Trt is an amazing advancement in men’s health that has helped so many people all over the world. We are no longer stuck with the horrible effects of low testosterone. Though it is an amazing way to deal with low testosterone, it also comes with a price. Testosterone replacement therapy will leave you virtually infertile. This isn’t a problem for those who have already had children, those who are older, or those who don’t want to conceive, but for those who actually plan on having children trt can be a major obstacle. The use of exogenous testosterone will always reduce a males sperm count to an infertile level. Imagine being married to a woman who has unequivocally denied ever wanting to have children. You spend years with this woman without a change of heart and, suddenly, she drops the “I want a baby” bomb on you. Having a child is a miracle of life, its a wonderful thing. What isn’t wonderful is the fact that you had started trt years ago with your wife’s adamant denial of having children in mind. You now face a major problem. You are obviously infertile thanks to your trt usage, but there is hope! Lets cover some basics.
The hypothalamic-pituitary-gonadal axis (HPTA) is a negative feedback loop system involving the hypothalamus, pituitary gland, and the gonads (testicles). Its main function in the body that concerns us in this article is the regulations of hormones which include testosterone and the development of sperm (spermatogenesis). In short, the hypothalamus releases a gonadotropin-releasing hormone (GnRH) which triggers the pituitary gland which directly affects the pituitary gland releasing the luteinizing hormone (LH) and follicle-stimulating hormone (FSH). The LH’s function is to signal the production of testosterone while the FSH signals the production of sperm. When testosterone is created in the body it is regulated by the aromatase enzyme. The male body likes to keep, roughly, a 10 to 1 ratio of testosterone to estrogen. When testosterone levels rise to a certain level the aromatase enzyme converts testosterone to estrogen. Estrogen, among other things, regulates the negative feedback loop in the HPTA by inhibiting the production of GnRH.
Lets review this system in simple terms
Hypothalamus -> GnRH -> Pituitary -> LH, FSH -> Gonads -> Testosterone, Spermatogenesis -> Hypothalamus +/- Estrogen = +/- GnRH
Its not just estrogen that will stop the loop. An excess of any of the hormones that play in the negative feedback loop could suppress the system. Hcg, which mimics the LH, is a perfect example.
TRT and Fertility
To the naked eye its obvious that estrogen is the main regulator of the HPTA in natural healthy males (there are other hormones involved that can suppress your hpta). When a subject begins a TRT protocol the exogenous presence of testosterone overrides the negative feedback loop. The pituitary stops sending LH and FSH to the gonads and the natural production of testosterone along with everything else the LH and FSH regulate shuts down. Since FSH is the main conductor of spermatogenesis and that system has been shut down, you become infertile.
Spermatogenesis is the process and development of sperm. It begins within the gonads and moves to the epididymis where sperm is stored until ejaculation. The important fact to take away from spermatogenesis is that the duration of the entire process can take anywhere between 2 to 3 months.
hCG and hMG Solutions to infertility
Wouldn’t it be wonderful if we could somehow just skip half this feedback loop and regulate the production of testosterone and spermatogenesis exogenously? Thankfully we have two very valuable compounds, hCG (Human Chorionic Gonadrotropin) and hMG (Human Menopausal Gonadotropin). hCG is a hormone typically produced by the embryo following implantation (all pregnancy tests test for the presence of hCG in the female subjects urine). Through science we have been able to synthetically produce hCG. In males, the importance of hCG comes with its ability to mimic LH. Injecting hCG is the equivalent of the pituitary releasing LH and giving the gonads the signal to produce testosterone. The gonads go back to work, keeping your system from shutting down completely. Though hCG has no effect on FSH, it does have an effect on spermatogenesis. Though your system is shut down there is FSH lingering around in the body. Studies have shown that there is usually more than enough FSH in the body to cause a rise in a males sperm count enough to conceive. If the desired response from hCG is not met, the use of hMG is a more practical approach. hMG kicks both LH and FSH into gear and causes a considerable rise in sperm production. Keep in mind that the production of sperm takes up to 3 months to complete so the use of these medications have to be sustained for at least 3 months before you start to see the real benefit from them.
Ive read 3 different fertility specialists articles in the last month and each one had a different dosage and frequency of hCG injection that they preferred. Once said 600iu every other day, the second said 1500iu twice a week, and the last one surprisingly said 5000iu once a week. One study on males taking exogenous testosterone had 49 subjects who had a sperm count less than 1 million (average is 20 million and up) on 3000iu of hCG sub-q every other day. An increase in spermatogenesis was found in 47 of the 49 men. The average duration to the return of spermatogenesis was 4.6 months and the mean sperm count was 22.6 million/ml. So higher dosages of hCG seem to be conclusively beneficial to those on TRT (1). Since hCG itself at that dosages seems to produce enough sperm to conceive, the use of hMG would be justified on a case to case basis. This is concrete proof that you can still conceive a child while on trt, if following the correct hCG protocl.
Another study confirmed that intra-testicular testosterone can be maintained during testosterone replacement therapy with co-administration of low dose HCG, which may support continued spermatogenesis in patients on testosterone replacement therapy. 26 hypogonadal men with a mean age of 35.9 years were included. TRT was combined with intramuscular injections of human chorionic gonadotropin (500 IU) every other day. Mean follow-up was 6.2 months. Of the men 19 were treated with injectable testosterone and 7 were treated with transdermal gel. Mean serum hormone levels before vs during treatment were testosterone 207.2 vs 1,055.5 ng/dl, free testosterone 8.1 vs 20.4 pg/ml and estradiol 2.2 vs 3.7 pg/ml. Pre-treatment semen parameters were volume 2.9 ml, density 35.2 million per ml, motility 49.0% and forward progression 2.3. No differences in semen parameters were observed during greater than 1 year of followup. 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. It was concluded that HCG appears to maintain semen parameters in hypogonadal men on testosterone replacement therapy. Concurrent testosterone replacement and human chorionic gonadotropin use may preserve fertility in hypogonadal males who desire fertility preservation while on testosterone replacement therapy. hCG monotherapy has also shown great results as shown in a recent study done on those with infertility issues second to anabolic steroid use had patients take 10000iu of hCG twice weekly, or 2-3000iu 3 times weekly resulted in normal sperm count within 3 months. (3)
In the end, this is a question of what your fertility specialist wants to do. It seems very obvious that at least 500iu hcg should be ran with your trt weekly to preserve spermatogenesis and keep you fertile.
I hope that this article helps you in your fertility goals.
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1. J Sex Med. 2015 Jun;12(6):1334-7. doi: 10.1111/jsm.12890. Epub 2015 Apr 22.
The Use of HCG-Based Combination Therapy for Recovery of Spermatogenesis after Testosterone Use.
Wenker EP1, Dupree JM2, Langille GM3, Kovac J4, Ramasamy R5,6, Lamb D6, Mills JN7, Lipshultz LI5,6.
2. Hsieh, T.C., et al., Concomitant intramuscular human chorionic gonadotropin preserves spermatogenesis in men undergoing testosterone replacement therapy. J Urol, 2013. 189(2): p. 647-50. – See more at: http://www.brinkzone.com/mens-health/trt-and-fertility-how-to-get-the-best-of-both-worlds-part-2/#sthash.iXmLRbj0.dpuf
3. Menon, D.K., Successful treatment of anabolic steroid-induced azoospermia with human chorionic gonadotropin and human menopausal gonadotropin. Fertil Steril, 2003. 79 Suppl 3: p. 1659-61. – See more at: http://www.brinkzone.com/mens-health/trt-and-fertility-how-to-get-the-best-of-both-worlds-part-2/#sthash.iXmLRbj0.dpuf