At some point in life, every male will start to notice the signs and symptoms of low testosterone. They will notice a decline in energy, decrease in strength and endurance, difficulty losing fat, a drop in libido, less than optimal erections, and changes in their mood. For most men this starts to happen in their late 30’s and 40’s, but I see more and more men in their twenties who have symptoms of low testosterone and when I check their levels they are in the bottom quartile of the normal range or even deficient. For these younger males, using human chorionic gonadotropin (HCG) and clomid is preferential to boost testosterone versus using testosterone supplementation.
1. What is the harm of starting a younger male on testosterone right away?
The first question I ask every male patient that comes into my office asking about hormone replacement therapy and testosterone treatment is if they still have plans to have children in the future. When you give men testosterone either via a cream or injection, it turns off the body’s natural production of testosterone. It does this by creating a negative feedback loop on the area of the brain that regulates testosterone production, the hypothalamus and pituitary gland. In most cases, this is irrelevant because the man is not producing enough testosterone in the first place and is symptomatic. However, the hypothalamus and the pituitary also signal the testicles to make sperm. The pituitary gland will secrete something called follicle stimulating hormone (FSH) which signals the sertoli cells in the testicles to make sperm. Using testosterone will ultimately cause your FSH levels to drop to <0.2 (essentially zero) and as a result your sperm counts will decline. I would estimate that 90% of my patients on testosterone supplementation have an FSH level of zero and I know this because I check levels frequently. Using testosterone does not guarantee that your sperm counts will decline to where it affects fertility, however, in my experience treating thousands of patients it significantly impacts sperm counts. 2. What alternative treatments are there to boost testosterone levels?
In men who wish to preserve fertility, I will typically use a combination of daily human chorionic gonadotropin (HCG) injections and an oral capsule of clomid at various strengths and taken anywhere from once per week to daily, depending on results. HCG mimics a hormone called luteinizing hormone (LH) which is produced primarily in the pituitary gland in the brain. In men, LH signals the leydig cells in the testicles to start producing testosterone. HCG is structurally very similar to luteinizing hormone and when men inject it, the HCG will bind to LH receptors on leydig cells and trigger them to produce testosterone. The result is that the body naturally starts making more testosterone on its own.
Clomid works differently to help the body naturally produce more testosterone. When men produce testosterone, it gets metabolized to tow things, estradiol and dihydrotestosterone. One of the ways the brain determines how much to stimulate the testicles to make testosterone is by sensing how much estradiol there is circulating in the blood. Generally, the higher the testosterone level, the higher the estradiol level. Clomid works by blocking the pituitary’s ability to detect estradiol in the blood and as a result it thinks that testosterone levels are low. This triggers the pituitary gland to make more FSH and LH and thereforefurther promote the natural production of testosterone. In my practice I get a wide range of results when using HCG and clomid. Some men respond to HCG alone and others need high doses of HCG and daily doses of clomid combined. The results for many men are exactly the same, compared to men injecting testosterone. Recently I had two men with testosterone levels in the 1200’s using this protocol and they felt fantastic. More importantly, they both maintained excellent sperm counts which we tested using Lab Corp.
3. What if I have been on testosterone and have surpassed sperm counts and now want to have kids?
This scenario happens more frequently that people realize. I have seen numerous younger men in my practice who have been on testosterone for a few years with FSH levels os <0.2 and are making no sperm. There have been a few published studies recently which demonstrated that if you use high dose HCG (1,500 units daily) and clomid 30-50mg daily that it will take 3-12 months for the testicles to start making sperm again. In the use of published studies looking at this, most men were able to regain fertility on this protocol. The problem is that in medicine we cannot guarantee patients that once their sperm counts go to zero that they will be able to father children. It is for that reason,younger men should take the more conservative approach of using HCG and Clomid prior to using testosterone. Lastly, the question becomes what to do if you have been using HCG and clomid,your testosterone levels don’t improve, and you remain symptomatic? This happens frequently in my practice and these patients will generally end up using testosterone. I will still keep them on HCG injections 3x per week and have them go and free/donate sperm and speak to a fertility specialist. Below is a link to a study looking at time to recover sperm counts in men with suppressed sperm counts as a result of testosterone therapy. https://www.ncbi.nlm.nih.gov/pubmed/27855957
Unfortunately, every male will experience a decline in testosterone levels at some point in their life. For most this will occur in the 4th decade of life and beyond, but for many, this can start happening in their twenties (see my video on traumatic brain injury to see why) and is debilitating. The good news is that we have safe and proven treatments to boost testosterone while preserving sperm production and fertility. If you are suffering from symptoms of low testosterone and would like me to review your labs, you can do so by contacting my staff through my website at www.DoctorBreen.com