Can TRT Cause Infertility in Men? Fertility Risks Uncovered?

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Are you considering starting TRT but may want a family someday? You aren’t alone. Many men who begin exploring testosterone replacement therapy (TRT) are shocked to discover that while it can help restore energy, mood, and muscle mass, it can also come with a serious risk to fertility. Although testosterone is central to male reproductive health, introducing testosterone from outside of the body may disrupt your hormonal system.

In this article, we will break down the relationship between TRT and male fertility, including how TRT affects sperm production, who is at the most risk, and what you can do to protect your fertility, even while boosting testosterone levels.

Why does TRT reduce sperm?

Your body performs such functions through a built-in regulatory mechanism called a negative feedback loop, which maintains hormone levels (like testosterone) within a designated range. When testosterone is introduced externally from that range (like from testosterone replacement therapy), your body thinks there is enough testosterone in your system and decreases natural testosterone production.

This means a couple of things for sperm:

• TRT can suppress the body's natural hormonal signals needed for sperm production to occur.
• The pituitary gland stops sending out gonadotropic hormones (LH and FSH) that signal the testes to produce sperm.
• This suppression may cause the sperm count to plummet—or even reach zero.
• In some instances, sperm production may never return to normal, even after the discontinuation of TRT.

Because of the potential to affect semen quality, fertility counseling should be completed prior to any testosterone-influencing treatment.

Can TRT cause male infertility?

Yes, it can. While TRT helps to alleviate symptoms due to low testosterone, TRT can positively affect sperm production. Several men only discover that their sperm count has been affected—sometimes to zero—after a semen analysis. 

This is how the hormonal path works: 

• The brain's hypothalamus monitors testosterone levels. 
• The hypothalamus tells the pituitary gland to release LH and FSH. 
• These hormones signal the testes to produce both testosterone and sperm. 

When the man starts taking exogenous testosterone on TRT, the brain is now getting high levels of testosterone and therefore thinks, "hey we've got enough testosterone," and shuts this process down, which can lead to infertility.

Risk Factors That Increase Fertility Problems with TRT

TRT does not influence everyone equally. Multiple factors will contribute to a person's risk for future fertility issues, and knowing this information will allow you to make the best treatment decisions for you.

Duration and Dosage of TRT

The duration of time while on TRT, and the dosage itself, will make a difference. The longer someone is on TRT, the more suppressed their natural sperm production will be. 

• Higher doses of testosterone will result in further suppression of LH and FSH.
• Long-term treatment may result in a permanent shutdown in sperm production.
• A lower dosage may pose less risk of lower sperm production, but there is never zero risk. 

Recovery of fertility after cessation of TRT may take several months - or may not happen at all - based on the length of treatment and the degree of suppression.

Age and Baseline Testicular Health

Younger men tend to fare better than older men when it comes to resuming normal sperm and testosterone levels following suppression. 

• As men age, they have a diminished hormonal response to low testosterone.
• Existing testicular issues, like varicocele or injuries, can lead to worse outcomes.
• The better the baseline function of the testicle at the outset = the better fertility prospects down the road. 

The older you get, or the poorer the health your testicles are in, the more cautious you should be about TRT and all of the reproductive health risks.

Preexisting Fertility Disorders

If you already have sperm problems (low count, poor motility, abnormal shape), embarking on TRT could make matters worse.

• Conditions like oligospermia or hypogonadism put you at even bigger risk.
• TRT could even suppress any paltry natural sperm production you have.
• And if you have clinical hormonal issues, like prolactin, that only complicates things further.

A full fertility workup prior to TRT can help with treatment planning. 

Lifestyle and Environmental Influences

If you have bad habits and are exposed to environmental toxins, then these will exacerbate the risks to fertility from TRT. 

• Smoking, being overweight, stress, alcohol, and poor eating habits will negatively affect sperm quality. 
• Environmental factors can also come into play. Endocrine disruptors such as BPA in plastic-perfumed chemicals or heavy metals can impact hormone signalling and could ultimately impact your fertility. 
• Also, sedentarity will negatively impact your natural testosterone production. 

A healthier approach to lifestyle as a whole prior to and throughout your TRT treatment could better position the body and its fertility.

Concurrent Medications and Health Conditions

TRT does not happen in isolation. All current medicines and health problems will affect the impact of TRT on your fertility. 

• Opioids, antidepressants, steroids, and chemotherapy will all have a negative impact on sperm production. 
• Diabetes, hypertension, and conditions such as infection (i.e. mumps) will all be detrimental to the testes.
• The more factors, the more risk.

Finally, collecting a full medical screen prior to starting TRT is also an important part of any potential identifying risks that may compound the risks to your fertility.

Alternative Treatments to TRT That May Preserve Fertility

Get testosterone elevation but not close the door on fatherhood? Good news—there are several non-TRT alternatives that can increase your body's own testosterone production--without shutting down sperm production.

Use of Clomiphene Citrate

Clomid is not just for women. It is an oral medication that can help stimulate natural testosterone and sperm production in men.

• Clomid competes with estrogen in the brain, resulting in amplified amounts of GnRH and subsequently increases in the amount of LH and FSH.
• These maturing hormones trigger your testes to make testosterone and sperm.
• Clomiphene is also perfect for younger men and men who are trying to have children.
• Clomiphene is often utilized either as a standalone therapy or as an adjunct to TRT in order to regulate the natural hormones again.

Human Chorionic Gonadotropin (hCG) Therapy

hCG is a hormone that mimics LH, preventing the testes from shutting down while on or off-trt.

• Maintains natural sperm levels.
• Prevents testicular atrophy.
• It can be used alone or with Clomid for better results.

Men often use hCG as a means of mitigating the cessation of spermatogenesis and testosterone production that TRT can result in while preserving fertility.

Aromatase Inhibitors as an Option

AIs like anastrozole lower estrogen, which lowers LH and FSH.

• Suitable for men presenting with both metabolic syndrome and increased estrogen levels (especially as a result of weight). 
• Helps in maintaining natural testosterone levels.
• It helps in maintaining sperm production and the overall balance of hormones.

All AIs should be prescribed and monitored, as there is a negative health rabbit hole of answering hypogonadal men with AIs for too long.

Lifestyle Interventions for Natural Testosterone Boost

Sometimes, you just need to give nature a boost.

• Strength training and cardio increase natural T.
• Weight loss can decrease estrogen (from belly fat).
• Zinc, Vitamin D, healthy fats and sleep all increase T.
• Avoid Toxins, processed foods and alcohol.

These simple changes can greatly improve both hormones and fertility.

Experimental and Emerging Therapies

Research is revealing some exciting new ways to increase testosterone without disrupting fertility.

• Selective Androgen Receptor Modulators (SARMs): These provide anabolic effects with limited hormonal disruption.
• Kisspeptin therapy: This is a peptide in your brain that can restart natural hormone signalling.
• Peptides like Gonadorelin: These are agents that mimic GnRH to induce the release of hormones from the pituitary.

All of these therapies are still experimental and promising alternative options for future TRT patients.

Strategies to Preserve Fertility While on TRT

With the necessity of TRT comes the reality of potential impacts on fertility. However, there are strategies available to protect your fertility. These include medications and natural approaches that together can help protect reproductive health. 

Co-administration of hCG with TRT

Perhaps the most common fertility-protecting option of concomitant hCG with TRT. 

• Keeps the sperm production process going. 
• It helps maintain guide testicular size and function.
• Dosage is typically 2-3 days a week. 

Many physicians now incorporate hCG into their TRT plan for younger men and men with family plans in mind.

Periodic TRT Drug Holidays

Taking time off from TRT may allow your body to reboot its natural production.

• Allows the hormone axis to reset.
• It can also be used with Clomid or hCG for improved recovery time.
• Symptoms may fluctuate during off-periods.

Best undertaken with the accompaniment of a medical professional.

Sperm Banking and Cryopreservation

You can bank or freeze your sperm before starting TRT, a fool-proof, simple backup plan.

• Sperm in storage can be used later for IUI, IVF or ICSI.
• Sperm banking is ideal for men looking at long-term or high-dose therapies.
• This offers peace of mind to you and provides potential options for the future.

Freezing your sperm is quick, non-invasive, and can be done at any local fertility clinic or facility.

Use of SERMs During TRT

Using medication, such as Clomid or tamoxifen, during TRT can lower the risk of losing fertility.

• They block estrogen feedback signals and maintain hormonal production.
• These types of medications help maintain your sperm count, as well as healthy size testicles.
• SERMs are often used in conjunction with hCG and/or testosterone for double protection.

This treatment option has become popular in men's clinics interested in providing options for men looking for fertility-based TRT.

Lifestyle Modifications to Support Fertility

Even if you are taking some medication for your HPG axis, your lifestyle matters. 

• Stay fit, lean, and active. Being a healthy weight means less conversion of testosterone to estrogen.
• Avoid anything that is known to damage fertility.
• Sleep well, manage your stress, and your hormones will be more balanced. 
• Eat a high-nutrient diet that supports fertility.

Practices add to the benefits that you could get from any treatment option.

Conclusion

TRT can alter your life for the better if you have low testosterone (as many men do!). However, there is a cost or trade-off associated with TRT. One of those trade-offs that some people are concerned with—we can help sort this out—is fertility suppression. This occurs when your body stops making sperm in response to external testosterone.

How can this be a good thing? First, fertility suppression can be managed or reversed with good planning, helpful support, and the proper treatment. Treatments include but are not limited to hCG, SERMs, sperm banking, and lifestyle support, which will allow you to have the best of both worlds—feeling your best while protecting your reproductive future.

At The KIF, we build TRT programs based on your lifestyle and fertility concerns. To get started, choose the free consultation ($0), and we will discuss your goals and concerns.

Our TRT starter kit is $249 and includes a full telehealth evaluation and a one-month prescription. Additionally, we will provide monthly TRT support tailored to your needs, and everything will be delivered straight to your door, all included in a monthly subscription.

If you need a refill, our TRT refill service is only $149/month, and guidance from our clinical team is included.

Your health, hormones, and ambitions about having a family are important. Contact The KIF, and we'll create a treatment plan that works for you on every level.