Testosterone Therapy and Fertility: What to Know Before You Start

You are tired, your libido is down, and testosterone keeps coming up in ads and conversations. You also hope to have children in the next few years. Those two goals can pull against each other, and it is far better to know that before the first dose than after.

Why Testosterone Can Lower Sperm Counts

Your testicles make sperm with help from two signals sent by the brain: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Sperm production also depends on a high level of testosterone inside the testicles themselves, much higher than the level in your blood.

When testosterone comes from outside the body, as a gel, injection or pellet, the brain senses plenty of it and turns down LH and FSH. Testosterone inside the testicles then falls, and sperm production can drop, sometimes to zero. A review in Translational Andrology and Urology explains this and notes that both users and health care professionals are often unaware of it.

This can happen even when your blood testosterone looks normal or high on treatment. A good blood level does not mean healthy sperm production.

What the Guidelines Say

The major guidelines agree on the basic point:

• The American Urological Association (AUA) testosterone deficiency guideline says testosterone should not be prescribed to men who are currently trying to conceive. It also says the long-term effect on sperm production should be discussed, and that men interested in fertility should have a reproductive health evaluation before treatment.
• The AUA and American Society for Reproductive Medicine male infertility guideline says clinicians should not prescribe testosterone to men interested in current or future fertility.
• The Endocrine Society guideline recommends against testosterone therapy in men planning fertility in the near term.

What to Tell and Ask Your Clinician

The single most useful thing you can say at a testosterone visit is whether you might want children, and roughly when. "Maybe someday" counts. Also mention:

• Any testosterone, anabolic steroids or hormone products you use now or have used, including from nonmedical sources.
• Any past fertility testing or semen analysis, for you or your partner.
• How long you and your partner have been trying, if you are trying now.
• All medicines and supplements you take.
• Past problems with your testicles, such as injury, surgery or infection.

Then bring your own questions. These are a good start:

• Could testosterone therapy affect my ability to have children, and for how long?
• Should I have a semen analysis before any treatment?
• Is there a cause for my low testosterone that we should look at first?
• Are there options that may help my symptoms without lowering sperm production, and what are their risks?
• Would any of those options be off-label, and what monitoring would they need?
• Should I think about storing sperm before any hormone treatment?
• When should I see a urologist or fertility specialist?

Options a Clinician May Discuss

If you have symptoms and confirmed low testosterone but want to protect your fertility, testosterone therapy is usually not the first step. What may be discussed instead depends on your labs, your history and your timeline.

• Looking for a cause. Sleep problems, weight, alcohol, some medicines and other health conditions can all affect testosterone. The AUA guideline says all men with testosterone deficiency should be counseled on lifestyle changes.
• Medicines that work differently. The AUA guideline says clinicians may use certain other medicines, from groups called aromatase inhibitors, selective estrogen receptor modulators and human chorionic gonadotropin (hCG), in men with low testosterone who want to maintain fertility. This is a conditional recommendation, many of these uses are off-label, and they are not right for everyone.
• A reproductive evaluation first. A semen analysis and a visit with a urologist or fertility specialist can give you a baseline before any hormone decision.

These are topics for a conversation with a prescriber who knows your history. They are not do-it-yourself options, and some carry their own risks and monitoring needs.

If You Already Take Testosterone

If you are on testosterone and now want children, talk with your prescriber before changing anything. The review in Translational Andrology and Urology reports that, in studies of testosterone as a male contraceptive, most men regained normal sperm production within a year of stopping. Recovery varies from person to person, though, and stopping can bring back the symptoms that led you to treatment.

A urologist with fertility experience can help plan how and when to stop and whether other treatment makes sense while your body recovers.

When to See a Fertility Specialist

The AUA and ASRM male infertility guideline describes infertility as not conceiving after 12 months of trying when the female partner is under 35, or after 6 months when she is 35 or older. It recommends that both partners be evaluated at the same time. For men, the first evaluation includes a reproductive history and one or more semen analyses.

Consider asking for a referral sooner if you have used testosterone or anabolic steroids, have known low testosterone, or have a history of testicular problems. A urologist with fertility training, or a fertility clinic that sees both partners, is a good place to start.

Next Steps

If you want a careful workup that takes your family plans into account, learn about our testosterone consultation. Before your visit, read how to prepare for a testosterone blood test and what a low testosterone evaluation can and cannot tell you. When you are ready, book a visit.