When should sperm count be checked in patients undergoing testosterone replacement therapy (TRT)?

Sperm Count Monitoring in Testosterone Replacement Therapy

Sperm count should be checked before initiating testosterone replacement therapy (TRT) in men interested in future fertility, and patients should be informed that exogenous testosterone typically suppresses spermatogenesis and may cause azoospermia. 1

Pre-Treatment Evaluation

• Fertility Assessment:

  • Men interested in preserving fertility should undergo testicular examination to evaluate size, consistency, and descent 1
  • Serum follicle-stimulating hormone (FSH) should be measured to assess underlying reproductive health 1
  • Consider semen analysis before starting TRT, especially if fertility is a concern 1

• Warning Signs:

  • Elevated FSH levels in testosterone deficient men (hypergonadotropic hypogonadism) typically indicates impaired spermatogenesis 1
  • Patients with severe oligospermia (<5 million sperm/mL) or non-obstructive azoospermia should be offered reproductive genetics testing (karyotype and Y-chromosome microdeletion analysis) 1

Patient Counseling

• Explicitly inform patients that TRT may significantly impair spermatogenesis, with up to 40% of men developing azoospermia 2
• The long-term impact on fertility must be discussed before starting treatment 1
• Document this discussion in the medical record

Monitoring Recommendations

1. Baseline semen analysis before starting TRT for all men interested in future fertility
2. Follow-up semen analyses:
   • For men actively trying to conceive: Check sperm count every 3-6 months while on TRT
   • For men with future fertility interests: Annual semen analysis is reasonable

Fertility Preservation Options

For men requiring TRT who wish to preserve fertility:

1. Sperm cryopreservation before starting TRT (preferred method) 1

   • Should be discussed with all postpubertal males before starting TRT
   • Even limited sperm samples can be used with intracytoplasmic sperm injection (ICSI) 1

2. Alternative approaches during TRT:

   • Low-dose human chorionic gonadotropin (hCG, 500 IU every other day) concurrent with TRT may maintain spermatogenesis 2
   • Consider selective estrogen receptor modulators as an alternative to TRT for men wishing to preserve fertility 1

Recovery of Spermatogenesis

• Men on TRT who later wish to conceive should discontinue testosterone well in advance of planned conception 1
• Recovery of spermatogenesis after TRT discontinuation is highly variable in terms of time course and degree 1
• Prior TRT may negatively impact spermatogenic response to gonadotropin therapy, especially in men with severe hypogonadism 3

Common Pitfalls to Avoid

• Failure to assess fertility desires before starting TRT
• Not informing patients about the impact of TRT on fertility
• Assuming fertility is preserved with topical testosterone formulations (all forms of TRT can suppress spermatogenesis) 4
• Delayed fertility preservation - sperm banking should occur before initiating treatment, as quality may be compromised after even a single treatment 1

Special Considerations

• Men who required ICSI for conception may have higher rates of subsequent testosterone deficiency and should be monitored closely 5
• Men with oligospermia at baseline may have different responses to TRT and should be counseled accordingly 6

TRT has significant benefits for appropriate patients, but the impact on fertility must be carefully considered and managed, especially in younger men who may desire children in the future.