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deficiency, and in many both testosterone deficiency and infertility coexist. Male hypogonadism is a relatively common disorder (Tables 2 and 3), particularly in aging males, and in those with diabetes, the metabolic syndrome, and Klinefelter's syndrome. It affects patients' fertility, sexual function, and general health.1'2 The clinical features of male hypogonadism depend on the age and stage of sexual development.1,2 If testicular function is deficient or if there is androgen unresponsiveness during fetal life, the phenotype is that of a female, and the classic presentation is testicular feminization syndrome. Both testosterone deficiency and infertility are observed with almost all patients with secondary or tertiary hypogonadism. In primary hypogonadism, infertility may present without testosterone deficiency, as observed in some males with Klinefelter's syndrome.

In adolescent males with prepubertal hypogonadism, androgen deficiency is seldom recognized before the typical age for onset of puberty except in adolescents with associated growth retardation or other anatomic and endocrine abnormalities. During the expected pubertal years, hypogonadism is suspected if the testes fail to enlarge normally or sexual maturation fails to occur.1,2

Pubertal failure is well characterized by several clinical features, as shown in Table 4. In adults, regression of secondary sexual characteristics and loss of libido and impotence suggest the onset of hypogonadism, as summarized in Table 4. Infertility and androgen deficiency are manifestations of postpubertal hypogonadism. The clinical symptoms and signs may evolve slowly and subtly, and may be incorrectly attributed to aging in older males (Table 2). Male-pattern body hair growth often slows, while changes of the voice and size of the phallus, testes, and prostate may be undetectable. In younger adult males, a delay in temporal hair recession and balding may go unnoticed.

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