Testosterone Injections and Male Fertility
Starting testosterone injections does not make a man permanently infertile, but it will severely suppress or completely stop sperm production while on treatment, and recovery after stopping can take months to years. 1
How Testosterone Injections Affect Fertility
Exogenous testosterone administration provides negative feedback to the hypothalamus and pituitary gland, which inhibits gonadotropin (LH and FSH) secretion. 1 This suppression of natural hormones leads to:
- Decreased or complete cessation of sperm production (oligospermia or azoospermia), depending on the degree of testosterone-induced suppression 1
- Inhibition of intratesticular testosterone production, which is essential for spermatogenesis, even though blood testosterone levels remain normal or elevated 2
Recovery After Stopping Testosterone
Most men will eventually recover sperm production after stopping testosterone therapy, but the timeline is highly variable and often prolonged: 1
- Recovery occurs in most azoospermic males after cessation 1
- The time course may be months or rarely years 1, 3
- Some patients may not recover normal spermatogenesis even with sufficient time 4
Critical Counseling Point
The 2024 AUA/ASRM guidelines explicitly state that for males interested in current or future fertility, clinicians should NOT prescribe exogenous testosterone therapy. 1 This is a strong recommendation that prioritizes fertility preservation.
Alternative Treatment for Men Desiring Fertility
If your patient wants to maintain fertility potential while treating low testosterone, human chorionic gonadotropin (hCG) is the first-line treatment instead of testosterone: 3
- Dosing: hCG 500-2500 IU, administered 2-3 times weekly 3
- Mechanism: hCG stimulates testicular Leydig cells to produce intratesticular testosterone, maintaining both testosterone levels AND spermatogenesis 2
- Additional therapy: FSH injections may be added after testosterone normalizes on hCG if needed for optimal sperm production 1, 3
Common Pitfall to Avoid
Many clinicians prescribe testosterone for symptomatic hypogonadism without adequately counseling about fertility implications. Even if the patient is not actively trying to conceive now, future fertility plans must be discussed before starting testosterone. 1 Men who may want children in the "distant future" can be offered testosterone therapy, but only after thorough counseling about the inhibitory effects and prolonged recovery time. 1
Bottom Line for Your Patient
Your patient with testosterone level of 244 ng/dL who was started on testosterone injections:
- Is likely experiencing suppressed sperm production right now while on testosterone 1
- Is NOT permanently infertile - most men recover after stopping 1
- Should stop testosterone immediately if fertility is desired and switch to hCG therapy 3
- May need months to years for sperm production to return after stopping testosterone 1, 3