Electronic Supplementary Material Table S3 Outcome Assessment Following AAS Cessation

Electronic Supplementary Material Table S3 Outcome assessment following AAS cessation

First author
(Year of publication) / N / Duration of AAS cessation / Outcomea / Recovery period of hormone, semen and testicular impairment following AAS cessation
Cohort study
Al-Janabi (2011) [45] / 24 / 12 weeks / Users (n=16)
Clinical examination
NR
Hormone analysis
LH: 82.35%
FSH: 108%
T: 12.90%
PRL: 5.20%
Semen analysis (baseline, n=16; week 12, n=7)
Liquefaction: 12.97%
Semen volume: -9.09%
Sperm concentration: 84.09%
Total sperm count: 67.55%
Sperm motility (categories a+b): -3.24%
Normal sperm morphology: 18.74%
Sperm agglutination: 184%
Round cells: 25.81%
Nonusers (n=8)
Clinical examination
NR
Hormone analysis
Hormone levels were not measured at 12 weeks but only at baseline.
Semen analysis (baseline, n=8; week 6, n=4)
Liquefaction: 27.08%
Semen volume: 21.05%
Sperm concentration: 58.81%
Total sperm count: 79.85%
Sperm motility (categories a+b): -10.05%
Normal sperm morphology: 3.06%
Sperm agglutination: -37.65%
Round cells: -44.90%
The majority of semen samples had normal whitish-opaque color.
Significant increase in sperm concentration and total sperm count within groups of users and nonusers (p<0.05) but still sperm concentration of the users was significantly lower compared to nonusers (p<0.05).
No significant difference in sperm motility percentages within each group and between the 2 groups.
The percentage of normal sperm morphology was within normal limits (>50%) in both groups. Although the percentages of normal sperms have increased in both groups, this increase was not significant (p>0.05).
The percentages of agglutinated sperm increased significantly in AAS users and in comparison with nonusers (p<0.05).
Round cells count increased in AAS users but this increase did not reach significance. However, round cells increased significantly compared to nonusers (p<0.05). / LH, FSH: low at 12 weeks
T: normal at 12 weeks
Sperm concentration: normal at 6-12 weeks
Sperm motility: low at 12 weeks
Garevik (2011) [41] / 35 / 12 months / Hormone analysisb(n=21 individuals who tested positive for nandrolone)
LH: 2.3±1.9 IU/L
FSH: 3.31±1.5 IU/L / LH, FSH: normal at 6 months
However, some subjects had a sustained suppression of LH and FSH for a period of 1 year.
Karila (2004) [39] / 18 / 6 monthsc / Minor users (total cumulative dose≤12,785 mg), n=9
Hormone analysis (at 6 months)
LH: 385.71%
FSH: 383.33%
T: -50.40%
SHBG: 100%
Semen analysis (at 6 months)
Semen volume: 0%
Sperm concentration: 110.26%
Sperm motility (categories a+b): 27.66%
Normal sperm morphology: 78.57%
Major users (total cumulative dose12,785 mg), n=9
Hormone analysis (at 6 months)
LH: 1400%
FSH: NA
T: -91.37%
SHBG: 69.23%
Semen analysis (at 6 months)
Semen volume: -25%
Sperm concentration: 170.37%
Sperm motility (categories a+b): 15%
Normal sperm morphology: 43.75%
One subject was diagnosed to be azoospermic during the whole withdrawal period.
Subjects that had ≥1 children
Before the study: 27.78% (5/18)
Six years after the study: 55.56% (10/18) / T: low at 6 months (major users=6.1±3.3 nmol/l)b
Sperm density: normal at 6 months (77±70x106/ml)b
Alen (1987) [36] / 15 / 13 weeks / Users (n=7)
Hormone analysis
LH: 70.21%
FSH: 300%
GH: -89.76%
T: -42.52%
E2: -58.33%
Cortisol: 5.66%
SHBG: 170.91%
Nonusers (n=8)
Hormone analysis
LH: no effect
FSH: no effect
T: no effect
E2: no effect
GH: no effect
Cortisol: no effect
SHBG: no effect / T: low at 9 weeks (14.6±8.8 nmol/l)b
All the other variables: normal at 9 weeks
Martikainen (1986) [46] / 6 / 3 weeks / Baseline to week 15d
Hormone analysis
Pregnenolone: -44.83%
17-hydroxypregnenolone: -15.34%
DHEA: -27.07%
5-androstene-3β,17β-diol: 31.51%
Progesterone: -68.18%
17-hydroxyprogesterone: -63.29%
Androstenedione: -38.05%
T: -87.59%
5α-dihydrotestosterone: -74.16%
E2: -25.93%
Pregnenolonesulphate: -3.97%
17-hydroxypregnenolone sulphate: 9.87%
DHEAS: -24.48%
Androstene-3β,17β-diol sulphate: 34.62%
Testosterone sulphate: -19.48%
hCG stimulation test
Hormone analysis
Pregnenolone: -8.15%
17-hydroxypregnenolone: 60.00%
DHEA: 2.08%
5-androstene-3β,17β-diol: -5.67%
Progesterone: 23.16%
17-hydroxyprogesterone: 32.22%
Androstenedione: 5.14%
T: 108.00%
5α-dihydrotestosterone: 27.06%
E2: 7.72%
Pregnenolonesulphate: -9.61%
17-hydroxypregnenolone sulphate: -14.54%
DHEAS: 1.96%
Androstene-3β,17β-diol sulphate: -5.80%
Testosterone sulphate: 2.33% / The impairment of testicular endocrine function lasted at least 16 weeks after drug withdrawal.
Alen (1985) [35] / 11 / 16 weeks / Users (n=5)
Hormone analysis
LH: 134.44%
FSH: 609.77%
PRL: -57.64%
T: -79.45%
Ε2: -87.77%
ACTH: -55.11%
Cortisol: -16.12%
Nonusers (n=6)
Hormone analysis
LH: -12.73%
FSH: 20.29%
PRL: -4.93%
T: -5.74%
Ε2: -3.85%
ACTH: -26.60%
Cortisol: -1.96% / LH, FSH: normal at 6-12 weeks
T: low at 12 weeks (9 nmol/l)
Ruokonen (1985) [44] / 9 / 16 weeks / Users (n=4)
Hormone analysis
Pregnenolone: -2.32%
Progesterone: -29.02%
17-hydroxypregnenolone: 28.85%
17-hydroxyprogesterone: 224.72%
DHEA: 19.72%
Androstenedione: -69.51%
5-androstene-3β,17β-diol: 30.77%
T: -78.43%
5α-dihydrotestosterone: -83.49%
Pregnenolonesulphate: 81.97%
17-hydroxypregnenolone sulphate: 11.84%
DHEAS: 15.60%
5-androstene-3β,17β-diol sulphate: 41.90%
T sulphate: -48.05%
SHBG: 227.27%
CBG: 14.29%
Nonusers (n=5)
Hormone analysis
Pregnenolone: NR
Progesterone: NR
17-hydroxypregnenolone: NR
17-hydroxyprogesterone: NR
DHEA: NR
Androstenedione: NR
5-androstene-3β,17β-diol: NR
T: NR
5α-dihydrotestosterone: NR
Pregnenolonesulphate: NR
17-hydroxypregnenolone sulphate: NR
DHEAS: NR
5-androstene-3β,17β-diol sulphate: NR
T sulphate: NR
SHBG: 1.22%
CBG: 14.29% / T: low at 16 weeks
T precursors: low at 16 weeks
SHBG: low at 16 weeks
Alen (1984) [47] / 14 / 6 months / Semen analysis
Sperm count (number of spermatozoa x 106/ml)b
Month 9: Users= 7.0±7.2, Nonusers= 100.3±58.8
Month 10.5: Users= 42.7±38.6, Nonusers= 106.0±35.4
Total number of spermatozoa (x 106)b
Month 9: Users= 24.5±28.2, Nonusers= 325.8±103.8
Month 10.5: Users= 202±21.2, Nonusers= 271.0±50.9
Acid phosphatase activity (x 106 IU/ml)e
Month 9: Users= 16.2±6.93, Nonusers= 28.1±9.5
Month 10.5: Users= 24.9±1.41, Nonusers= 23.1±1.6
Fructose concentration (mg/ml)e
Month 9: Users= 2.24±0.95, Nonusers= 2.20±0.21
Month 10.5: Users= 2.93±1.24, Nonusers= 2.68±0.25 / All men examined after the phase of taking AAS showed at least partial recovery of spermatogenesis, but the sperm production could not be considered to be normal until 4.5-7 months’ hormone-free period.
Schurmeyer (1984) [34] / 5 / Up to 24 weeks / Hormone analysis
LH: 3311.21%
FSH: 1260.96%
T: 320.00%
PRL: 10.53%
Semen/testicular analysis
Testicular volume: 66.04%
Seminal fructose: 23.58%
Ejaculate volume: -20.00%
Sperm density: increase
Sperm motility: increase
% normally formed sperm: increase
HOP teste: increase / LH, FSH: low at 16 weeks
T: normal at 6 months
Azoospermia persisted for 4 to 14 weeks after treatment. However, the volunteer who first became azoospermic had 0.2 million sperm per ml in the first post-treatment week. Seminal measurements had returned to normal 8 weeks after treatment in one subject, 14 weeks in another and 20 weeks in two. In the fifth subject recovery was slow; 24 weeks after treatment the sperm concentration was still only 1 million/ml. However, when subject 5 was investigated 30 weeks after treatment, all his seminal parameters had returned to normal: 33 million sperm/ml, 75% motile sperm, 51% normally formed sperm.
Holma (1977) [25] / 15 / 3 months / Sperm density, motility and morphology had recovered entirely in three months following AAS cessation. / Sperm density, motility, morphology: normal at 3 months
Cross-sectional study
Kanayama (2015) [53] / 55 / NA / Former users (n=19)b
Hormone analysis
Total T: 319±163 ng/dl
T<200 ng/dl: 5/19 (26%)
T: 200-348 ng/dl: 5/19 (26%)
T>348 ng/dl: 9/19 (47%)
Free T: 107±51 pg/ml (n=18 due to missing data)
LH: 3.9±2.5 mIU/ml
FSH: 4.7±4.6 mIU/ml
Semen/testicular analysisf
Testicular volume: 19.9±4 ml
Erectile function (IIEF): 26.3±6.1
Orgasmic function (IIEF): 9.3±1.4
Sexual desire (IIEF): 5.6±2.5
Intercourse satisfaction (IIEF): 11.6±1.8
Overall satisfaction (IIEF): 6.3±3.1
Total (IIEF): 60.8±10.8
Nonusers (n=36)b
Hormone analysis
Total T: 449±153 ng/dl
T<200 ng/dl: 1/36 (3%)
T: 200-348 ng/dl: 7/36 (19%)
T>348 ng/dl: 28/36 (78%)
Free T: 132±49 pg/ml (n=18 due to missing data)
LH: 4.6±2.1 mIU/ml
FSH: 5.2±4.1 mIU/ml
Semen/testicular analysisf
Testicular volume: 22.2±3.4 ml
Erectile function (IIEF): 27.6±4.3
Orgasmic function (IIEF): 9.5±0.9
Sexual desire (IIEF): 7.8±1.4
Intercourse satisfaction (IIEF): 11.5±2.9
Overall satisfaction (IIEF): 7.2±2.1
Total (IIEF): 64.3±8.6 / Five AAS users showed testosterone levels below 200 ng/dl despite abstinence from AAS for 3-26 months.
Urhausen (2003) [38] / 31 / NA / Ex-users (n=14)
Hormone analysisg
T: 14.6±4.2 (6.6–22.2) nmol/l
SHBG: 32.0±14.8 (17.0–76.9) nmol/l
E2: 90.3±30.5 (24.2–147) pmol/l
LH: 3.24±1.34 (0.11–5.39) IU/l
FSH: 5.08±1.86 (2.95–8.24) IU/l / T: low in two ex-users after ≥1 year (6.6 and 9.0 nmol/l, respectively)
Pope (1994) [49] / 156 / NA / Testicular lengthb
Users (n=88)
Total users: 44.4±6.2 mm
Past users: 46.1±5.5 mm
Current users: 42.1±6.5 mm
Nonusers (n=68)
49.5±6.3 mm / NR
Knuth (1989) [42] / 82 / NA / Athletes with a drug-free interval of <3 months (n=11)
Hormone analysish
LH: 2.7±0.6 U/L
FSH: 2.1±0.6 U/L
T: 13.2±1.8 nmol/L
Dihydrotestosterone: 2.0±0.3 nmol/L
E2: 274±21 pmol/L
Semen analysis
1 man was azoospermic
3 men showed severe oligoospermia
1 man had sperm concentrations in the oligozoospemic range
Impaired motile sperm (compared to nonusers)
No difference for the proportion of normally formed sperm (compared to nonusers)
Athletes with a drug-free interval of >4 months (n=11)
Hormone analysish
LH: 4.5±1.1 U/L
FSH: 3.2±0.5 U/L
T: 16.1±5.1 nmol/L
Dihydrotestosterone: 2.7±0.9 nmol/L
E2: 184±17 pmol/L
Semen analysis
Sperm concentrations within the range of normal controls
3 men were severely ologozoospermic
1 man showed moderate oligozoospermia
Reduced sperm motility (compared to nonusers)
Reduced normal sperm morphology (compared to nonusers) / Normal levels of LH, FSH and T compared to normal values.

Abbreviations

RCT: randomized controlled trial, AAS: anabolic androgenic steroids, N: total number of participants, n: number of participants in group, NR: not reported, NA: not applicable, T: testosterone, Ε2: estradiol, PRL: prolactin, SHBG: sex hormone-binding globulin, CBG: cortisol binding globulin, hCG: human Chorionic Gonadotropin, HOP: heterologous ovum penetration, IIEF: International Index of Erectile Function, SEM: standard error of mean.

Footnotes

a Changes represent the percent change from baseline and have been assessed using the following formula: [(mean at the end following AAS cessation - mean at the start following AAS cessation)/mean at the start following AAS cessation]x100%.

b Values are expressed as mean±SD.

c Follow-up is 6 months for hormone and semen analysis, and 6 years for fertility assessment (number of children conceived and successful pregnancies).

d Values refer to the difference of the mean at the end following AAS cessation (15 weeks) minus the mean at the start of AAS use, divided to the mean at the start of AAS use.

e HOP test: % eggs penetrated

f Scores on erectile function, orgasmic function, intercourse satisfaction and total score, are restricted to men reporting at least one sexual partner in the past month (15 AAS users and 32 nonusers).

g Values are expressed as mean±SD (minimum-maximum).

h Values are expressed as mean±SEM.

Conversion to International System of Units (SI)

·  Testosterone: multiply ng/dl with 0.0347 to convert to nmol/l.