Testosterone and Fertility
I see young men on the Peak Testosterone Forum
with low testosterone all the time. In fact, probably around half of the
regular posters are young men under 40. And usually these younger guys
with low T are miserable - even more miserable than the older men. They
also are panicked, because this threatens their sex life. This means that
they are often very anxious to solve their problems with HRT (testosterone
therapy). And in most cases, this works well as far as symptom relief and
does indeed make them feel better. (In my opinion, young guys should do everything possible NOT to go on traditional TRT. Many other options are available that should be attempted first.)
Unfortunately, many doctors forget to tell their patients just one little detail: HRT
dramatically lowers sperm
counts! For example, one of our posters asked forum member the following story:
"I went to my GP about 9 months ago with the usual symptoms and tested at total T
of 360. (I'm 35.) He gave me a 400mg shot "to try" and I seemed to respond.
Retested about 3 months later at 280, got another huge 400mg shot and seemed to
respond again. So he went ahead and prescribed me test enanthate, and I've been
shooting about 50mg every 5 days* with so-so results." 
Then he asked this
question: "I still want kids. Have I sterilized myself? My doc said that
fertility is likely to be off already with low T and that replacing to
physiologic levels won't suppress it further -- and may help. If I understand
what I've read here, this is NOT the consensus view."
So this doctor not only did not tell him about the issue, but actually said that
HRT might improve his fertility! Apparently, this doctor did not realize
that testosterone is actually a pretty significant contraceptive. (Don't rely
on it though!) For
example, one study of Chinese men looked at testosterone undecanoate, which is now approved as Nebido here in the U.S., and found that it
was incredibly effective as a contraceptive: "the mean serum testosterone
concentration increased 131%, and the mean serum LH and FSH concentrations
decreased 72% and 70%, respectively, after TU injections during the treatment
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Of course, the very significant decrease in FSH will lower fertility
substantially and this was verified by the fact that 97% of the men developed
azoospermia or severe oligozoospermia, i.e. a sperm count less than 3 million
per ml, which would make pregnancy very difficult. And this is certainly
not the only ester that causes infertility. Testosterone enanthate has
been noted by researchers to cause infertility for example.  And enanthate is very similar
to the cypionate ester that is so often used here in the U.S. as part of an HRT
And sure there are men who successfully get their woman pregnant while on HRT.
It only takes one little swimmer to do it, eh? However, it is more the exception
than the rule. Any loss of fertility can be a huge stressor for some couples.
Women in particular can become despondent and depressed, but the stress can
really hit the male as well. One study on infertile couples showed that ACTH levels rose in the guys,
indicating HPA difficulties. And this increased stress caused lower sperm counts and motility
in the study participants.  Thus,
infertility can create even greater infertility and create a downward spiral.
CAUTION: Because of all this, you want to do all you can to stack
the cards in your favor if you want kids. Below I give you some of the standard
treatment methodologies to handle low testosterone and preserve or increase
fertility, so that you can discuss things with your doctor and ask all the right
questions. Don't forget that there are both "production issues" and
"obstruction issues." Male factor infertility is not always just a
hormonal issue and sometime you can get "blockage" issues. It's always smart to talk to a fertility specialist if you can afford it.
Some urologists even handle fertility and have built up this expertise. Take
some of the discussion points on this page to him or her.
Testosterone Fertility Solutions
So, if HRT causes such a loss in fertility, then how can a man
boost his T and preserve his
fertility at the same time? Or does he have to choose between one or the
It turns out that there are a number of options for men in
this category that can solve these sorts of issues. Let's take a minute and
look at each:
1. HCG Monotherapy (with HMG as needed). One option that I see
increasing number of men undergoing HCG Monotherapy, as opposed to the standard
"HRT Trifecta" of testosterone cypionate, HCG and Arimidex. HCG is
commonly given now to men in conjunction with testosterone to preserve
testicular size/volume primarily. However, HCG can also be given by itself
in order to stimulate the man's own natural testosterone production. The
reason that this works is that most men with low T actually have secondary
hypogonadism where the pituitary or hypothalamus is the broken link. As it
turns out, HCG is an LH (leutinizing hormone) analog and will mimic the
effects of LH on the testes, i.e. stimulate them to produce testosterone,
assuming the testes are in good shape of course.
I should also mention that usually some low dose Arimidex needs to be taken with
this kind of treatment, because estradiol levels can ramp up significantly.
So it is monotherapy in the sense that no testosterone is given, but, in
reality, there is often a second pharmaceutical involved. For more information,
see my link The Hows and Whys of HCG Monotherapy.
And, actually, sometimes HMG is added to the regimen as well
if a man's fertility parameters (from a semen analyis) have not responded after
a few months. HMG is actually a combination of FSH
(follical stimulating hormone) and LH, with each brand being a little different
formulation. The FSH actually much more directly stimulates sperm
production than HCG, which primarily induces testosterone production.
The HCG/HMG combination can take awhile to work, usually around 6-9 months
before you begin to see reasonable increases in sperm counts and so on. This
method is not foolproof and has a mixed track record.  Your fertility doctor
can give you a good idea as to whether or not you are a good candidate.
2. HCG + HRT. Dr. Lipshultz has several studies under his belt showing that most men on HRT can maintain their fertility if they add in low dose HCG. One study put men either on injections or daily transdermal (topical) testosterone gels and then added in 500 IU every other day of HCG. The abstract states the remarkable results that "no impact on semen parameters was observed as a function of testosterone formulation. No patient became azoospermic during concomitant testosterone replacement and human chorionic gonadotropin therapy. Nine of 26 men contributed to pregnancy with the partner during followup."  Fertility is so important that I encourage you to talk to fertility specialist and come up with a treatment plan that will work for your situation rather than just go by this one study. But, yes, it looks like you can have your cake and eat it too!
3) Clomid. When you think of fertility medications, Clomid is probably the
name that first pops into most everyone's mind. It is used by both men and
women, of course, and is often the first line medication because of it's convenience, relatively
low cost and ability to stimulate sperm production. What could be
simpler? No injections. No needles. Just take a pill.
And it works very well for some men, who get both nice boosts in testosterone,
and libido. We had a man on
Peak Testosterone Forum
whose testosterone went up to 1500 ng/dl on Clomid! Sot it can give a
One study found more modest, yet significant increases from 248 to 610 ng/dl with a
25 mg daily dosage. (See my link on
Clomid and Testosterone for details.) And
sperm counts can go from a couple million to a 100 million in just a couple of
months as well.
However, the reality regarding Clomid is far from the ideal
generally speaking and there are a number of
persistent issues that plague this medication:
a) There is very often no libido boost whatsoever in men taking Clomid.
Their testosterone may triple and yet they have no real increase in sexual
b) It often stops working or at least loses efficacy after a few months.
Some women interested in getting pregnant bypass this concern by trying to
"harvest" their husband's sperm during those few months for a future IVF.
Yeah, that probably won't be the last time you're milked...
c) Clomid can display estrogen-like effects in the brain and increase
moodiness and other related symptoms.
d) There are some concerns about long term effects and I outline these in
my link on
Potential Long Terms Risks of Clomid Therapy.
Again, some men seem to thrive on it and do very well and, unfortunately, there is
no good way to predict who will do well and who will not.
4. Armidex Monotherapy. This is not very common from what I have seen, but
some fertility specialists will put young men on Armidex by itself. Men
get their estradiol, the most potent estrogen, through an enzyme called
aromatase (that is stored primarily in fat cells) that converts some
testosterone into estradiol. Arimidex (anastrozole) is an aromatase
inhibitor and thus slows down this conversion of testosterone into estradiol.
Therefore, it will raise both testosterone and lower estradiol simultaneously
and can preserve fertility. (It doesn't seem to have a good reputation for
actually raising fertility, but talk to your doctor about this.)
How much can Armidex raise testosterone? You can read about it more in my
link on Testosterone and Arimidex, where I
discuss a study where Arimidex increased testosterone by 62% and decreased estradiol by 24%.
5. Combinations of the Above. You can find every combination
imagineable. HCG + Arimidex; Clomid + Arimidex; HCG + Clomid + Arimidex.
And some doctor use letrazole instead of Arimidex (anastrozole). If you go
to a fertility specialist, he will test you in every way -
ultrasounds, hormone blood draws, genetic and semen analysis, etc. - and then will decide on
the best course of action.
1) The Journal of Clinical Endocrinology & Metabolism, Feb 1 2003,
8(2):562-568, "A Multicenter Contraceptive Efficacy Study of Injectable
Testosterone Undecanoate in Healthy Chinese Men"
2) The Journal of Clinical Endocrinology & Metabolism, Oct 1 1993,
77(4):1028-1032, "Body composition and muscle strength in healthy men receiving
testosterone enanthate for contraception"
4) Neuroendocrinology Letters, 2005, "Levels of plasma ACTH in men from infertile
5) Andrologia, 1981 May-Jun, 13(3):187-97, "A modern approach to the gonadotropin
treatment in oligozoospermia"
6) The Journal of Urology,
189(2):647–650, "Concomitant Intramuscular Human Chorionic Gonadotropin Preserves Spermatogenesis in Men Undergoing Testosterone Replacement Therapy"