Will Being on TRT Make a Man Sterile?

Understanding the effects of testosterone on male fertility and reproductive functioning.

We are often asked by men interested in starting TRT the question “Does testosterone therapy cause infertility?” Testosterone replacement therapy in men is a popular therapeutic treatment option for men with low T looking to improve their overall health, wellness, and vitality, but what about its effect on sperm production and fertility in male patients? TRT is often prescribed to address various health concerns in men, with signs and symptoms such as fatigue, low libido, mood swings, decreasing muscle mass and weight gain. Yet there are significant questions and concerns about its impact on male fertility.  While testosterone therapy can provide relief from these and other symptoms associated with low T, (also known as hypogonadism), its effects on male fertility are complex and multifaceted and worth discussing.

To understand the relationship between testosterone therapy and male fertility, it's essential to grasp how testosterone is produced and how it affects the male reproductive system. Testosterone, the primary male sex hormone, plays a crucial role in sperm production, libido, and overall sexual function. Therefore, alterations in testosterone levels can have profound implications for fertility. Testosterone production in men primarily occurs in the testes, specifically within specialized cells called Leydig cells. Every male will have a different testosterone level so it’s difficult to say exactly what a normal testosterone level is.

These cells, located in the interstitial tissue surrounding the seminiferous tubules, respond to hormonal signals from the hypothalamus and pituitary gland. This intricate process, known as the hypothalamic-pituitary-gonadal axis, regulates testosterone synthesis. The pituitary gland secretes two key hormones to stimulate testosterone and sperm production in men: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH signals the Leydig cells in the testes to produce testosterone, while FSH stimulates the production of sperm in the seminiferous tubules. This coordinated action regulates male reproductive function.

Exogenous testosterone can suppress the brain signals that support intratesticular testosterone and sperm production. Sperm counts can become very low or fall to zero. However, suppression varies, and TRT is not reliable contraception: pregnancy can still occur. Use appropriate contraception if avoiding pregnancy, and discuss fertility goals before starting treatment.

There have been several studies worth noting that have explored the impact of testosterone therapy on male fertility, yielding mixed findings. Some research suggests that testosterone therapy can indeed suppress sperm production, leading to a decline in sperm count and motility. However, the extent of this effect can vary depending on factors such as the dosage of testosterone administered, the duration of treatment, and individual patient characteristics.

A normal blood testosterone result during TRT does not mean sperm production is normal. Exogenous testosterone should not be presented as a way to improve sperm count or motility. Fertility-directed treatment aims to address the underlying reproductive problem rather than simply raise the blood testosterone number.

The cause of low testosterone matters when selecting treatment. Primary hypogonadism involves the testes; secondary hypogonadism involves the hypothalamic-pituitary signaling system. Exogenous testosterone can suppress sperm production in either setting. Some men with secondary hypogonadism may respond to specialist-directed gonadotropin treatment, whereas testicular failure can limit that response.

Men on testosterone replacement therapy (TRT) who wish to improve fertility can explore several methods:

hCG: This medication acts at the LH receptor and may be used for selected men with hypogonadotropic hypogonadism. It is not a guarantee of fertility, especially when added to ongoing TRT. Treatment selection and response require specialist assessment.

Gonadotropin treatment: A specialist may use hCG, with FSH added when appropriate, to stimulate testicular function in selected men with deficient pituitary signaling. These treatments are not interchangeable with testosterone replacement and are not appropriate for every cause of infertility.

Enclomiphene and clomiphene: These are selective estrogen receptor modulators. Clomiphene may be prescribed off-label for selected men; enclomiphene is not an FDA-approved standalone medication. A compounded enclomiphene product is unapproved, which is different from off-label use of an approved drug. Neither should be described as a routine, proven add-on to TRT for preserving fertility.

Clomiphene (Clomid) is FDA-approved for ovulatory dysfunction in women who desire pregnancy. Male use is off-label. Selection depends on the diagnosis, hormone findings, contraindications and fertility goals. The hCG and clomiphene comparison explains their different roles and limitations.

Reviewing TRT: Simply lowering the dose or changing its delivery method does not reliably protect fertility. Discuss a fertility-directed treatment plan with the prescribing clinician and a reproductive specialist; do not change treatment without clinical guidance.

Lifestyle Changes: Adopting a healthy lifestyle can also help to support fertility. This includes maintaining a healthy balanced diet, getting regular exercise, reducing stress, getting enough sleep each night, and avoiding excessive alcohol and tobacco use. This can often be hard to do, but the logic is sound and the effects have been well documented.

Consulting a Specialist: Men considering TRT who are concerned about fertility should consult with an expert in hormone replacement therapy, fertility specialist or endocrinologist. They can provide personalized guidance and may recommend additional treatments or interventions tailored to individual needs and goals. Not everyone has the same past medical history, goals or needs and this must be taken into consideration when creating a patient’s protocol.

Despite the potential risks associated with testosterone therapy, it remains a valuable treatment option for men with hypogonadism, especially when accompanied by debilitating symptoms. However, clinicians must carefully weigh the benefits of TRT against its potential impact on male fertility, particularly in men of reproductive age who want to start a family and have children.

The 2024 AUA/ASRM guideline advises against prescribing exogenous testosterone for men interested in current or future fertility. It finds evidence too limited to recommend adding hCG or other medications to continuing TRT as a fertility-preservation strategy. Discuss alternatives and whether sperm banking is appropriate before treatment.

Semen analysis assesses sperm concentration, movement and other features; a testosterone blood test or testicular size cannot substitute for it. When TRT is stopped, sperm production may take months, sometimes longer, to recover, and recovery is not assured for an individual patient. A specialist can guide testing and follow-up. See planning care when coming off TRT.

TRT can substantially impair fertility even when it improves low-testosterone symptoms. It is neither a fertility treatment nor reliable contraception. Discuss present and future family-building plans before starting therapy, and seek reproductive evaluation if fertility becomes a concern during treatment.

Website: www.NovaGenix.org   Telephone: (561) 277-8260 email info@novagenix.org

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Further sources: Endocrine Society testosterone guideline; Clomid FDA labeling; FDA guidance on compounded drugs.