Journal of Clinical Endocrinology & Metabolism
, doi:10.1210/jc.2008-0121
The Journal of Clinical Endocrinology & Metabolism Vol. 93, No. 6 2202-2205
Copyright © 2008 by The Endocrine Society
Effects of an Early Postnatal Treatment of Hypogonadotropic Hypogonadism with a Continuous Subcutaneous Infusion of Recombinant Follicle-Stimulating Hormone and Luteinizing Hormone
P. Bougnères,
M. François,
L. Pantalone,
D. Rodrigue,
C. Bouvattier,
E. Demesteere,
D. Roger and
N. Lahlou
Department of Pediatric Endocrinology (P.B., M.F., L.P., D.R., C.B.) and Pediatric Hormone Laboratory (N.L.), Hôpital Saint Vincent de Paul, Pôle d’Endocrinologie Cochin, University René Descartes, F-75014 Paris, France; Serono France (E.D.) 92658 Boulogne Cedex, France
Address all correspondence and requests for reprints to: P. Bougnères, Pediatric Endocrinology, Hôpital Saint Vincent de Paul, Pôle d’Endocrinologie Cochin, University René Descartes, F-75014 Paris, France. E-mail: bougneres{at}paris5.inserm.fr.
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Abstract
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Background: The neonatal-midinfancy surge in pulsatile gonadotropin secretion is attributable to an increase in GnRH pulse amplitude and is associated with a rapid expansion of Leydig and Sertoli cell populations with concomitant surges in testosterone, inhibin, and anti-Mullerian hormone production as well as an increase in testicular volume. Boys with congenital hypogonadotropic hypogonadism (HH) do not activate these processes. A potential cause for azoospermia and infertility in adult life is deficient proliferation of immature Sertoli cells before and during puberty due to the absence of FSH.
Objective: The objective of the study was to investigate whether early postnatal continuous sc infusion of gonadotropins could mimic the physiological growth of testes and to evaluate responses of the Leydig and Sertoli cells to early gonadotropin replacement.
Design and Methods: Two neonates (P1 with hypotuitarism and P2 with HH) with micropenis and microorchidism were treated for 6 months with high doses of recombinant LH and FSH (a gift of Luveris and Gonal-F from Serono, Lyon, France) delivered sc with an insulin pump.
Results: Gonadotropin continuous sc infusion increased mean serum LH and FSH to normal or supranormal levels. Mean testosterone increased from undetectable levels to 7.6 and 5.2 nmol/liter, respectively, in P1 and P2. Inhibin B and anti-Müllerian hormone increased to normal levels. Mean testicular volume increased from 0.45 to 0.57 ml at birth to 2.10 ml at 7 months. Stretched penile length increased from 8 to 30 mm (P1) and 12 to 48 mm (P2).
Conclusions: The present regimen induced physiological postnatal testes growth and high-normal activation of Leydig and Sertoli cells.
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Introduction
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At birth hypogonadotropic hypogonadism (HH) is revealed by a micropenis with or without cryptorchidism (1, 2). HH in the male infant can be isolated or associated with other pituitary hormone deficiencies (congenital hypopituitarism). The infantile GnRH-gonadotropin spurt allows to make the diagnosis of HH by using this brief window of normally increased FSH, LH, testosterone, and inhibin B values (3). If the diagnosis of euosmic HH is missed in infancy, it will be made only much later during adolescence or even adulthood. The diagnosis of HH in the male newborn is supported by detecting low levels of plasma LH, FSH, testosterone, and inhibin B and lack of LH response to the iv administration of GnRH (2, 4, 5, 6). Our current knowledge of HH genetics can be separated into mutations associated with multiple pituitary hormone deficiencies, including gonadotropin deficiency (e.g. Prophet of Pit-1, HESX1, LIM class of homeodomain protein-3, plant homeodomain-like finger gene-6) and isolated HH [e.g. Kallmann syndrome, FGFR1 (KAL2), GNHR, G protein-coupled receptor 54 (KiSS1-derived peptide receptor), small nuclear ribonucleoprotein polypeptide SmN (Prader-Willi), leptin, leptin receptor, dosage-sensitive sex reversal-adrenal hypoplasia congenita critical region on the X chromosome, gene 1].
Infants with HH and micropenis require testosterone therapy to increase the length of their penis. Some clinicians have used repeated injections of human chorionic gonadotropin (hCG). A single study has proposed that male infants with hypothalamic hypogonadism be given a course of recombinant human (rh) FSH and rhLH injections (7). This treatment increased testicular size, presumably because FSH increased the number of Sertoli cells (as reflected in an increase in plasma inhibin B levels), without increasing testosterone concentrations.
Prepubertal treatment of HH with rhFSH stimulates inhibin B production and testicular growth (8). The treatment of many patients with HH condition is attempted only at adolescence or early adulthood. In addition to androgen replacement therapy, fertility has become an increasingly important concern. In adolescents or adult patients treated with monotherapy or combinations of hCG, human menopausal gonadotropins (hMG), and rhFSH (9, 10, 11, 12, 13), results depend on pretreatment testicular size and whether or not there has been cryptorchidism.
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Patients and Methods
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Patient 1 was the first child of nonconsanguinous parents. The 46,XY patient was referred at 2 wk because of micropenis (7 mm). Testes were intrascrotal but very small (< 10 mm diameter). He had a total lack of LH and FSH as well as testosterone (Table 1
). Inhibin B and anti-Mullerian hormone (AMH) were below the lower normal limit (10) (Table 1). A single dose (100 IU/kg) of hCG increased testosterone to 0.08 nmol/liter. IGF-I level was 14 ng/ml, prolactin 45 ng/ml, fasting cortisol 3 µg/dl with ACTH 6 pg/ml, and T4 5.1 µg/dl with TSH 4.7 µU/ml. MRI found an interrupted stalk and hypoplastic pituitary with ectopic functional neurohypophysis. The child received 4 mg hydrocortisone, 20 µg L-(T4), and 0.5 mg Saizen rhGH per day. At the age of 8 wk, he began treatment with continuous sc infusion (CSI) at a mean infusion rate of 56 IU rhLH and 67 IU of rhFSH per day. CSI was well tolerated and stopped at 25 wk of life.
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TABLE 1. Serum concentrations of reproductive hormones before, during, and after treatment of the two studied infants with gonadotropin CSI
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Patient 2 was an Asian child adopted by French parents. The patient was referred at the age of 14 wk because of micropenis (12 mm). Testes were intrascrotal and small (<10 mm diameter). The karyotype was 46,XY. LH, FSH, and testosterone were all undetectable and inhibin B and AMH persistently below the normal range (10) (Table 1
). A single dose (100 IU/kg) of hCG increased testosterone to 0.47 nmol/liter. Other pituitary axes were normal. No mutation of KAL1 nor FGFR1 was found (Dr. C. Dodé, Laboratory of Molecular Genetics, Cochin). At 20 wk, the child began treatment with CSI at a mean infusion rate of 50 IU rhLH and 125 IU r FSH per day. CSI was well tolerated and stopped at 48 wk of life.
Drugs
The treatment started after written consent from both parents under institutional review board auspices. rhLH and rhFSH (Luveris 37.5 IU and Gonal-F 37.5 IU) were obtained from Serono (Geneva, Switzerland) and dissolved in solvent for infusion with a Paradigm insulin pump (Minimed, Northridge, CA) whose catheter was changed every 48–72 h. No adverse effects were observed at the infusion site.
Assays
Serum FSH, LH, testosterone, AMH, and inhibin B were measured as reported (14). Normal 95% ranges at 3 months (14) are presented in Table 1. Testes length and volume were evaluated using sonography.
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Results
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rhLH and rhFSH CSI increased serum gonadotropins to high values (14) (Table 1). Serum testosterone, inhibin B, and AMH reached concentrations in the high normal range (Table 1). Mean testicular length increased from 7 mm at birth to 25 mm at 7 months (P1) and from 8 to 21 mm at 7 months (P2). Testicular volume increased from 0.57 ml (P1) and 0.45 ml (P2) at birth to 2.10 ml at 7 months (P1 and P2). Stretched penile length increased from 8 mm to 21 mm (P1) and from 12 mm to 48 mm (P2).
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Discussion
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The natural history of the hypothalamic GnRH pulse generator-pituitary gonadotropin-gonadal apparatus in the male infant has been summarized by Grumbach (3) in a recent master review. FSH and LH levels are low in umbilical cord blood plasma owing to the inhibitory effect of the high circulating levels of placenta-derived estrogens on both the GnRH pulse generator and pituitary gonadotropes (5, 6, 15). Within a few minutes after birth, a brief surge in LH secretion is followed by an increase in the serum concentration of testosterone, which persists for about 12 h (16, 17). FSH levels during the first neonatal days are low. After the fall in circulating placentally derived estrogens during the first few days after birth, the sex steroid inhibited pituitary gonadotropin-gonadal system is activated around 1–2 wk of age (18); the increase in FSH and LH secretion evokes increased secretion of gonadal sex steroids (19). This transient surge in the hypothalamic GnRH pulse generator-pituitary gonadotropin-gonadal apparatus, sometimes called the minipuberty of early infancy (3), is associated with a pubertal concentration of circulating LH and FSH. In the male infant, serum FSH and LH levels increase during the second postnatal week, reach a maximum between 1 and 3 months and decline by about age 6 months to the low levels that are present until the onset of puberty. Serum testosterone follows the pattern of LH secretion, reaching a peak at about 3 months with a subsequent decline to prepubertal values by 6–9 months of age (5, 19, 20). Soon after birth Leydig cell numbers increase to reach a peak at about 3 months of age, followed by striking regression and apoptosis of the fetal (and infantile) Leydig cells (21, 22, 23).
Circulating inhibin B increases soon after birth to reach a peak at 4–12 months, decreasing to a nadir from 3 to 9 yr and increasing again with the onset of puberty (20). Its profile reflects the continued wave of Sertoli cell proliferation (which begins in the fetus) during infancy, which continues at a low level during childhood and increases again with the onset of puberty and persists until late puberty when terminal differentiation of Sertoli cells occurs (24). In HH, the plasma concentration of inhibin B remains low (25, 26). In males, AMH/Mullerian-inhibiting substance, the earliest Sertoli cell hormone secretion in the human fetus, is present in cord blood; rises rapidly in concentration during the first month, reaching a peak level at about 6 months of age; and then slowly declines during childhood, falling to low levels in puberty (27, 28). Its secretion is mainly constitutive.
In summary, the neonatal-midinfancy surge in pulsatile gonadotropin secretion is attributable to an increase in GnRH pulse amplitude and is associated with a rapid expansion of Leydig and Sertoli cell populations with concomitant surges in testosterone, inhibin, and AMH production as well as an increase in testicular volume due to increase in seminiferous tubular cell mass (90% made of Sertoli cells) and tubule length (23, 29). Sertoli cell number, including postnatal proliferation, is a determinant of spermatogenic function (reviewed in Ref. 30). The total number of germ cells increases up to about 100 d (31), indicating mitotic activity, and then decreases mainly by apoptosis (32). According to these phenomena, the suggestion reviewed by Grumbach (3) is that the transient postnatal to midinfancy function of the GnRH pulse generator in the male infant is related to future spermatogenic function and fertility (25, 26, 30).
In an attempt to mimic the physiological development by replacing gonadotropins early in life, the current treatment doses were initially inspired by a case of infantile HH treated with LH and FSH injections (7) and then derived empirically from our own observations. The treatment was successful in inducing testicular and penile growth. The dosage augmented LH and FSH to the normal range for 3-month-old boys. The results were comparable with those from studies in adult volunteers, showing a significant increase in serum concentrations of FSH and LH within 12 h and a more rapid decline of LH than of FSH (33). Serum testosterone values were high throughout treatment, and thus, unlike the gonadotrope, Leydig cells do not seem to need intermittency of trophic hormone delivery. The dose of FSH was effective in increasing both FSH and inhibin B concentrations to normal. In adults, serum inhibin B concentrations are negatively correlated with FSH, but this feedback mechanism is not observed in the first 2 yr of life (20).
In young adults with congenital HH, the combined rhFSH/hCG stimulation of the testis suppresses AMH secretion and lowers inhibin levels, whereas rhFSH alone increases AMH and inhibin (34). This is interpreted as a suppressive effect of LH-driven testicular androgens outweighing the stimulation of Sertoli cells by rhFSH. This did not occur in the two reported infants, despite the strong LH stimulation of testosterone secretion, suggesting that the suppressive effect of testicular androgens is not functional during the first months of life. This resistance of postnatal Sertoli cells to androgens is reminiscent of observations in postnatal mouse whose AMH is not inhibited by intratesticular testosterone due to the lack of androgen receptors in Sertoli cells (35).
Another observation is the relative resistance of the postnatal Sertoli cells of our HH infants to rhFSH because very high serum concentrations of FSH (8-fold the upper limit of normal in P1 and 18-fold in P2) were needed to obtain inhibin B and AMH levels within the normal range. For comparison, FSH concentrations around 11–14 IU/liter suffice to induce inhibin B and AMH increases in adult HH patients (35). In conclusion, early postnatal treatment of HH with CSI of rhFSH and rhLH induced testicular and penile growth and augmented serum concentrations of testosterone, inhibin B, and AMH, closely mimicking the physiological development that occurs early after birth. This treatment increased testicular size, presumably by FSH-induced increase of the number of Sertoli cells, and revealed a complete resistance of Sertoli cells to the effect of androgens and a degree of resistance of these cells to FSH, compared with mature Sertoli cells. It remains to be seen whether early gonadotropin replacement will improve the reduced fertility potential often seen in adult patients with congenital HH despite hormonal treatment.
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Acknowledgments
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We thank M. A. Frey for the clinical care of P2.
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Footnotes
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P.B. designed the study, set gonadotropin dosage, and wrote the manuscript; M.F. started CSI in P1 and C.B. in P2; L.P. collected the data; N.L. performed the hormone measurements and provided studies in normal infants. D.R. referred patient 2.
Disclosure Statement: The authors have nothing to disclose.
First Published Online April 1, 2008
Abbreviations: AMH, Anti-Mullerian hormone; CSI, continuous sc infusion; hCG, human chorionic gonadotropin; HH, hypogonadotropic hypogonadism; rh, recombinant human.
Received January 18, 2008.
Accepted March 20, 2008.
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References
|
|---|
- Bin-Abbas B, Conte FA, Grumbach MM, Kaplan SL 1999 Congenital hypogonadotropic hypogonadism and micropenis: effect of testosterone treatment on adult penile size. Why sex reversal is not indicated. J Pediatr 134:579–583[CrossRef][Medline]
- Lovinger RD, Kaplan SL, Grumbach MM 1975 Congenital hypopituitarism associated with neonatal hypoglycemia and microphallus: four cases secondary to hypothalamic hormone deficiencies. J Pediatr 87:1171–1181[CrossRef][Medline]
- Grumbach MM 2005 A window of opportunity: the diagnosis of gonadotropin deficiency in the male infant. J Clin Endocrinol Metab 90:3122–3127[Abstract/Free Full Text]
- Grumbach MM, Gluckman PD 1994 The human fetal hypothalamus and pituitary gland: the maturation of neuroendocrine mechanisms controlling the secretion of fetal pituitary growth hormone, prolactin, gonadotropin, adrenocorticotropin-related peptides, and thyrotropin. In: Tulchinsky D, Little AB, eds. Maternal-fetal endocrinology. 2nd ed. Philadelphia: W. B. Saunders; 193–261
- Grumbach MM, Kaplan SL 1990 The neuroendocrinology of human puberty: an ontogenetic perspective. In: Grumbach MM, Sizonenko PC, Aubert ML, eds. Control of the onset of puberty. Baltimore: Williams, Wilkins; 1–62
- Kaplan SL, Grumbach MM, Aubert ML 1976 The ontogenesis of pituitary hormones and hypothalamic factors in the human fetus: maturation of central nervous system regulation of anterior pituitary function. In: Greep R, ed. Recent progress in hormone research. New York: Academic Press; 32:161–243
- Main KM, Schmidt IM, Toppari J, Skakkebaek NE 2002 Early postnatal treatment of hypogonadotropic hypogonadism with recombinant human FSH and LH. Eur J Endocrinol 146:75–79[Abstract]
- Raivio T, Toppari J, Perheentupa A, McNeilly AS, Dunkel L 1997 Treatment of prepubertal gonadotrophin-deficient boys with recombinant human follicle-stimulating hormone. Lancet 350 263–264
- Barrio R, de Luis D, Alonso M, Lamas A, Moreno JC 1999 Induction of puberty with human chorionic gonadotropin and follicle-stimulating hormone in adolescent male with hypogonadotropic hypogonadism. Fertil Steril 71: 244–248
- European Metrodin HP Study Group 1998 Efficacy and safety of highly purified urinary follicle-stimulating hormone with human chorionic gonadotropin for treating men with isolated hypogonadotropic hypogonadism. Fertil Steril 70:256–262[CrossRef][Medline]
- Fuse H, Akashi T, Kazama T, Katayama T 1996 Gonadotropin therapy in males with hypogonadotropic hypogonadism: factors affecting induction of spermatogenesis after gonadotropin replacement. International J Urol Nephrol 28:367–374[CrossRef]
- Burgues S, Calderon M 1997 Subcutaneous self-administration of highly purified follicle stimulating hormone and human chorionic gonadotrophin for the treatment of male hypogonadotropic hypogonadism. Spanish Collaborative Group on Male Hypogonadotropic Hypogonadism. Hum Reprod 12:980–986[Abstract/Free Full Text]
- Bouvattier C, Tauber M, Jouret B, Chaussain J-L, Rochiccioli P 1999 Gonadotropin treatment of hypogonadotropic hypogonadal adolescents. J Pediatr Endocrinol Metab 12:339–344
- Lahlou N, Fennoy I, Carel JC, Roger M 2004 Inhibin B and anti-Müllerian hormone, but not testosterone levels, are normal in infants with nonmosaic Klinefelter syndrome. J Clin Endocrinol Metab 89:1864–1868[Abstract/Free Full Text]
- Massa G, de Zegher F, Vanderschueren-Lodeweyckx M 1992 Serum levels of immunoreactive inhibin, FSH, and LH in human infants at preterm and term birth. Biol Neonate 61:150–155[CrossRef][Medline]
- Corbier P, Dehennin L, Castanier M, Mebazaa A, Edwards DA, Roffi J 1990 Sex differences in serum luteinizing hormone and testosterone in the human neonate during the first few hours after birth. J Clin Endocrinol Metab 71:1344–1348[Abstract/Free Full Text]
- de Zegher F, Devlieger H, Veldhuis JD 1992 Pulsatile and sexually dimorphic secretion of luteinizing hormone in the human infant on the day of birth. Pediatr Res 32:605–607[Medline]
- Schmidt H, Schwarz HP 2000 Serum concentrations of LH and FSH in the healthy newborn. Eur J Endocrinol 143:213–215[Abstract]
- Forest MG 1990 Pituitary gonadotropins and sex steroid secretion during the first two years of life. In: Grumbach MM, Sizonenko PC, Aubert ML, eds. Control of the onset of puberty. Baltimore: Williams and Wilkins; 451–477
- Andersson AM, Toppari J, Haavisto AM, Petersen JH, Simell T, Simell O, Skakkebaek NE 1998 Longitudinal reproductive hormone profiles in infants: peak of inhibin B levels in infant boys exceeds levels in adult men. J Clin Endocrinol Metab 83:675–681[Abstract/Free Full Text]
- Nistal M, Paniagua R, Regadera J, Santamaria L, Amat P 1986 A quantitative morphological study of human Leydig cells from birth to adulthood. Cell Tissue Res 246:229–236[CrossRef][Medline]
- Lejeune H, Habert R, Saez JM 1998 Origin, proliferation and differentiation of Leydig cells. J Mol Endocrinol 20:1–25[CrossRef][Medline]
- Chemes HE 2001 Infancy is not a quiescent period of testicular development. Int J Androl 24:2–7[CrossRef][Medline]
- Cortes D, Müller J, Skakkebaek NE 1987 Proliferation of Sertoli cells during development of the human testis assessed by stereological methods. Int J Androl 10:589–596[Medline]
- Pitteloud N, Hayes FJ, Dwyer A, Boepple PA, Lee H, Crowley Jr WF 2002 Predictors of outcome of long-term GnRH therapy in men with idiopathic hypogonadotropic hypogonadism. J Clin Endocrinol Metab 87:4128–4136[Abstract/Free Full Text]
- Sharpe RM, Fraser HM, Brougham MF, McKinnell C, Morris KD, Kelnar CJ, Wallace WH, Walker M 2003 Role of the neonatal period of pituitary-testicular activity in germ cell proliferation and differentiation in the primate testis. Hum Reprod 18:2110–2117[Abstract/Free Full Text]
- Rey RA, Belville C, Nihoul-Fékéte C, Michel-Calemard L, Forest MG, Lahlou N, Jaubert F, Mowszowicz I, David M, Saka N, Bouvattier C, Bertrand AM, Lecointre C, Soskin S, Cabrol S, Crosnier H, Leger J, Lortat-Jacob S, Nicolino M, Rabl W, Toledo SP, Bas F, Gompel A, Czernichow P, Josso N, et al 1999 Evaluation of gonadal function in 107 intersex patients by means of serum antimullerian hormone measurement. J Clin Endocrinol Metab 84:627–631[Abstract/Free Full Text]
- Lee MM, Misra M, Donahoe PK, MacLaughlin DT 2003 MIS/AMH in the assessment of cryptorchidism and intersex conditions. Mol Cell Endocrinol 211:91–98[CrossRef][Medline]
- Müller J, Skakkebaek NE 1983 Quantification of germ cells and seminiferous tubules by stereological examination of testicles from 50 boys who suffered from sudden death. Int J Androl 6:143–156[Medline]
- Sharpe RM, McKinnell C, Kivlin C, Fisher JS 2003 Proliferation and functional maturation of Sertoli cells, and their relevance to disorders of testis function in adulthood. Reproduction 125:769–784[Abstract]
- Müller J, Skakkebaek NE 1984 Fluctuations in the number of germ cells during the late foetal and early postnatal periods in boys. Acta Endocrinol (Copenh) 105:271–274[Abstract/Free Full Text]
- Berensztein EB, Sciara MI, Rivarola MA, Belgorosky A 2002 Apoptosis and proliferation of human testicular somatic and germ cells during prepuberty: high rate of testicular growth in newborns mediated by decreased apoptosis. J Clin Endocrinol Metab 87:5113–5118[Abstract/Free Full Text]
- Le Cotonnec JY, Loumaye E, Porchet HC, Beltrami V, Munafo A 1998 Pharmacokinetics and pharmacodynamic interactions between recombinant human luteinizing hormone and recombinant human follicle-stimulating hormone. Fertil Steril 69:201–209[CrossRef][Medline]
- Al-Attar L, Noël K, Dutertre M, Belville C, Forest MG, Burgoyne PS, Josso N, Rey R 1997 Hormonal and cellular regulation of Sertoli cell anti-Müllerian hormone production in the postnatal mouse. J Clin Invest 100:1335–1343[Medline]
- Young J, Chanson P, Salenave S, Noël M, Brailly S, O'Flaherty M, Schaison G, Rey R 2005 Testicular anti-mullerian hormone secretion is stimulated by recombinant human FSH in patients with congenital hypogonadotropic hypogonadism. J Clin Endocrinol Metab 90:724–728[Abstract/Free Full Text]
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Abstract
Introduction
