Testosterone Therapy and Fertility: How To Treat Symptoms Without Closing Doors

Testosterone therapy helps some men feel better, but it collides with fertility because exogenous testosterone suppresses pituitary signals that drive testicular testosterone and sperm production. That conflict is manageable if you plan ahead. The steps are straightforward. Define the problem, set priorities, choose tools that match those priorities, and monitor with real data.

Start with a real evaluation

Before any therapy, write down goals for energy, libido, body composition, mood, and fertility. If children are in the plan, even hypothetically, treat fertility as a separate outcome with its own testing. Think it through carefully. Baseline semen analysis gives count and motility. Baseline hormones should include morning total testosterone on two days, sex hormone-binding globulin if needed, LH, FSH, and prolactin. Review sleep apnea, alcohol, training, body weight, and medications that lower testosterone or impair erections. Many reversible factors hide in that list and are simple to address.

Understand the mechanism

Exogenous testosterone suppresses LH and FSH from the pituitary. Intratesticular testosterone falls, and spermatogenesis slows or stops. Some men maintain function for a while, but most will see sperm parameters decline. If a pregnancy is wanted in the next year, do not start standard monotherapy without a plan.

One exception to that is intranasal testosterone which has less of a suppressive effect on sperm production.

Options that preserve fertility

There are three main paths. First, human chorionic gonadotropin with testosterone to maintain intratesticular testosterone in some men. Second, selective estrogen receptor modulators such as clomiphene or enclomiphene to raise endogenous testosterone without suppressing LH and FSH, often used as an alternative to exogenous testosterone in men who still want children. Third, hCG with or without FSH when a man on therapy needs near-term fertility and wants to restart spermatogenesis. These approaches are off-label and should be run with a clinician who does this work.

A newer more novel method is intranasal testosterone as well.

When fertility is needed soon

Men on therapy who decide to pursue pregnancy in the next few months usually stop testosterone and start hCG depending on their test results. Recovery of sperm production is not instant. Timelines vary from a few months to a year or more. Patience and follow-up semen analyses are part of the plan. If banking is possible before therapy, do it. It avoids pressure later.

When symptoms matter but fertility is a firm goal

In symptomatic men with low testosterone who want children, clomiphene (aka Clomid) or enclomiphene can raise endogenous production and improve symptoms while preserving fertility. These are not perfect solutions. Some men feel better, others do not and generally the weakness of a medication like Clomid is that it sometimes improves lab numbers without fixing the symptoms. Next, sperm parameters still deserve monitoring. If response is poor, a trial of TRT with concurrent hCG is an option for selected cases, with a clear endpoint and monitoring.

Monitoring that actually helps

Track symptoms and function, not just numbers. The numbers can improve but the symptoms may not. General lab monitoring includes hemoglobin/hematocrit, lipids, creatinine, liver enzymes, total and free testosterone. Check PSA when indicated. If fertility is a goal, schedule semen analyses at realistic intervals rather than guessing. Coordinate care with a reproductive specialist when timelines are tight or when recovery is slow. Put everything on one page so the plan is obvious.

Do the basics in parallel

Sleep apnea treatment, weight loss when indicated, strength training, and moderate alcohol are not side notes. They move testosterone, erectile function, and mood in the right direction. They also reduce the dose needed if therapy is used at all. Many men feel better on fewer drugs when sleep is treated and training is consistent.

Language and expectations

Not all low numbers are the same. Distinguish primary from secondary hypogonadism. If LH and FSH are suppressed, check for contributors like sleep loss, heavy alcohol, or opioids. If LH and FSH are high, testicular failure is more likely.

Side effects and risk management

Erythrocytosis is common with exogenous testosterone and it's not always dose dependent. Check hematocrit and hemoglobin and adjust dose or interval rather than ignoring the number. Acne, edema, and changes in mood can appear. These are dose dependent. Discuss fertility trade-offs and contraception because accidental pregnancies can happen when parameters are “low but not zero.” Clarify nitrate use when PDE5 inhibitors are part of care.

Hypertension is also not uncommon due to increased water retention. Likewise, exogenous testosterone can upregulate fatty liver disease and increase it. HDL levels can be suppressed and LDL levels can have a modest increase. The combination of these can raise the risk for atherosclerosis.

The key point

Testosterone therapy and active fertility goals conflict without planning. With forethought and the right tools, many men can treat symptoms and preserve options. Write the plan, set the checkpoints, and stick to them.

At True North Metabolic men's health clinic, we provide TRT services that are mindful of fertility status.

References

Hsieh TC et al. Concomitant hCG during TRT maintains intratesticular testosterone. J Urol. 2013; follow-ups 2018–2022.

Krzastek SC et al. Enclomiphene for secondary hypogonadism. Reprod Biol Endocrinol. 2019.

Patel AS et al. TRT, fertility impact, and recovery timelines. World J Mens Health. 2019