IN PREVIOUS PAPERS 8 9

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1 Diminished Response of the Circulating Eosinophils to Adrenalin in Azoospermic and Oligospermic Patients J. Landau, M.D., B. Eckerling, M.D., and S. Feldman, M.D. IN PREVIOUS PAPERS 8 9 impairment of dark-adaptation in a number of oligospermic patients was reported. These results were interpreted as a syndrome of oligospermia and impaired dark-adaptation of central origin, and the opinion was expressed that the mechanism of this syndrome may be conditioned by the pituitary-hypothalamic system. This observation led us to study the effect of adrenalin on the circulating eosinophils in azoospermic and oligospermic patients. The test was introduced by Recant et al. 1 in order to evaluate the integrity of the hypothalamo-pituitary-adrenocortical system, and is based on the four-hour fall in circulating eosinophils after the subcutaneous injection of 0.3 mg. of adrenalin. According to these authors a fall of 50 per cent or more in circulating eosinophils excludes both pituitary ACTH and adrenocortical deficiency. The adrenalin acts on the hypothalamus, and the effect on the eosinophils is dependent on an intact chain of stimuli from the anterior hypothalamus to the anterior lobe of the pituitary and ultimately to the adrenal cortex, which liberates cortical steroids, which in tum cause the eosinopenia. MATERIAL AND METHODS A group of 21 patients, either oligospermic or azoospermic, ranging in age from 22 to 40 years, was examined. These patients were in pedect From the Department of Ophthalmology and the Department of Obstetrics and Gynaecology, Rothschild-Hadassah-University Hospital and the Hebrew University Hadassah Medical School, Jerusalem, Israel. 285

2 286 LANDAU ET AL. [Fertility & Sterility health, with no history of local urogenital disturbances or inflammatory diseases and without local pathologic findings which could explain the oligospermia or azoospermia. A control group of 27 young men selected at random was examined under similar conditions. The tests were performed in the afternoon hours. The first count was taken one hour after the last meal, after which 0.3 mg. of adrenalin was injected subcutaneously. Four hours later a second eosinophil count was taken. During this interval no food was taken by the patients, but they were allowed to drink water, and they enjoyed complete rest. Eosinophils were counted by the method of Forsham et al., 5 except that freely flowing capillary blood was used. Both sides of a 0.9-mm. 2 Levy counting chamber of 0.1 mm. depth were counted and the results averaged. In the case of 3 azoospermic patients who had not previously responded to adrenalin, 25 mg. of ACTH was injected intramuscularly and the eosinophils were counted immediately before and four hours after the injection. RESULTS Of the 21 patients with disturbed spermatogenesis who were examined, 13 did not show a drop in the circulating eosinophils, four hours after 0.3 mg. of adrenalin had been injected subcutaneously. In the remaining 8 patients a decrease ranging from 4 per cent to 35 per cent was observed: in 4 of them the drop amounted to less than 20 per cent and in the other 4 to less than 36 per cent. The average decrease in these 8 cases was 21 per cent (Table 1, Fig. 1). In the control group of 27 young males selected at random, 21 showed a drop in the circulating eosinophils ranging from 19 per cent to 85 per cent (actually only 1 displayed a drop of less than 20 per cent). The average decrease in this group was 42 per cent. In 6 cases no decrease in the circulating eosinophils occurred after 0.3 mg. of adrenalin had been administered subcutaneously (Table 2, Fig. 1). The 3 azoospermic patients who received 25 mg. ACTH showed a drop in the circulating eosinophils of 29 per cent, 37 per cent, and 65 per cent respectively, the average being 44 per cent. DISCUSSION The results obtained in this study may indicate that in the majority of azoo- and oligospermic patients examined the integrity of the hypothalamo ~-

3 Vol. 4, No. 4, 1953] CIRCULATORY EOSINOPHILS 287 pituitary-adrenocortical system is disturbed. Out of 21 patients, 13 did not respond at all and showed, instead, a rise of the circulating eosinophils, while the other 8 showed a diminished response to adrenalin. In the control group, 21 out of 27 young males examined at random showed an average lsi I 'to IJO Ito I I 0 IOQ '0 &o?o '0 So ItO Jo,20 IQ 0.. IO to. 3o l,o So o '0 100 Fig. 1. Percentage change of the c~culating eosinophils in the control series (left) and in either oligospermic or azoospermic patients (right) four hours after subcutaneous injection of 0.3 mg. adrenalin.

4 288 LANDAU ET AL. [Fertility & Sterility drop of 42 per cent, 2 showed no drop, and 4 displayed a rise in the circulating eosinophils. According to Recant et al., 10 the mean fall of eosinophils in normal subjects four hours after subcutaneous injection of 0.3 mg. adrenalin is 62 per cent, and every normal subject shows a drop of at least 50 per cent. Other authors have reported lower figures. Thus Broch and Haugen, 3 in a control group of 23 persons, found a decrease of eosinophils in 18 cases, no change TABLE 1. Percentage Change of Circulating Eosinophiles Four Hours After the Subcutaneous Injection of 0.3 mg. Epinephrine in Oligospermic and Azoospermic Patients Before After Percentage Name Age Diagnosis epinephrine epinephrine change s.s. 40 Azoospermia G.I. 38 Azoospermia P.A. 30 Oligospermia M.I. 37 Azoospermia S.D. 30 Azoospermia M.H. 37 Azoospermia 132 ll5-14 E. A. 39 Azoospermia 99 13~ +33 B.M. 31 Azoospermia A.M. 30 Azoospermia C.H. 26 Azoospermia A.A. 40 Oligospermia B.M. 29 Oligospermia K.R. 40 Azoospermia 77 llo +43 M.A. 22 Oligospermia A.A. 24 Azoospermia llo N.A. 25 Oligospermia Z.N. 25 Azoospermia F.S. 30 Azoospermia L.I. 31 Azoospermia R.M. 40 Azoospermia G.M. 40 Azoospermia 88 ' in 2 cases, and a rise in 3 cases. Samuels, in a group of 20 healthy people, found an average drop of 42 per cent, four hours after an intramuscular injection of 1 mg. of adrenalin. Fisher and Fisher examined a group of 25 healthy persons and found that in 3 cases the drop in circulating eosinophils was 2.5 per cent, 10 per cent, and 14 per cent respectively, while in 1 case there was a rise of 29 per cent. Sauer injected 0.5 mg. of adrenalin and fotmd a decrease of less than 38 per cent in 6 out of 20 cases examined

5 Vol. 4, No. 4, 1953] CIRCULATORY EOSINOPHILS 289 The examinations in this study were pedormed in the afternoon hours with one hour of fasting only, since it has been shown by various authors that there is a drop of the circulating eosinophils in the morning hours as a part of the spontaneous diurnal variations of the eosinophil TABLE 2. Percentage Change of Circulating Eosinophiles Four Hours After the Subcutaneous Injection of 0.3 mg. Epinephrine in Normal Individuals Selected at Random Before After Percentage Name Age epinephrine epinephrine change O.R B.Z llo -71 S.T. 40 llo B.M A.R llo -29 M.S. 20 llo s.s. 19 llo B.S llo -50 A.l H.M K.S M.O A.B K.N S.M B.C D.B C.M M.E B.M A.l S.R M.F. 25 llo D.S. 31 llo llo 0 L.Z A.R R.Z count. This drop is even more marked during fasting. 2 In the afternoon hours there is a slow spontaneous rise of the circulating eosinophils. Fisher and Fisher pointed out that between 11:00 A.M. and 3:00P.M. there were less spontaneous variations of the eosinophil count than between 8:00A.M. and noon. The authors mentioned 3 4 ' 12 ' 13 performed their tests during the

6 290 LANDAU ET AL. [Fertility & Sterility morning hours, their patients fasting. The different times of the examination may probably account for the slightly lower response obtained in our control group. Very recently, Swanson et al. stated that the morning is an unsuitable time for measuring the eosinophil response to an agent, because of the spontaneous diurnal variations, and added that if it is important to know the relation of a fall of the circulating eosinophils to a specific agent, the test should be pedormed in the afternoon. They stated further that the effect of normal meals on the eosinophil count can be disregarded and that fasting is unnecessary. From the results obtained in this study it may be assumed that the lack of response of the circulating eosinophils to adrenalin may possibly express, in at least a large number of oligospermic and azoospermic patients, a disturbance in the hypothalamo-pituitary-adrenocortical system. The question arises as to where the disturbance might be localized in this system, either in the adrenal cortex or in the hypothalamo-pituitary centers. The patients examined did not show any clinical signs of adrenocortical insufficiency, and the fact that 3 patients-who did not respond at all to adrenalin-showed a significant decrease of the circulating eosinophils after the injection of 25 mg. of ACTH, may.indicate that the defect does not lie in the adrenal cortex, but more probably in the higher centers. It must be emphasized that the patients examined in this study were in pedect health, and did not show any pituitary disturbances, nor any other endocrine derangements. It may therefore be inferred that the defect is possibly located in the hypothalamus. Anderson et al. reported a case of a man suffering from a glioma of the floor of the third ventricle with an essentially normal hypophysis and "intrinsic testicular type of hypogonadism." They postulate that the failure of the seminiferous tubules in their patient-as well as in those of Kleinfelter-Reifenstein and Albright-was caused by a lesion of the hypothalamus. Hume and Wittenstein found that electrolytic lesions in the anterior hypothalamus in dogs abolished the usual response of the circulating eosinophils to adrenalin, but not to ACTH. As the response of the circulating eosinophils to adrenalin varies on different occasions even in the same person 2 it is clear that such a response in a single case could not express the integrity of the hypothalamo-pituitaryadrenocortical system. and can therefore not be used as a clinical test. It is

7 Vol. 4, No. 4, 1953] CIRCULATORY EOSINOPHILS 291 only the average response of a homogeneous group of persons, compared with a control group, which can justify the evaluation of the hypothalamopituitary-adrenocortical system in the given group. SUMMARY The effect of adrenalin on circulating eosinophils was studied in 21 patients, either oligospermic or azoospermic. Of this group, 62 per cent did not show a fall of the circulating eosinophils, while in a control group of 27 young healthy males selected at random 22 per cent did not show a drop of the eosinophils four hours after the subcutaneous injection of 0.3 mg. adrenalin. In 3 azoospermic patients, who did not respond to adrenalin, the injection of 25 mg. of ACTH caused a drop in circulating eosinophils. The question of localization of the disturbance in the hypothalamo-pituitaryadrenocortical system is discussed. It seems probable that in some oligospermic and azoospermic patients the hypothalamic region may be the site of the disturbance. It may thus be assumed that yet another sign might be added to the hypothalamo-pituitary syndrome of oligospermia and impaired dark-adaptation-the lack of response of the circulating eosinophils to adrenalin. REFERENCES 1. ANDERSON, E., HAYMAKER, W., and RAPPAPORT, H. Am. Pract. 1:40, BEsT, W. R., and SAMTER, M. Blood 6:61, BRoCH, 0. J., and HAuGEN, H. N. Acta endocrinol. 5:143, FISHER, B., and FISHER, E. R. Am.]. M. Sc. 221:121, FoRSHAM, P. H., THORN, G. W., PRUNTY, F. T. G., and HILLS, A. G. ]. Clin. Endocrinol. 8:15, HALBERG, F., VIsSCHER, B., FLINK, E. B., BERGE, K., and BocK, F. journal-lancet 71:312, HuME, D. M., and WITTENSTEIN, G. I. In Proceedings of First Clinical ACTH Conference. Philadelphia, Blakiston, 1950, p LANDAU, J., and PoLISHUK, Z. Acta med. orient. 7:153, LANDAU, J., EcKERLING, B., and PoLISHUK, Z. Harefuah 41:193, RECANT, L., HuME, D. M., FoRSHAM, P. H., and THORN, G. W. ]. Clin. Endocrinol. 10:187, Run, F. Acta psychiat. et neurol., Supp. 40, SAMUELS, A. J. ]. Clin. Investigation 30:941, SAUER, G. C. ]. Invest. Dermat. 16:111, SwANSON, J. N., BAUER, W., and RoGES, M. Lancet 262:129, 1952.