Society has increasingly witnessed more and more men falling prey to hypogonadism (low testosterone – Low T). On the one hand, it’s a condition we’re more aware of, and treatment options and abilities have increased. On the other hand, it appears many lifestyle interactions may also be relevant to the men who fall into the Low T category. In any event, low testosterone is often accompanied by less than optimal sperm production and motility. Unfortunately, traditional testosterone therapy (testosterone replacement therapy or TRT) can also have a negative impact on semen. There are, of course, men who simply have low sperm counts for other reasons.
Preserving Fertility While on TRT
As more and more men are undergoing TRT and having children later in life, one important factor for some is preserving their ability to conceive until the time is right. It is for this reason, many men through fertility treatment plans have used HCG, Aromatase Inhibitors (AI’s), and Selective Estrogen Receptor Modulators (SERMs) to help increase sperm motility and count. These items can also be used to increase testosterone intratesticular, which is imperative for spermiogenesis.
For the man who suffers from low testosterone and wishes to conceive, the use of exogenous testosterone may be problematic to his end goal. Exogenous testosterone causes LH and FSH production to cease, which is detrimental to sperm production, especially that of FSH. While direct exogenous testosterone use coupled with hCG may, in fact, help preserve fertility, for the man actively attempting to conceive, this may not be a viable option. His production of semen may still be too low while using testosterone in spite of the accompanying hCG.
Holistically Increasing Testosterone and Semen
If an individual’s testosterone levels are low but still within a semi-healthy range, and if he wishes to conceive soon, his best bet is going to be a holistic approach. For such a man, losing weight if he is overweight and cleaning up his diet with proper nutrient balance along with regular exercise may increase his testosterone production, in turn, possibly increasing his potency. It is by no means guaranteed this will work, but it’s often the first best step for such an individual before beginning some type of therapeutic regiment. Along with diet and exercise, limiting stress and ensuring one gets enough sleep will be equally important. The following should be implemented through such an approach:
- Avoid being overweight
- Minimize caffeine
- Ensure proper nutrient balance in diet
- Low to no sugar intake
- Resistance training 3-4 days per week, 30-40 minutes per session
- 7-8 hours of uninterrupted sleep per night
- Finding a way to relax and reduce stress every day: an hour a day of alone time per day is useful to reduce stress. Use this time to read, meditate, or any other stress-reducing activity.
- Being aware of the potential exposure to environmental toxics like pesticides, flame retardants, and plastic monomers that decrease testosterone and sperm counts.
SERMs to Increase Testosterone and Semen
Clomiphene citrate (Clomid) is a SERM that was first produced in the 1960’s and has been used as a fertility aid ever since. First developed for female ovarian stimulation, it has since been used, off-label, for treatment in men. SERMs like Clomid and also tamoxifen citrate (Nolvadex) have the ability to prevent the negative feedback loop on the HPG axis, which can result in the increase of both LH and FSH from the pituitary. This can result in increases in testosterone levels, LH, FSH and spermatogenesis. Typical doses for men receiving Clomid, the most commonly prescribed SERM, range from 25mg every other day to 50mg every day for the purpose of increasing testosterone without decreasing sperm count. However, some men may not experience improvements in libido with the use of clomiphene.
hCG to Increase Testosterone and Semen
Another possible strategy for increasing testosterone while also trying to conceive has increasingly become Human Chorionic Gonadotropin (hCG). While this only applies to those suffering from secondary hypogonadism, it is perhaps the most effective means of increasing testosterone levels while also promoting enhanced spermatogenesis. Treatment with hCG mimics LH; specifically, it is an analogue to LH. This will effectively cause the testes to begin their own natural testosterone production and also increase testosterone inside the testicles, which is imperative to the production of semen. Typical doses for such purposes may run 1000-2500iu per day; some fertility specialists may prescribe even more for this particular use.
Other possible treatments may include aromatase inhibitors (AI’s) such as anastrozole or letrozole. However, such plans are somewhat rare. AIs can increase testosterone by reducing the negative feedback on the HPG axis via a reduction in serum estrogen, thereby increasing gonadotropin levels. However, this is often not a preferred method of treatment as it may result in E2 levels that are too low for proper health and function.
Measuring 17-OHP to Determine Fertility Treatment Efficacy
Another important factor: Intratesticular testosterone can be measured through the biomarker 17-hydroxyprogesterone (17-OHP). This may be useful in determining if direct testosterone therapy is needed or if alternative treatment measures, such as those discussed above, are the more viable options. Studies have shown men supplementing with exogenous testosterone to have undetectable levels of 17-OHP and men supplementing with Clomid or hCG to exhibit increases in 17-OHP. 17-OH has been directly linked to sperm count, so if your level is low, so will your sperm count. The 17-OH progesterone test is a faster way to determine if hCG or clomiphere are improving your testicular function to a healthy level without having to wait for the three to four months required to measure sperm counts after starting treatment. Understanding where the patient’s 17-OHP stands may help the physician better understand how to proceed with fertility treatment plans.
Testosterone Therapy Without Low Sperm Count
There is a new form of exogenous testosterone that has shown promising results in men who need testosterone treatment but also wish to conceive. As traditional testosterone treatments lower sperm count, Natesto, a specific nasal testosterone gel used twice per day, may not have a strong or negative impact. Studies have shown Natesto “to increase serum testosterone levels while maintaining semen parameters.” It has been theorized this occurs the gel consist of “short-acting properties,” thereby having a less significant impact on the HPG axis. However, more studies will need to be done to confirm as well as provide a better understanding of this nasal gel in how it may impact fertility. Other testosterone replacement options like a twice per day oral testosterone undecanoate are also being explored to minimize the impact of testosterone on the HPG axis.
Chu KY, Achua JK, Ramasamy R. Strategies to increase testosterone in men seeking fertility. Turk J Urol 19.10.2020.