Infertility Due to Azoospermia, Infertility, Male
Conditions
Brief summary
This clinical interventional study aims to assess whether treatment with with leflutrozole can improve sperm production in infertile men with non-obstructive azoospermia selected by serum anti-mullerian hormone (AMH) or Inhibin B as a positive predictive biomarker.
Detailed description
Non-obstructive azoospermia (NOA) is the most severe form of male factor infertility and reflects a profound impairment of spermatogenesis. Men with NOA typically require surgical sperm retrieval procedures, such as testicular sperm aspiration (TESA), testicular sperm extraction (TESE), or micro-TESE, followed by intracytoplasmic sperm injection (ICSI). Even with surgical retrieval, sperm recovery rates remain limited and live birth rates are modest. At present, no pharmacological treatments are approved for male infertility, underscoring a substantial unmet clinical need. Aromatase inhibitors reduce the conversion of testosterone to estradiol by inhibiting the CYP19A1 enzyme, thereby increasing the testosterone-to-estradiol ratio and stimulating gonadotropin secretion. Letrozole and anastrozole have been used off-label in infertile men, including selected patients with NOA, with small studies demonstrating that aromatase inhibition may induce the appearance of spermatozoa in the ejaculate. Leflutrozole is a novel, non-steroidal aromatase inhibitor and a derivative of letrozole with an extended half-life, allowing once-weekly oral dosing at substantially lower doses than conventional daily aromatase inhibitor regimens. Previous clinical studies in men with obesity-associated functional hypogonadism have demonstrated that once-weekly leflutrozole improves serum testosterone concentrations and semen parameters with an acceptable safety profile. The NOVA-NOA trial is a single-center, prospective, interventional study designed to evaluate the efficacy and safety of leflutrozole in men with non-obstructive azoospermia. The study investigates whether 20 weeks of treatment with oral leflutrozole 0.3 mg administered once weekly can induce the presence of spermatozoa in the ejaculate and thereby potentially reduce the need for surgical sperm retrieval. Following informed consent and confirmation of azoospermia at screening and baseline, eligible participants receive oral leflutrozole 0.3 mg once weekly for a total treatment duration of 20 weeks. Semen samples are collected prior to treatment and during therapy at predefined visits (Weeks 12, 16, and 20) to evaluate spermatogenic response. If spermatozoa are identified in any semen sample during treatment, participants are offered repeat semen sampling and referral to a fertility clinic for cryopreservation according to standard clinical practice. Participants continue study treatment until Week 20 irrespective of early detection of spermatozoa. Blood and urine samples are collected longitudinally to characterize changes in reproductive hormones, metabolic parameters, mineral homeostasis, bone turnover markers, and circulating concentrations of leflutrozole. Seminal fluid is additionally analyzed for leflutrozole concentrations when sufficient ejaculate volume permits. These assessments are intended to describe the endocrine and systemic effects of sustained aromatase inhibition in men with NOA and to support mechanistic interpretation of any spermatogenic response. Safety is evaluated throughout the study using repeated clinical assessments, laboratory monitoring, and systematic recording of adverse events. Key safety measures include monitoring of hematocrit, hemoglobin, prostate-specific antigen, liver biochemistry, and cardiovascular parameters. Participants are followed until Week 24 for on-site safety assessments, corresponding to more than five half-lives of the investigational medicinal product, and complete an additional safety and pregnancy outcome follow-up by telephone at Week 36. Statistical analyses are conducted on an intention-to-treat basis. The primary efficacy analysis evaluates whether treatment with leflutrozole induces the presence of spermatozoa in the ejaculate, using an exact binomial testing framework under the assumption that untreated men with NOA would not spontaneously develop spermatozoa during the observation period. Secondary analyses describe within-participant changes in hormonal, metabolic, and exploratory semen parameters over time. The overall objective of the NOVA-NOA trial is to determine whether, once-weekly leflutrozole administered without concomitant medication can induce spermatogenesis sufficient for the appearance of spermatozoa in the ejaculate of men with non-obstructive azoospermia, thereby offering a potential non-surgical pathway to biological fatherhood for a subset of this patient population.
Interventions
Leflutrozole capsule 0.3 mg once weekly administered orally
Sponsors
Martin Blomberg Jensen
ReproNovo SA
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
MALE
Age
18 Years to 55 Years
Healthy volunteers
No
Inclusion criteria
* Signed informed consent by participant * Signed informed consent by participant's partner (must just be obtained before the par-ticipant starts treatment at Visit 1), if applicable, regarding blood samples, data collec-tion about fertility treatment as well as pregnancy and pregnancy outcome * 18-55 years * Azoospermia verified by at least 2 semen samples, average semen volume \>= 1,0 ml with no identifiable sign of obstruction (samples taken at Visit -1 and at Visit 0 prior to confirmation of eligibility and dosing). * Serum AMH or Inhibin B level above the lower limit of quantification (LLOQ) at screening or within 6 months prior to screening * Testosterone \< 15 nmol/L at screening or within 6 months prior to screening * Serum estradiol above the lower limit of normal range (48 pmol/L) at screening or within 6 months prior to screening
Exclusion criteria
* Klinefelter or other major genetic conditions including large deletions on sex chromosomes * Average testis size \> 20 mL unless obstruction has been excluded * TESE procedure \< ½ year ago * LH concentration \> 15 IU/L at screening * Current abuse of steroids * BMI \> 45 kg/m2 * Severe chronic diseases requiring daily medication * Prior thromboembolic event within the last 24 months * Cardiovascular event within the last 6 months judged as significant by the investigator * Osteoporosis requiring medical treatment * Use of any prescription or non-prescription medication (apart from routine vitamins, occasional use of paracetamol, acetylsalicylic acid, or ibuprofen) which could interfere with pharmacokinetic or pharmacodynamic results, as judged by the investigator, such as: * Herbal products and non-routine vitamins * Insulin * Medication such as systemic corticosteroids, tricyclic antidepressants, and atypical antipsychotics * Surgery scheduled for the trial duration period, except for minor, non-gastrointestinal surgical procedures at the discretion of the investigator * Cancer (past or present, except basal cell skin cancer or squamous cell skin cancer), which in the investigator's opinion could interfere with the results of the trial * Serum prostate specific antigen (PSA) \> 3 ng/mL at screening or within 6 months prior to screening * Hematocrit \>50% at screening or within 6 months prior to screening * Mental incapacity, language barriers or unwillingness to comply with the requirements of the protocol, which may preclude adequate understanding or co-operation during the trial, as judged by the investigator
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients with spermatozoa in the ejaculate at Week 12-20. | From enrollment to Week 20 (end-of-treatment) | The primary endpoint is proportion of patients with spermatozoa in the ejaculate at Week 20 (end-of-treatment). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in serum reproductive hormones | Change from baseline to week 20 (end-of-treatment) | Change in serum concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone, estradiol, inhibin B, anti-Müllerian hormone (AMH), and sex hormone-binding globulin (SHBG). |
| Change in seminal fluid reproductive biomarkers | Change from baseline to week 20 (end-of-treatment) | Change in concentrations of RANK ligand (RANKL), osteoprotegerin (OPG), anti-Müllerian hormone (AMH), and inhibin B measured in seminal |
| Change in reproductive hormone ratios | Change from baseline to week 20 (end-of-treatment) | Change in serum inhibin B/FSH ratio, testosterone/LH ratio, testosterone/estradiol ratio, and AMH/testosterone ratio. |
| Change in body mass index | Change from baseline to week 20 (end-of-treatment) | Change in body mass index (BMI) weight and height will be combined to calculate BMI in kg/m\^2 |
| Change in glycemic and insulin resistance markers | Change from baseline to week 20 (end-of-treatment) | Change in HbA1c, fasting plasma glucose, fasting insulin, C-peptide, and homeostatic model assessment for insulin resistance (HOMA-IR) |
| Change in lipid profile | Change from baseline to week 20 (end-of-treatment) | Change in total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. |
| Change in hematocrit | Change from baseline to week 20 (end-of-treatment) | Change in hematocrit measured as a safety-related secondary outcome |
| Change in markers of bone turnover | Change from baseline to week 20 (end-of-treatment) | Change in serum procollagen type 1 N-terminal propeptide (PINP) and C-terminal telopeptide of type I collagen (CTX). |
| Change in urinary mineral homeostasis | Change from baseline to week 20 (end-of-treatment) | Change in spot urine concentrations of albumin, calcium, magnesium, iron, ferritin, phosphate, zinc, bicarbonate, and citrate. |
| Change in serum mineral homeostasis | Change from baseline to week 20 (end-of-treatment) | Change in serum concentrations of albumin, calcium, phosphate, magnesium, iron, ferritin, transferrin, hepcidin, and zinc |
| Change in seminal fluid mineral concentrations | Change from baseline to week 20 (end-of-treatment) | Change in seminal fluid concentrations of albumin, calcium, phosphate, magnesium, iron, ferritin, and zinc |
| Change in calciotropic hormones | Change from baseline to week 20 (end-of-treatment) | Change in serum parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), and α-Klotho. |
| Change in vitamin D metabolites | Change from baseline to week 20 (end-of-treatment) | Change in serum concentrations of cholecalciferol, 25-hydroxyvitamin D (25-OHD), 24,25-dihydroxyvitamin D, 1,25-dihydroxyvitamin D, and derived vitamin D metabolite ratios |
| Change in adrenal and androgen precursor hormones | Change from baseline to week 20 (end-of-treatment) | Change in serum concentrations of androstenedione, cortisone, and dehydroepiandrosterone sulfate (DHEAS). |
| Leflutrozole concentrations in serum in participants | From enrollment to the end of trial at 24 weeks | Plasma concentration of Leflutrozole in participants |
| Leflutrozole concentration in seminal fluid | From enrollment to the end-of-treatment at 20 weeks | Leflutrozole concentration in seminal fluid |
| Leflutrozole concentration in partners | From enrollment to week 16 after inclusion | Plasma Leflutrozole concentration in the female partner |
| Change in sperm parameters when measurable | Change from baseline to week 20 (end-of-treatment) | Change in sperm count, concentration, motility, and morphology in participants with detectable spermatozoa in the ejaculate. |
| Change in height | Change from baseline to week 20 (end-of-treatment) | Change in height (centimeters) |
| Change in weight | Change from baseline to week 20 (end-of-treatment) | Change in weight (kilograms) |
Countries
Denmark
Contacts
CONTACTMads Joon Jorsal, MD
CONTACTEmil Brink Wriedt, MD
PRINCIPAL_INVESTIGATORMartin Blomberg Jensen, D.M.Sc.
Herlev Hospital
Outcome results
None listed