These patients have low sperm counts and normal levels of FSH and LH, but a low serum T. Before treatment, a prolaebou should be obtained to rule out a pituitary tumor. In these men clomiphene citrate 25 mg daily (1/2 tab) blocks the negative feedback inhibition of estrogen to the pituitary increasing LH and FSH release and subsequently increasing serum T and improving sperm densities. Semen parameters improve in 94% of men with 40% pregnancy rate achieved. Serum T, estradiol, and a semen analysis are obtained every 3 months. Failure to respond may be attributable to over- or understimulation. If posttreatment testosterone levels remain low, increase the dose to 50 mg daily. If levels exceed 1000 ng/dL and/or estradiol levels exceed 60 ng/L, reduce the dose by 50%. We have observed nonbacterial pyospermia develop in 17% of previously nonpyospermic clomiphene citrate-treated men. As no clomiphene-treated man who has developed pyospermia has contributed to a pregnancy, we serially monitor semen analyses for its development.
