 ].
The study was approved by the University of Lausanne ethics committee and informed consent was obtained from all participants. Participants in the online survey provided an electronic, opt-in format consent while focus group members provided written consent. All participants received investigator contact information to address questions/concerns and were given the option to provide an email address if they agreed to be contacted by the investigators for follow-up clarification.

A hypercholesterolemia diagnosis was confirmed if the patient had a nonfasting LDL-cholesterol above 4.0 mmol/L. Type 2 diabetes mellitus was defined as a repeated fasting glucose above 6.7 mmol/L (or nonfasting glucose above 11.0 nmol/L). Hemoglobin A1c was used to assess long-term glycemic control. As hypothyroidism in PWS can be both primary and central (61 (link)), hypothyroidism was defined as a free T4 below 11 pmol/L, regardless of thyroid stimulating hormone. Hypogonadism in males was defined as a morning testosterone level below 10.0 nmol/L or a random testosterone level below 10.0 nmol/L combined with clear clinical features of hypogonadism (sparse body hair, micropenis, and the absence of spontaneous morning erections). Hypogonadism in females was defined as absent, scarce, or irregular menses. The diagnosis of hypogonadism was based on both laboratory values and clinical parameters because of the effect of adipose tissue aromatase activity on estradiol and testosterone levels (62 (link)), and the fact that hypogonadism in PWS can be both primary and central (63 (link)). Due to intellectual disability in most patients, gynecological evaluation was not routinely performed. When females used oral contraceptives or estrogen replacement therapy before screening, we asked for the presence of the menstrual cycle before the start of estrogen replacement therapy.
Severe vitamin D deficiency was defined as a 25-hydroxyvitamin D level below 20 nmol/L and a mild vitamin D deficiency was defined as a 25-hydroxyvitamin D level below 50 nmol/L. When patients used cholesterol-lowering medications, oral antidiabetics, insulin, levothyroxine, or testosterone replacement therapy before the start of the screening, we requested pretreatment laboratory values to verify the diagnosis.

The Massachusetts General Hospital IHH cohort consisted of a total of 1,453 IHH (KS and nIHH) patients enrolled in a research study within the Massachusetts General Hospital (MGH) Harvard Center for Reproductive Medicine. This cohort was clinically defined by (i) absent or incomplete puberty by age 18 years, (ii) serum testosterone < 100 ng/dL in men or estradiol < 20 pg/mL in women with low or normal levels of serum gonadotropins, (iii) otherwise normal anterior pituitary function, (iv) normal serum ferritin concentrations, and (v) normal MRI of the hypothalamic-pituitary region (4 (link)). These stringent clinical criteria allowed us to infer a hypothalamic site defect in these patients. In addition, since hypothalamic GnRH deficiency is often intertwined with olfactory dysfunction (KS form of IHH), both self-reported olfaction as well as University of Pennsylvania Smell Identification Test scores were used to classify patients as either KS (when olfaction was abnormal: anosmia/hyposmia) or nIHH (normal smell) (48 (link), 49 (link)). For male patients who were evaluated at prepubertal age, other signs of neonatal hypogonadism were evaluated, including hypospadias, micropenis, and cryptorchidism. Clinical charts and patient questionnaires were reviewed for phenotypic evaluation for both reproductive and nonreproductive phenotypes.
The diagnosis of SOX2 disorder was established in IHH probands in whom molecular genetic testing identified a heterozygous intragenic SOX2 pathogenic variant, a deletion that is intragenic, or a deletion of 3q26.33 involving SOX2 (1 ). Eye defects were classified as severe or mild as previously described (3 (link)). Severe eye defects were defined as bilateral ocular malformations including anophthalmia and microphthalmia. Mild eye defects were defined as unilateral anophthalmia or microphthalmia, coloboma, optic nerve hypoplasia/aplasia, strabismus, hypertelorism, nystagmus, small palpebral fissures, and myopia. Patients were evaluated for other nonocular features that have been associated with the syndrome, including neurocognitive developmental delay, seizures, hearing loss, and esophageal abnormalities, as well as genital anomalies including hypospadias, micropenis, and cryptorchidism. Patients’ pituitary function was assessed by detailed laboratory evaluation of all pituitary hormones, including thyroid-stimulating hormone, free thyroxine, prolactin, IGF1, adrenocorticotropic hormone, and morning cortisol, and pituitary anatomy was evaluated with pituitary MRIs.

Human genes that were considered known POI causal genes were all previously identified deleterious variants in patients with syndromic or isolated POI, and their causative association was evaluated by functional verification in animal models or in vitro studies or by observing co-segregation with POI in large families or co-occurrence in multiple unrelated patients. We generated the list of known POI genes by searching the PubMed and OMIM databases for articles published up to December 2021, using terms related to genes (for example, ‘gene’, ‘genetic’, ‘mutation’ or ‘variant’) in conjunction with terms related to POI (for example, ‘ovarian insufficiency’, ‘ovarian failure’, ‘ovarian dysgenesis’, ‘ovarian aging’, ‘ovarian dysfunction’, ‘gonadal failure’, ‘gonadal dysgenesis’, ‘reproductive dysfunction’ or ‘hypogonadism’). The roles of genes in POI etiology were then carefully evaluated for each unique search result. In total, a list of 95 known causative genes was compiled as well, and the associated phenotypes references for each known POI gene are listed in Supplementary Table 2.

This cross-sectional study was conducted from September 4–21, 2020. A stratified cluster random sampling method was employed to recruit participants (Supplementary Fig. 1), and the sample was obtained from the sampling frame of seven categories developed by stratifying all geographical regions. Sampling followed a tiered process that included three levels: provincial-level administrative regions, cities, and hospitals. Two representative provinces were randomly selected in each of the central and eastern regions (considering population density): one representative province was randomly selected in each of the other geographical regions, and the provincial capital city, together with two random secondary cities, were chosen in these provinces. Four tertiary hospitals and four secondary hospitals (two in the provincial capital city and one in each secondary city) were selected. Next, excessive sampling was conducted in Beijing, Shanghai, and Guangdong provinces, considering the economic level, urban size, and population density. Four tertiary and four secondary hospitals were selected from the three provincial-level administrative regions. Outpatient physicians involved in patient recruitment at all hospitals were trained to improve data collection consistency. Couples who had not been able to conceive a child even though they had frequent, unprotected sexual intercourse for a year or longer were recruited in the urology/andrology department and reproductive center. The husband’s personal, sexual, and medical/medication history were documented, after which he underwent a physical examination, semen analysis, and hormonal evaluation. Men with sperm disorders, hypogonadism, ejaculation disorders, or other factors affecting infertility were included in this study. Men with mental retardation or other diseases leading to an inability to understand the questionnaire items were excluded from this study. Written informed consent was obtained before the respondents completed the questionnaire.