Testosterone (T) replacement therapy and fertility in men of reproductive age, "Beyond the Abstract," by Lindsey E. Crosnoe, BS, and Edward D. Kim, MD

BERKELEY, CA (UroToday.com) - Very simply stated, prescribing testosterone (T) therapy is bad for sperm production. As a urologist with specialty training in male fertility, I see men every week presenting with poor sperm counts while receiving testosterone prescribed by a health care professional. These men often state that their prescribing physician didn't ask whether they were interested in having children or maintaining their fertility.

The scope of the problem:

  1. In a recent survey of U.S. urologists, Ko, et al. observed that approximately 25% have used exogenous T to treat hypogonadism associated with male infertility. If that many urologists are unaware that exogenous T therapy has adverse effects on spermatogenesis, this lack of recognition may be even more common among primary care physicians (PCPs). PCPs are responsible for the majority of T prescriptions in the U.S. Because of the potential of T therapies to decrease spermatogenesis and the increasing number of men receiving hormone replacement therapy, this practice pattern is concerning.
  2. T prescriptions have been increasing by 30-40% annually in the U.S.
  3. Many younger men of reproductive age are being treated with T therapy. Additionally, men are fathering children at an older age.

The science:

  1. Exogenous T therapy suppresses production of luteinizing hormone (LH) by the pituitary gland via a negative feedback loop.
  2. As a result, the testicular production of T decreases dramatically. This decreased intratesticular production of T causes sperm production to decrease.
  3. Cessation of T therapy likely results in a restoration of baseline semen quality after 12-18 months, based on contraceptive trials with T. However, there is a paucity of information with the use of exogenous T for the treatment of hypogonadism.

Recommendations for treatment of hypogonadal men of reproductive age:

  1. Stop exogenous T therapy.
  2. The selective estrogen receptor modulator (SERM), clomiphene citrate, represents an effective therapy for men with low or normal LH levels. SERMs increase intratesticular production of T.
  3. Human chorionic gonadotropin (hCG) represents an alternative therapy, but is more labor-intensive regarding administration and expensive.

Conclusion:

An alarming number of physicians do not recognize that T therapy can cause male infertility. We need to prevent this iatrogenic cause of male infertility. Although Food and Drug Administration labeling for T therapies indicates that treatment may result in azoospermia or impairments of spermatogenesis, this warning/precaution is often not recognized.

The significance of this paper is that prior to its publication, there has been a distinct absence of expert recommendations on the topic of hormone replacement therapy in men of reproductive age.

Written by:
Lindsey E. Crosnoe, BS, and Edward D. Kim, MD, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

University of Tennessee Graduate School of Medicine, Knoxville, TN USA

The treatment of hypogonadism in men of reproductive age - Abstract

 

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