Department of Reproductive Health, Center of Postgraduate Medical Education, Warsaw, Poland.
Endokrynol Pol. 2023;74(5):480-489. doi: 10.5603/ep.95626. Epub 2023 Oct 2.
Obesity is currently one of the most serious public health problems which affects up to 30-40% of the population, and its prevalence is higher in men than in women. Complications of obesity include atherosclerosis, cardiovascular diseases, and type 2 diabetes mellitus, but it also has a negative impact on the hormonal system and fertility. The hormonal consequences of excess body fat in men are functional hypogonadism, which not only causes clinical symptoms of testosterone deficiency, but is also a risk factor for obesity (a vicious circle mechanism). Reduced fertility in obese men may be a consequence of functional hypogonadotropic hypogonadism (decreased gonadotropins and testosterone secretion, reduced libido, and erectile dysfunction), but other mechanisms associated with excess adipose tissue, like hyperinsulinaemia, hyperleptinaemia, chronic inflammation, and oxidative stress also play an important role. Therefore, in obese men deterioration of semen parameters (sperm concentration, motility, and morphology) and reduced fertility are observed, also concerning the effectiveness of assisted reproductive techniques. Reducing the mass of adipose tissue causes an increase in testosterone concentrations and has a beneficial effect on semen parameters. Functional hypogonadism in obese men should be diagnosed only after exclusion of organic causes of hypogonadism. Lifestyle changes, including physical exercise and low-caloric diet, and optimization of comorbidities, are still first line of treatment. In some patients, if such treatment is ineffective, pharmacotherapy or bariatric surgery may be considered. Testosterone replacement therapy is contraindicated in obese men with functional hypogonadism, especially in those who desire fertility. Selective oestrogen receptor modulators and aromatase inhibitors improve sperm quality but are not recommended for the treatment of hypogonadism in obese men. GLP-1 analogues appear to be effective and safe in the treatment of low testosterone and infertility in obese men and may be the main method of pharmacotherapy in the future.
肥胖目前是最严重的公共健康问题之一，影响了多达 30-40%的人群，其患病率在男性中高于女性。肥胖的并发症包括动脉粥样硬化、心血管疾病和 2 型糖尿病，但它也对激素系统和生育能力产生负面影响。男性体内多余脂肪的激素后果是功能性性腺功能减退症，它不仅导致睾酮缺乏的临床症状，而且也是肥胖的一个危险因素（恶性循环机制）。肥胖男性生育力降低可能是功能性促性腺激素低下性性腺功能减退症的后果（促性腺激素和睾酮分泌减少、性欲降低和勃起功能障碍），但与多余脂肪组织相关的其他机制，如高胰岛素血症、高瘦素血症、慢性炎症和氧化应激也起着重要作用。因此，肥胖男性观察到精液参数（精子浓度、活力和形态）恶化和生育力降低，这也影响了辅助生殖技术的效果。减少脂肪组织的质量会导致睾酮浓度增加，并对精液参数产生有益的影响。只有在排除了性腺功能减退的器质性原因后，才能诊断肥胖男性的功能性性腺功能减退症。生活方式的改变，包括体育锻炼和低热量饮食，以及合并症的优化，仍然是一线治疗方法。在某些患者中，如果这种治疗无效，可能会考虑药物治疗或减肥手术。功能性性腺功能减退症的肥胖男性禁忌使用睾酮替代疗法，尤其是那些希望生育的患者。选择性雌激素受体调节剂和芳香化酶抑制剂可改善精子质量，但不推荐用于治疗肥胖男性的性腺功能减退症。GLP-1 类似物在治疗肥胖男性的低睾酮和不育方面似乎有效且安全，可能是未来药物治疗的主要方法。
