Low T and infertility can go hand in hand. Many men who have abnormal semen analysis will also have lower levels of testosterone. All men who have low sperm counts should receive a full evaluation by a urologist specializing in male fertility to get a better understanding of what is going on with his health and his fertility. A full evaluation calls for a physical exam, a second semen analysis and a blood test to measure testosterone and follicle stimulating hormone (FSH) at a minimum. If either hormone comes back abnormal additional blood tests which may include luteinizing hormone, estradiol, thyroid stimulating hormone, prolactin, progesterone and sex hormone binding globulin to get a more detailed picture of what is going on. Testosterone Replacement Therapy (TRT) is a popular and effective treatment for low T, but it doesn’t come without drawbacks. It bypasses the natural testosterone production system and can cause men to completely stop producing sperm. However, there are a number of alternative treatment options for low testosterone that have been shown to be effective at relieving symptoms associated with low T while preserving, and in some cases boosting, fertility.
Is testosterone linked to sperm production?
The testicles have two main jobs. They make testosterone and they make sperm. Testosterone is used in the testicle to support the development of sperm, the production of seminal fluid, supports prostate health and sexual function. When trying to understand the cause of an abnormal semen analysis, testosterone levels are a good place to start. Knowing a man’s T level can help doctors identify if there has been any damage to testicular tissues and help them better understand other sexual or reproductive health issues that he may have. If T levels are also low, it is important to ensure that the doctor knows you are trying to start a family as some low T treatments have a negative impact on fertility.
What causes Low T in young men?
There has been a lot of recent press about low T and aging. For men, testosterone levels peak in the 20s and slowly decline with age. Unlike women who experience dramatic changes in their hormone profiles with the onset of menopause, the decline in testosterone is slow about 1% per year. However, as men age, T levels can dip so low that they cause symptoms such as a loss of libido, depression, and inability to focus.
So, what causes low T in young men? Most low T cases come from systemic health issues such as chronic illness, diabetes, obesity, excessive drinking or smoking or various prescription medications. Less commonly, a varicocele (an enlarged scrotum in the vein) will interfere with testicular function and cause a reduction in semen quality and occasionally a drop in testosterone levels. Some rarer causes of low T include congenital or genetic defects that can impact testicular function, endocrine or autoimmune diseases that impact hormone production, infection or injury of the testicle, cancer treatment or radiation exposure.
Treating low T: What are the options?
Press and television commercials about low T has caused an uptick in testing and prescriptions of Testosterone Replacement Therapy which has been shown to be beneficial in ameliorating symptoms in men with low testosterone levels. However, silver bullets rarely exist in real life and TRT is a good case in point. Natural testosterone production is part of complex biochemical process that regulates several important systems in the body. Introducing external testosterone, either medically or recreationally, can cause a ripple effect that can cause both intended and unintended consequences to a man’s cardiovascular system, skeletal system, metabolism and reproductive system to name a few. Before starting any type of therapy for low T, it is important to understand the underlying cause and your health goals to ensure that the treatment plan will be effective. This is particularly true for young men or men who have concerns about fertility as TRT has been shown to have a negative impact on sperm production.
Varicocele Repair: A treatment for low T and infertility
Varicoceles are tricky because they impact different men differently. Some men can have large varicoceles that have little to no impact on testicular function. Others can have relatively small varicoceles that wreak havoc causing issues with sperm production and testosterone. Most of the time a varicocele can be diagnosed with a simple physical exam by a well-trained urologist. Larger varicoceles can cause discomfort or pain, especially after long periods of standing. They also may be visible as a large bluish vein in the scrotum or make the scrotum feel a little lumpy, like a “bag of worms.” If the varicocele is on the smaller side, ultrasound tests may be ordered to confirm. If a varicocele is found, it is helpful to have a measure of testosterone and a semen analysis to assess the impact on testicular function.
Varicoceles are often left untreated if they do not cause pain or impact testicular function. In cases, where a varicocele impacts sperm and or testosterone production, treatment is via a minimally invasive procedure is often effective at improving testicular function. Antioxidant supplements may be recommended in parallel to help improve fertility.
Clomid: Using Clomid to boost testosterone and sperm production
Clomid causes the pituitary gland to increase production of luteinizing hormone (LH) and follicle stimulating hormone (FSH). In women, this helps with maturation and release of eggs during ovulation. In men, these two hormones stimulate the testicle to increase production of testosterone and sperm. For men do not have testicular failure, Clomid may be an option to help boost T levels. Unlike TRT, Clomid rarely has a negative impact on fertility and has even been shown to be somewhat effective in boosting sperm count in cases where the cause of a low count is unknown (and testosterone levels are normal). Clomid can also be used in conjunction with TRT to support the body’s natural testosterone production. This can lower the dose of exogenous testosterone needed or protect fertility during TRT treatment.
It’s important to note that use of Clomid in men is off-label, meaning that it has not been formally approved for the treatment of low T or infertility in men. However, there are quite a few studies that document use of Clomid in men. Side effects of Clomid use in men that have been observed include facial flushing, excessive sweating, gynecomastia and breast tenderness, weight gain, hypertension, cataracts, and acne.
HCG Treatment: hCG’s role in testosterone production
Human chorionic gonadotropin (hCG) is most commonly known as a pregnancy hormone because it is produced by the placenta after an embryo has implanted in the uterus and is measured by pregnancy test strips. Interestingly, hCG is structurally similar to LH and can be used as a medication (Pregnyl, Follutein, Profasi, Novarel) to directly supplement LH in both men and women. The most common use of hCG is during IVF treatment to help trigger ovulation. For men, hCG directly supplements LH and directly stimulates legdig cells to produce testosterone. HCG treatment can be coupled with FSH injections to stimulate the production of sperm. In practice, hCG is most commonly used during TRT to help maintain intratesticular testosterone levels and therefore preserve fertility. It also seems to be effective in helping men who have lost fertility due to abuse of anabolic steroids.
Aromatase Inhibitors: How Aromatase Inhibitors can improve testosterone levels
Aromatase is an enzyme that converts testosterone into a form of estrogen called estradiol. Low levels of estrogen are important for bone density and cognitive and cardiovascular function. However, too much estrogen can cause unpleasant side effects such as loss of libido or sexual function and the development of breast tissue (gynecomastia) or tenderness of nipples. Aromatase is present in testis, liver, brain and fat tissue. The presence of aromatase in fat tissue can cause low T and high estrogen levels in overweight and obese men. Aromatase inhibitors (AIs) can reduce the amount of testosterone that is converted into estradiol. This can cause an increase in levels of LH, FSH and T and may consequently improve spermatogenesis. These medications are most effective treatment of low T or male infertility in obese patients or when the testosterone to estradiol ratio is less than ten.
Talking to your doctor
Talking to a doctor in general can be difficult. Visits are short and it can be difficult to remember everything that is on your mind. This is especially true when talking about low T. Symptoms can be random and non-specific, not to mention embarrassing or difficult to put into words. Figuring out the right treatment option can also be difficult. There are a lot of different factors to consider and it can take a few tries to find something that is effective at meeting your goals. Here are a few tips to help reduce frustration.
- Get educated: The more you know about yourself, your biology and your options the more comfortable you will feel with a treatment option. Dr Google is a good starting point but don’t limit yourself to online articles. Ask questions. Your doctor should be able to explain what is going on in a way that makes sense to you. Develop a list of questions based on what you’ve learned from your own research to help connect the dots in your mind.
- Keep a journal: Because symptoms can be helpful in giving your doctor insight into what is going on, it is helpful to track some data. Are you having difficulty with erections – how often? Do you wake up with morning wood? Are you tired? How long do you sleep at night? How well? As best as you can try to remember when things started, what has changed in your life or has it always been this way.
- Think about the future: Sometimes the hardest part of talking with your doctor is talking through goals. Do you want to have kids in the future? What is the biggest pain point right now? What feels bad now and what do you hope will be better?
- Be honest: I remember finally being honest with a dentist that flossing was uncomfortable and I just didn’t like doing it. He told me that this was pretty common and had a list of options that I could try instead. Honesty creates an opportunity for dialog. Your doctor is not an enemy or a boss handing out a list of impossible rules that you will get graded on at your next appointment. Rather, they are a guide to help you meet your health and life goals. An honest discussion can be the starting point that will help you improve your sex life, become a father or feel more in control of your life. It’s worth the awkward conversation.
- Ahmad Majzoub and Edmund Sabanegh, Jr, Testosterone replacement in the infertile man, Transl Androl Urol. 2016 Dec; 5(6): 859–865.
- Guay AT, Jacobson J, Perez JB, et al. Clomiphene increases free testosterone levels in men with both secondary hypogonadism and erectile dysfunction: who does and does not benefit? Int J Impot Res 2003;15:156-65. 10.1038/sj.ijir.3900981
- Taylor F, Levine L. Clomiphene citrate and testosterone gel replacement therapy for male hypogonadism: efficacy and treatment cost. J Sex Med 2010;7:269-76.
- Ramasamy R, Scovell JM, Kovac JR, et al. Testosterone supplementation versus clomiphene citrate for hypogonadism: an age matched comparison of satisfaction and efficacy. J Urol2014
- Katz DJ, Nabulsi O, Tal R, et al. Outcomes of clomiphene citrate treatment in young hypogonadal men. BJU Int 2012
- Patankar SS, Kaore SB, Sawane MV, et al. Effect of clomiphene citrate on sperm density in male partners of infertile couples. Indian J Physiol Pharmacol 2007
- Wang C, Chan CW, Wong KK, et al. Comparison of the effectiveness of placebo, clomiphene citrate, mesterolone, pentoxifylline, and testosterone rebound therapy for the treatment of idiopathic oligospermia. Fertil Steril 1983
- Turek PJ, Williams RH, Gilbaugh JH, 3rd, et al. The reversibility of anabolic steroid-induced azoospermia. J Urol 1995
- Roth MY, Page ST, Lin K, et al. Dose-dependent increase in intratesticular testosterone by very low-dose human chorionic gonadotropin in normal men with experimental gonadotropin deficiency. J Clin Endocrinol Metab 2010
- Coviello AD, Matsumoto AM, Bremner WJ, et al. Low-dose human chorionic gonadotropin maintains intratesticular testosterone in normal men with testosterone-induced gonadotropin suppression. J Clin Endocrinol Metab 2005
- Raven G, de Jong FH, Kaufman JM, et al. In men, peripheral estradiol levels directly reflect the action of estrogens at the hypothalamo-pituitary level to inhibit gonadotropin secretion. J Clin Endocrinol Metab 2006
- Handelsman DJ. Testicular dysfunction in systemic disease.Endocrinol Metab Clin North Am 1994
- W Ronde W, De Jong FH. Aromatase inhibitors in men: effects and therapeutic options Reprod Biol Endocrinol. 2011; 9: 93.
- Roth MY, Amory JK, Page ST. Treatment of male infertility secondary to morbid obesity. Nat Clin Pract Endocrinol Metab. 2008;4:415–419.
- de Boer H, Verschoor L, Ruinemans-Koerts J, Jansen M. Letrozole normalizes serum testosterone in severely obese men with hypogonadotropic hypogonadism. Diabetes Obes Metab. 2005;7:211–215
- Loves S, Ruinemans-Koerts J, de Boer H. Letrozole once a week normalizes serum testosterone in obesity-related male hypogonadism. Eur J Endocrinol. 2008