Subfertility is defined as a decrease in fertility characterized by an extended period of unsuccessful attempts to conceive, including several factors that may be reversed [1] . Subfertility is a relative condition since its characterization just signifies the potential for conception within a certain timeframe.

Empirical data indicates that around 84% of fertile couples will achieve conception within a span of one year, while a further 92% will do so within a two-year period [2] . Infertility and for that matter childlessness are often seen as a very distressing and unfortunate circumstance for individuals and couples, with far-reaching implications for their families and even the surrounding community. Childlessness is often associated with a range of adverse psychosocial outcomes, which may have significant and lasting effects. Some studies have reported that majority of couples with subfertility are from developing countries where detrimental effects of childlessness are experienced [3] [4] . The repercussions of childlessness may include marital instability, abuse and stigmatization particularly in Ghana [5] [6] .

Male factor subfertility accounts for about 40% - 50% of childlessness [7] [8] and this is alarming especially in developing countries. There are treatment options available for male subfertility and these may include assisted reproductive technologies such as: aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs) which have shown promise results however, methods are invasive, expensive, and may not guarantee success in every case [9] . The use of testosterone replacement therapy (TRT) has also gained popularity in the treatment of infertility [10] - [12] , however, the potential side effects such as decrease in sperm count and motility, increase blood pressure, increase estradiol, increase red blood cells, gynecomastia have been reported [13] [14] . Alternatively, the European Association of Urology (EAU) and American Urology Association (AUA) recommendations have addressed the use of beta-human chorionic gonadotropin (βhCG) in men with subfertility to improve fertility [15] [16] .

After implantation, the placenta releases human chorionic gonadotropin (hCG) which is an analog of luteinizing hormone (LH). The LH-like activity of hCG stimulate the Leydig cells to produce testosterone and sperm production mechanisms within the testes, thus, useful in the treatment of male infertility [17] [18] . The side effects of βhCG treatment of infertility are found to be minimal as La Vignera, Condorelli [19] reported increase prostate specific antigen (PSA), prostate volume, hematocrit and estradiol. Thus, determining the effects of βhCG administration in the treatment of male subfertility is a compelling avenue of research. Understanding its potential benefits, safety, and cost-effectiveness can pave the way for more effective and accessible treatments for male subfertility, providing hope and support for successful conception and parenthood. Hence, the study aims to assess the effect of βhCG therapy on gonadal function in men clinically confirmed with subfertility.

This study aims to determine the effects of human chorionic gonadotropin (βhCG) treatment outcomes on male subfertility in a Ghanaian population. Infertility affects over 70 million couples worldwide [24] with male subfertility accounting for 40% - 50% of these cases [7] . According to Bobjer, Bogefors [8] , male factor fertility account for about half of infertility cases with most common causes being spermatogenesis agents, hereditary factors, vascular illnesses, and semen abnormalities [25] . In this study, all participants were clinically confirmed and diagnosed with subfertility based on the World Health Organization’s criteria [26] .

An adequate pituitary secretion of LH and FSH for testosterone biosynthesis and spermatogenesis are prerequisites for sperm production. Male hypogonadism has been extensively treated with testosterone replacement therapy [16] , which usually includes aromatase inhibitors, βhCG, selective Estrogen receptor modulators and exogenous testosterone [27] . However, exogenous testosterone administration has been shown to inhibit the HPG axis leading to infertility in men [28] . In this study, βhCG administration was the treatment of choice for male subfertility. The literature on the uses of βhCG in men has focused on its use in hypogonadal men to preserve fertility. The βhCG has been indicated as part of an algorithm to assist in the recovery of endogenous testosterone biosynthesis by stimulating Sertoli cell maturation [29] .

There have been several studies that showed a significant improvement in gonadal function following βhCG therapy [30] - [33] . Shoshany, Abhyankar [34] reported an improvement in the serum testosterone level from a mean 21.1 nmol/L to 36.9 nmol/L in men with physiologically normal levels of testosterone after administering βhCG. Joseph, Gibbs [35] also evaluated the use of hCG in hypogonadal men who wished to preserve fertility and found that βhCG improved serum testosterone levels by 281.1 ng/dl (9.78 nmol/L), from 284.46 ng/dL (9.87 nmol/L) to 565.55 ng/dL (19.62 nmol/L) after 90 days therapy. This is consistent with the current study which found a significant increase in serum testosterone levels after 90 days of treatment with βhCG. This may be attributed to the restoration of the Leydig cell function from the endogenous activity of βhCG.

Other studies have also made reports on a similar trend on the effect of βhCG administration on serum testosterone. Tsujimura, Matsumiya [30] evaluated the efficacy and safety of βhCG for hypogonadal patients in 21 men with hypogonadism between 3 to 24 months. Serum concentrations of testosterone and testosterone/estradiol (T/E) ratio increased significantly from 7.29 nmol/L to 9.37 nmol/L, and from 7.3 nmol/L to 9.5 nmol/L respectively. They reported an improvement in the Androgen Deficiency in the Aging Male (ADAM) score and the International Index of Erectile Function (IIEF) score in the patients treated with βhCG. Ishikawa, Ooba [31] follow-up on 26 hypogonadal patients found that those who were administered with βhCG had significantly raised levels of testosterone and testosterone/estradiol ratio. Additional comparable reports can be made with [19] evaluation of 40 hypogonadal patients treated for 6 months with βhCG.

Rainer, Pai [36] aimed to evaluate for symptom improvement and side effects of hCG monotherapy in hypogonadal men with testosterone >300 ng/dL (10.41 nmol/L). The pre-analysis supported the view that hCG is homologous to LH, and is known to stimulate endogenous testosterone, as an option for testosterone replacement therapy. A study conducted by Depenbusch, von Eckardstein [37] reported suppression of FSH and LH after administration of hCG in hypogonadal men. This current finding of a decrease in FSH and LH post treatment with βhCG is in agreement with earlier findings by Rainer, Pai [36] and Depenbusch, von Eckardstein [37] .

The production of sperms depends on a functionally intact hypothalamic-pituitary-gonadal (HPG) axis with normal pituitary secretion of LH and FSH for testosterone biosynthesis and spermatogenesis. Significant improvement in semen quality; semen volume, sperm concentration, total sperm count, total motile count, active forward linear progressive (AFLP) motility, sluggish motility, normal morphological forms and viable sperms was seen among the study participants after treatment with human chorionic gonadotropin (βhCG) from the baseline after 90 days. This conforms with other studies [35] [37] - [39] who found the ability of βhCG to preserve spermatogenesis and improve semen parameters in hypogonadal men. This may be as a result of the LH-like activity of βhCG to stimulate testosterone production by the Leydig cells, for the enhancement and maintenance of spermatogenesis [40] .

The ultimate evidence of fertility status among subfertile couples is pregnancy outcome. The administration of βhCG therapy can improve the fertility rate and better spermatogenesis with lower adverse effects in patients with deranged semen parameters. Previous studies reported the sperm morphology alone was good enough to predict pregnancy success [41] , while other authors demonstrated a definite decline in pregnancy rate when the normal sperm morphology declines below 8% [42] . Slama, Eustache [43] also measured the association between time to pregnancy and semen parameters and concluded that the proportion of normal sperm morphology raised the time to pregnancy to a threshold value of 19%. In contrast to this, Van der Merwe, Kruger [44] demonstrated that although each semen parameter showed a good predictive value for increased fertility rate, the clinical value of semen analysis increased when the parameters are used in combination. A study by Nallella, Sharma [45] also stated that sperm motility and concentration are better predictors of fertility potential than assessment of sperm morphology as stated in the WHO guidelines [46] and Tygerberg’s strict criteria [47] . In this study a significant increase in overall percentage change in total sperm count, sperm concentration, AFLP motility, normal sperm morphology [21] , and the total motile count was a tool for substantial discriminative ability in male factor fertility.

Despite several findings reporting about the significant effect of βhCG on semen parameters, other studies found inconsistent conclusions on the otherwise known literature. A placebo-controlled study on the effectiveness of βhCG in infertile men with oligospermia was conducted by Kumar, Gautam [48] and reported a strong evidence that βhCG treatment schedule did not improve semen parameters. It was concluded that increasing serum gonadotropin through the effect of βhCG above the normal physiological range does not improve the production of sperms. This may be as a result of altered LH pulse rate or decreased LH bioactivity. The theory of antibodies developed against βhCG preparation could be induced during treatment. In this study however, there was improvement in testicular function in the form seminal parameters due to the positive effect of βhCG on Leydig and Sertoli cells. This finding is in line with [20] [49] [50] who reported modest response rates in the concentration and total sperm count in semen parameters in hypogonadal, severe oligospermic men. An improvement in semen parameters was observed among participants in this study after treatment. This may imply that the mechanism hypothalamic-pituitary-gonadal axis was functionally restored.

The study found significant increment in diastolic blood pressure (p < 0.0001) and pulse (p = 0.0017) post treatment. This could be the clinical implications of βhCG treatment although most of the studies have concluded no adverse side effects of hCG therapy for hypogonadism [51] [52] . However, few studies have reported increase hematocrit, estradiol PSA, prostate volume, and mood swing [12] [19] . Future studies should consider monitoring potential long-term side effects of βhCG therapy on male subfertility.

The results from this study showed a significant improvement in gonadal function and semen parameters after βhCG treatment. Beta-human chorionic gonadotropin therapy for subfertility in men is recommended since it has demonstrated efficacy in improving gonadal function. However, findings from this study should be verified by a multi-institutional study to provide more evidence for this choice.

We wish to acknowledge the staff of the La Mete Urology Centre, Urology Unit and Laboratory Department of the Tamale Teaching Hospital.

The study received approval from the Ethics and Review Board of the Department of Research and Development at Tamale Teaching Hospital (Number: TTH/R&D/ SR/511).

All patients provided written informed consent before the start of the study.