How Does TRT (Testosterone Replacement Therapy) Impact Fertility ?

 The same testosterone that helps deal with ED (Erectile Dysfunction), increase libido, build muscle tone, improve mood and reduce fatigue has a downside — infertility. A paradox, that the same hormone that positively impacts sexual function negatively impacts fertility when administered externally. It acts more as a contraceptive when it is not produced by the body itself.

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External source of testosterone disrupts the hypothalamic-pituitary gonadal axis, (HPG axis) which is like a traffic cop directing traffic. This in turn inhibits production of luteinizing hormone and follicle stimulating hormone which suppresses natural synthesis of testosterone affecting sperm generation in the testes.

Lack of natural testosterone also causes testicular shrinkage which affects the leydig cells that synthesize testosterone in the testicles. This intra-testicular process of testosterone synthesizing also plays an important role in sperm quality & motility, which is affected by the suppression of follicle stimulating hormone.

All forms of testosterone supplement — creams, injections or gel affect sperm generation due to hormone disruptions. Although, it is believed gels do not affect fertility as much. An experimental nasal spray still undergoing trials seems to hold promise in terms of not affecting fertility by reducing sperm generation.

What are the treatment options available to remedy infertility from TRT?

Infertility caused by TRT is reversible in most cases by stopping T-therapy. Reversal is quicker if the duration of testosterone replacement therapy is shorter, longer if TRT has been administered for a longer period.

For a small percentage of men, infertility from TRT may not be reversible. Age is a factor that impacts reversal. For older men, reversal from TRT induced infertility may not be feasible.

Consulting a male reproductive specialist is important before starting TRT. This facilitates thorough understanding of risks and options available if pursuing TRT and wanting children.

A baseline semen analysis with routine serum total testosterone, LH, and hematocrit before starting TRT helps identify decreased baseline sperm count and provides a baseline value for future semen analysis after TRT use.

Avoiding testosterone replacement therapy until after having children is better. Else, freezing sperm mitigates risk to a certain extent. Pregnancy via IVF or artificial insemination can be induced using the frozen sperm is another way to have children while on TRT.

Human chorionic gonadotropin(HCG) , a pituitary hormone, helps treat low T if a pituitary disorder is the cause, without affecting sperm generation.

Clomid or clomiphene citrate, an infertility treatment oral drug for women, is prescribed off-label for men desiring children who are on TRT. This medication helps luteinizing hormone and follicle stimulating hormone production which in turn helps the body produce testosterone naturally, to augment sperm generation.

If someone is on testosterone but infertile and wants children, a thorough physical exam, and history is captured by the reproductive specialist. Hormone testing, and at least two semen analysis with other tests as required. Along with stopping testosterone completely, semen and hormone analysis has to be repeated periodically, since it will take many months for sperm count to reach levels before TRT is initiated.

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