Transsphenoidal approach (TSA) for pituitary tumor removal can lead to hypogonadism and fertility issues in male patients. While preoperative sperm banking is common for high-risk cases, unexpected post-operative hypogonadism or inability to bank sperm beforehand necessitates research into fertility stimulation (FS) treatments. This study aimed to evaluate outcomes of FS treatment in male patients after TSA for pituitary tumor and identify high-risk groups for fertility restoration failure.

This study included 18 male patients who underwent TSA for pituitary tumor followed by FS treatment between February 2012 and March 2024. Participants had confirmed azoospermia or inability to ejaculate post-TSA. FS protocol involved human chorionic gonadotropin and/or Follitropin-beta administration. Primary outcome was success of sperm banking or achieving pregnancy post-FS. Hormone levels, semen parameters, and patient characteristics were analyzed.

Median age at TSA was 25.5 years. Craniopharyngioma was the most common tumor type (44.4%). All patients showed hypogonadotropic hypogonadism post-TSA. After a median 5 months of FS, 15 out of 18 patients (83.3%) successfully conducted sperm banking or achieved pregnancy. Median post-FS testosterone level rose to 6.3 ng/mL. Factors associated with treatment failure included delayed FS initiation (>10 years post-TSA), history of testosterone replacement therapy, and severe pre-operative hypogonadism (testosterone <0.2 ng/mL).

FS treatment effectively restored fertility in the majority of male patients post-TSA for pituitary tumor. Early intervention and severity of pre-existing hypogonadism were critical factors influencing success. Patients with delayed treatment initiation, prior testosterone replacement therapy, or severe pre-operative hypogonadism should be considered high-risk for fertility restoration failure. These findings inform strategies for fertility preservation and restoration in male patients undergoing TSA.