Low Testosterone in Men – What You Should KnowNormal testosterone levels are necessary to provide an optimal environment within the testicles for normal sperm production. Testosterone levels also play a role in libido, erectile function, and ejaculatory function. There are many different reasons—some reversible, others not—for a man of reproductive age to have low testosterone levels:. As men get older, they tend to low testosterone normal sperm count lower levels of total testosterone. They also have higher levels of SHBG sex hormone binding globulinwhich decreases free and bioavailable testosterone levels. In many tfstosterone, no specific cause can be found for the low testosterone level, though we can speculate that there is likely some genetic abnormality affecting either the hormonal process that stimulates the testicles to low testosterone normal sperm count testosterone or the actual production of testosterone within the brassinosteroid biosynthesis inhibitors. This is the most common scenario when we find hypogonadism in younger men seeking treatment for infertility issues.
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Normal testosterone levels are necessary to provide an optimal environment within the testicles for normal sperm production. Testosterone levels also play a role in libido, erectile function, and ejaculatory function. There are many different reasons—some reversible, others not—for a man of reproductive age to have low testosterone levels:.
As men get older, they tend to have lower levels of total testosterone. They also have higher levels of SHBG sex hormone binding globulin , which decreases free and bioavailable testosterone levels. In many cases, no specific cause can be found for the low testosterone level, though we can speculate that there is likely some genetic abnormality affecting either the hormonal process that stimulates the testicles to produce testosterone or the actual production of testosterone within the testicles.
This is the most common scenario when we find hypogonadism in younger men seeking treatment for infertility issues. This is a known risk factor for hypogonadism, with studies showing that over 50 percent of obese males have low testosterone levels. Weight loss can boost testosterone levels in overweight men. Reducing alcohol consumption to less than four drinks a week may help. Studies have shown that up to 75 percent of men on long-term narcotics have low testosterone levels.
Prolonged use of methadone carries an especially elevated risk of hypogonadism. Cessation or significant reductions in narcotic use can help to improve testosterone levels. Large varicoceles have been associated with lower levels of testosterone production.
Small varicoceles are unlikely to have much impact on T levels. See the "Varicoceles" section for more information. Temporary decreases in testosterone levels may result from an acute illness or from significant trauma to the body. Lesions of the pituitary gland such as a tumor or damage from trauma or radiation can also result in decreased LH production.
This involves providing androgens directly in the form of hormone replacement injections, patches, gels, pellets , anabolic steroids, prohormones, or testosterone boosters. A key point in the management of male fertility is that increased endogenous production of testosterone in hypogonadal men can help to improve semen parameters and fertility, while exogenous testosterone administration causes significant drops in sperm counts and fertility.
Unfortunately, this seemingly basic concept is not as widely known as it should be within the medical community. I regularly see primary care physicians and even some urologists prescribing exogenous androgens to young male patients who are trying to have children. Hypogonadal men who are trying to have children or who would like to have children in the future should instead be treated with medications that increase their own endogenous testosterone production. This causes the testicles to make more testosterone.
Examples of SERMs include:. This is the most commonly used SERM for male fertility-related hypogonadism. Its use is reviewed in detail. Not generally used in the treatment of male hypogonadism. Similar to clomiphene but isolating only its biologically active isomer, enclomiphene was developed by. It is currently being investigated for use in hypogonadal men and undergoing FDA review. Aromatase is an enzyme located within the testicles, liver, and fat cells. Aromatase inhibitors are oral medications that decrease the action of the enzyme aromatase, thereby lowering the levels of estradiol while increasing testosterone levels.
Aromatase inhibitors are also used in the treatment of breast cancer in women due to their estrogen-lowering effects. Types of aromatase inhibitors include:. Anastrazole is the most commonly used aromatase inhibitor for male fertility-related hypogonadism. Its use is reviewed in detail in the "Anastrazole" section of this. This medication is commonly used in female infertility treatments but is not generally used for male infertility at.
Letrozole is also non-steroidal and therefore does not affect adrenal function. Testolactone is used by some urologists in the treatment of male hypogonadism, and it is thought to potentially. The primary downside of testolactone. Another steroidal aromatase inhibitor. Exemestane is generally not used in the treatment of male. HCG has a mechanism of action similar to that of luteinizing hormone LH.
HCG is generally considered to be stronger than clomiphene and anastrazole, but it is also more expensive and needs to be given by injection. While there may be some evidence that testosterone levels increase slightly with strength training, the evidence is controversial. Furthermore, the increases in blood testosterone levels are minimal and would not be expected to have any significant clinical impact on fertility.
For the treatment of low testosterone in men who wish to conceive children, clomiphene is usually the first choice due to its ease of use it comes in pill form and relatively low cost. Occasionally patients are immediately started on the stronger HCG injections without trying oral clomiphene or anastrazole first, such as in men who have been taking long-term exogenous testosterone replacement or anabolic steroids.
These men often do not respond well to oral clomiphene or anastrazole, and going straight to HCG is sometimes the best choice. There is some controversy among fellowship-trained experts regarding the use of medications to treat decreased sperm count in men with low testosterone levels. If FSH levels are normal or high, then some experts feel that increasing testosterone levels does not provide much fertility benefit unless testosterone levels are extremely low.
Definitive double-blind studies are difficult to perform, since infertile couples are understandably not often eager to sign up for a trial in which they might wind up in the control group of patients being given a placebo sugar pill for a year instead of in the group receiving a medication that could increase their chances of having a baby.
Despite the lack of definitive clinical data, I often opt for prescribing medication: Hormone values tend to respond within one to two weeks of starting a man on therapy.
Generally, repeat blood levels are drawn about two weeks after starting any new medication or after a change of medication dosage in order to assess the response. I also look for improvement in the symptoms of low testosterone which include decreased energy, reduced libido, decreased sexual function, etc. Some men see improvements in just a few days, while in others it may be three to twelve months before they see maximal improvement.
The spermatogenic cycle the length of time for a sperm precursor cell to form into a fully mature sperm is approximately ten weeks long, and so improvement in semen parameters generally occurs over the first one or two spermatogenic cycles roughly two and a half to five months after starting medications to enhance endogenous testosterone production.
I generally check a semen analysis around ten weeks after starting or adjusting medications, as long as the hormone levels have normalized on this medication regimen, but I remind patients that a repeat semen analysis in another ten weeks may be necessary. If a man with fertility problems is diagnosed with low testosterone and started on clomiphene, anastrazole, or HCG, the following is a general protocol that can be used although individual fertility doctors may have variations of this protocol in terms of timing and tests ordered:.
After two weeks, do a blood test between the hours of 7: The diagnosis code that can be used for this test is currently E The testing should include:. Adjust medication as needed with repeat blood tests two weeks after every medication change until hormone levels have.
Have a semen analysis about ten weeks after hormone levels have normalized. Modifications to this timeline will sometimes need to be made. An example would be a situation in which time is of the essence, such as when the woman is over forty years old, in which case repeat semen analysis testing may be moved up to an earlier date.
It is important to remember that it takes about ten weeks for a sperm precursor cell to develop into a fully mature sperm, and in order to optimize sperm numbers and quality, the proper environment is needed for this whole period.
Taking hormonal medication for just one or two months is not going to have a significant long-term impact on sperm quality. Male hormonal treatments are intended to be taken over the long term, typically until a pregnancy has been established.
Sometimes multiple medications to increase endogenous testosterone production are used in combination. Of course, any time you combine medications you have higher costs, as well as increased potential for side effects. One combination that typically does not work very well to raise endogenous testosterone production is clomiphene plus HCG. The reason is that clomiphene works by increasing LH secretion from the pituitary, and HCG is already increasing the LH levels in the bloodstream directly.
A better combination in terms of T production is combining anastrazole with either clomiphene or HCG. Since anastrazole works in a completely different manner than clomiphene or HCG, it can complement their effect on testosterone production while also keeping estradiol levels from getting too high.
He therefore decreases his HCG dosage to 1, IU three times per week and adds anastrazole 1 mg every other day to lower his elevated estradiol levels. In this situation, the Leydig cells that produce testosterone within the testicles are presumably not functioning properly and do not respond to LH stimulation. From a fertility standpoint, one can only maximize the hormonal environment as much as possible with the HCG and anastrazole and then, after the couple is done having children, change to exogenous testosterone replacement therapy.
There have been some case reports of men who have developed antibodies against HCG, making it less effective. Antibodies would not be expected to be the problem in men who have little or no remaining testicular tissue because of previous surgical removal or trauma, but they may be suspected in men who have some response to clomiphene but no significant response to HCG. Some experimental treatments have been suggested in an attempt to circumvent the antibody activity such as plasmapheresis , but no effective standard treatment has been identified.
An option would be to try HCG therapy in the form of Ovidrel, since this medication is made through genetic manipulation of bacteria as opposed to most of the other HCG formulations, in which the HCG is extracted from the urine of pregnant women , and therefore may have a chance of being more effective in the face of antibodies. The American Society of Andrology recommends that men with any of the following contraindications should not start testosterone replacement:.
The American Society of Andrology ASA has published guidelines for labs and other evaluations for men who are on testosterone replacement therapy:. PSA is a blood test that serves as a screening tool for prostate cancer. Testosterone makes prostate cancer grow, so men with prostate cancer would not want to increase their testosterone levels.
Prostate cancer is rare in young men, and the new American Urologic Association guidelines do not recommend screening for prostate cancer in men less than forty years of age. Men between the ages of forty and fifty-four should be screened only if they have certain risk factors, such as a family history of prostate cancer or are of African American descent.
In this screening test, the doctor places a gloved finger in the rectum to palpate the prostate gland for any nodules or other abnormalities. Along with a PSA test, the digital rectal exam is used by urologists and primary care physicians to screen for prostate cancer.
This test measures the percentage of red blood cells in the bloodstream. Elevated levels of testosterone can increase the hematocrit in some men, which can increase their risk of developing clotting problems, such as stroke or heart attack. Elevated testosterone levels can cause enlargement of the prostate in some men, especially as they get older. An enlarged prostate can block the flow of urine and cause symptoms such as a slow urinary stream and difficulty emptying the bladder.
These symptoms are rare in young men but can occur in some circumstances. Assessment for symptoms of urinary obstruction can be performed in older men, or younger men with a history of benign prostatic hyperplasia BPH, or enlarged prostate or voiding problems. A simple review of voiding symptoms is fine in most men. All men with low testosterone levels are at an increased risk for developing osteoporosis, or weakening of the bones, and should receive counseling on osteoporosis prevention.