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Dear PeakT members,

I have been reading here for a long time, but now I would like to contribute here, tell my story and ask for help/opinion.

I don't want to make it long, so I try to abbreviate where I can.

I am 38 y/o, 1,9m tall, slim, sporty, and have been dealing with low libido and especially ED for about almost 15 years. It started in 2005, when I was in my early 20s: I took Finasteride for several months, stopped and developed "PFS". Symptoms: Low libido, ED and sleep and concentration were also getting worse. However, my main focus is on low libido and ED. Sex since then was only possible with PDE5 inhibitors. In between, around 2009, it got better for a few months and I could have sex without ED drugs, but that was short lived. It never got back to the way it was before. Over the years it got worse. The ED drugs have, sometimes extremely high doses, worked worse and worse, until it is currently almost impossible. I can currently take 400mg + Sildenafil - it has no effect at all, except for the known side effects (vision, red head etc.).

I have tried many things, various medications and supplements, it would be a very long list to present here. But the well-known things like Clomid, Progesterone, L-Arginine and Tribulus were there, just to name a fraction.

I repeatedly had my blood work done. Over and over again, conspicuous:
1. Very low testosterone levels: Always around the 2.65-3.30 ng/ml range, sometimes even lower (reference 2.49-8.36). DHT often at the upper end of the range and currently also SHGB elevated with 62.7 nmol/l (reference 16.5-55.9).
2. Blood lipids constantly elevated, which I cannot or only with great difficulty get under control through sport and diet, it seems to be genetic: Current cholesterols 237 mg/dl (reference <200), HDL 37 (reference >40), LDL 178 (reference <160) and triglycerides 277 (reference <150).

Based on my symptoms and also Doppler ultrasound, it looks like I have developed some kind of venous leakage due to that hypogonadism. You can tell just by the fact that the ED drugs are no longer working, it's like I'm eating candy.

I have tried twice in these last 16 years to get my levels under control with TRT (Testogel, no injections). I remember always stopping after a few weeks because I didn't feel any improvement in symptoms - possibly I always stopped too soon. I now know that venous leakage in particular can take a long time to improve. Therefore, since October 2020, I am back on TRT with Testogel under the view of my andrologist, but so far, 4 months later, cannot see any improvement in ED or libido. I started taking two pumps of Testogel from the dispenser every morning. With this, I had a relatively high testo value shortly after starting therapy (about 10 ng/ml, measured about 2 months after starting). Then my doctor told me to take only one pump from the dispenser. Unfortunately, I now only achieve a very low Testo value around 3.03 ng/ml, which is actually no higher than if I did not take Testogel. Possibly it is due to the fact that now my body has simply stopped the complete self-production of Testo and my value is therefore - despite substitution - in the basement.

Finally, I would like to mention that I have a congenital upward curvature of the penis. My attending physician is an andrologist and also a specialist in penile straightening surgery. He therefore performed a penile straightening operation (NESBIT) and at the same time a venous ligation on me in June 2020 in the university hospital where he works, which was supposed to address the issue of venous leakage. We were both aware that this ligation often does not lead to success, but it was worth a try. Both could have helped improve erectile function and rigidity/stability according to the doctor. The surgery went ok so far, but unfortunately my symptoms did not improve - it actually got worse over time. Of course, I don't know if this is a result of the surgery or the further progression of my underlying condition. Since even shortly before the surgery I was virtually unable to achieve more than 50-60% erection with manual stimulation, which also collapses again after 5 seconds, it may well be that the surgery is not to blame here. I have now not had sex since June, which of course is also stressful for my marriage - but I have a very understanding wife.

I would be interested to know how you see my case? I'm still leaning towards doing something about the blood lipids, because that can also be a possible cause of my problems. Should I stay on TRT? If so, what can I do to keep my levels stable in the mid range? Should I take an injection? Or even HCG? Because we would also like to have children, which of course is currently a long way off.

Thanks for reading through and any advise!

Testosterone, Hormones and General Men's Health / Re: Enclomiphene report
« Last post by Gef on February 16, 2021, 07:15:10 am »
From what I have read on the subject, I suspect the DHEA supplements I have been taking may be the root cause of my sudden high level of DHT.
Testosterone, Hormones and General Men's Health / Micro dose hCG monotherapy
« Last post by Forty2 on February 16, 2021, 01:39:07 am »
I'm considering trying a very low dose of hCG mono such as 150iu 3 x week.
From some information I've come across, LH suppression from hCG is related to the spike in estradiol. With a very low dose you don't get the large estradiol spike so LH is not affected at all, or extremely minimally suppressed and testosterone is raised as much as 200ng/dL.
Could someone please confirm whether this information is correct?
Testosterone, Hormones and General Men's Health / Re: Enclomiphene report
« Last post by Gef on February 15, 2021, 05:05:12 pm »
I received my DHT test results an hour ago - 1383.3 pg/mL. It's has always been high in the past but never this high.
If you're willing then do report back on how it goes. Hopefully you won't need the AI any more.
That was very well explained. Thank you for your time. I am skipping my dose today to allow the numbers to come down, also skipping Anastrozole altogether. When I start up again on Thursday pm, I will be trying somewhere around 30-35mg twice a week. I will take your advice and give it 90 days then reanalyze things moving forward. It will be a relief not to take Anastrozole any longer.
Testosterone, Hormones and General Men's Health / Re: Enclomiphene report
« Last post by Cataceous on February 15, 2021, 01:28:16 pm »
With the most recent numbers both free T calculators put you on the low side. So you do have a possible reason for the lackluster subjective results.

The options for dealing with high SHBG aren't great. TRT is effective but extreme, since you're disabling the entire HPTA. Some guys have used SARMs, such as ostarine. It's possible that with the continued use of enclomiphene the suppressive effects would be reduced. I suppose AI use is also a possibility, though as a last resort. The E2/T ratio is only a little on the high side, so there's marginal leeway for some AI micro-dosing.
Suppose your pre-injection trough is 900 ng/dL and your peak is 1,300 ng/dL. A 20% reduction with unchanging SHBG is going to change the trough and peak to around 700 and 1,000 respectively. This still leaves you well above average. And your SHBG is a bit below average, which means total testosterone should be below average to attain average free testosterone. For example, the Vermeulen free T for the average healthy young man with TT of 650 ng/dL and SHBG of 30 nMol/L is 15 ng/dL. At an SHBG of 20 the total testosterone only needs to be 550 ng/dL to match the free T of 15 ng/dL.

If your goal is to attain more physiological numbers then a 40% dose reduction makes more sense. This is 30 mg twice a week. Then your trough free testosterone would roughly match the peak free testosterone of the average young man. Your peak free T would still be much higher, probably over 20 ng/dL. Your new peak total testosterone could be around 800 ng/dL.

Unfortunately dose reductions can be challenging. Typically guys feel bad initially and convince themselves they must need above-average testosterone to feel good. But if they endured the transition then they might find things getting better. It can take months to fairly evaluate the results of such a protocol change. I believe it's worth doing because the TRT experience is better overall when you don't have to grapple with side effects such as high estradiol and high hematocrit.
Testosterone, Hormones and General Men's Health / Re: Enclomiphene report
« Last post by Gef on February 15, 2021, 11:30:07 am »
Protocol has been: 12.5mg enclomiphene qd, 200mg DIM qd, 50mg DHEA qod.
Testosterone, Hormones and General Men's Health / Re: Enclomiphene report
« Last post by Gef on February 15, 2021, 11:20:05 am »
Test results: 02/11/21 with enclomiphene.
TT: 655 ng/dL    Free T: 61.9 pg/mL   Percent Free: 1.3%   
SHBG: 100 nmol/L
Estradiol: 38 pg/mL
Prolactin: 4.9 ng/mL
Progesterone: 0.5 ng/mL
It seems basic test averages of both clomiphene and enclomiphene are roughly about the same so far. However clomiphene was at a much lower dose than that of enclomiphene.
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