How Men Can Use HCG with Testosterone to Improve Fertility, Libido and Testicular Size- Part 2

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PART 1:
The Use of HCG to Prevent / Reverse Testicular Shrinkage and Preserve Fertility


PART 2:

Shippen's Chorionic Gonadotrophin Stimulation Test (for males under 60 years of age)


View attachment 489
Even though there seems not be an accepted and clinically proven protocol to dose HCG, Dr. Eugene Shippen (author of the book “The Testosterone Syndrome”), has developed his own after his experiences. Most doctors do not follow this protocol but I am showing it here since I get a lot of questions about it. I have never used this protocol myself since I have been on testosterone replacement for over 15 years.

Dr. Shippen has found that a typical treatment course for three weeks is best for determining those individuals who will respond well to HCG treatment. It is administered daily by injection 500 units subcutaneously, Monday through Friday for three weeks. The patient is taught to self administer with 50 Unit insulin syringes with 30 gauge needles in anterior thigh, seated with both hands free to perform the injection. Testosterone, total and free, plus E2 (estradiol) are measured before starting the protocol and on the third Saturday after 3 weeks of stimulation (he claims that salivary testing may be accurate for adjusting doses. This is source of great debate). Studies have shown that subcutaneous injections of HCG are equal in efficacy to intramuscular administration.

By measuring the effect on his HCG protocol on total testosterone, he identifies candidates that require testosterone replacement versus those who just require having their testicles “awaken” with HCG to produce normal testosterone. I am yet to see any data that substantiates his approach, however.

Here is how he determines Leydig (testicular) cell function:

1. If the HCG protocol causes less than a 20% rise in total testosterone he suggests poor testicular reserve of Leydig cell function (primary hypogonadism or eugonadotrophic hypogonadism indicating combined central and peripheral factors).

2. 20-50% increase in total testosterone indicates adequate reserve but slightly depressed response, mostly central inhibition but possibly decreased testicular response as well.

3. More than 50% increase in total testosterone suggests primarily centrally mediated depression of testicular function.

He then offers these options for treatment for patients depending on the response to HCG and patient determined choices.

1. If there is an inadequate response (< 20%), then replacement with testosterone will be indicated.

2. The area in between 20-50% will usually require HCG boosting for a period of time, plus natural boosting or “partial” replacement options.

I am yet to see what he means with natural boosting! Dr. Shippen believes that full replacement with testosterone is always the last option in borderline cases since improvement over time may frequently occur as the testicles' Leydig cell regeneration may actually happen. He claims that much of this is age dependent. He states that up to age 60, boosting is almost always successful. In the age range 60-75 is variable, but will usually be clear by the results of the stimulation test. Also, disease related depression of testosterone output might be reversible with adequate treatment of the underlying process (depression, obesity, alcohol, deficiency, etc.) He claims that this positive effect will not occur if suppressive therapy is instituted in the form of full testosterone replacement.

3. If there is an adequate response of more than 50% rise in testosterone, there is very good Leydig cell reserve. HCG therapy will probably be successful in restoring full testosterone output without replacement, a better option over the long term and a more natural restoration of biologic fluctuations for optimal response. But I am yet to see any data on long term use of HCG used in this approach! (I invite researchers to do such studies)

4. Chorionic HCG can be self-administered and adjusted according to response. In younger, high output responders (T > 1100ng/dl), HCG can be given every third or fourth day. This also minimizes estradiol blood levels which raise with HCG administration. In lower level responders (600-800ng/dl), or those with a higher estradiol output associated with full dose HCG, 300-500 units can be given Mon-Wed-Fri. At times, sluggish responders may require a higher dose to achieve full testosterone response.

Dr. Shippen believes in checking salivary levels of free testosterone on the day of the next injection, but before the next injection to determine effectiveness and to adjust the dose accordingly. He claims that later as Leydig cell restoration occurs, a reduction in dose or frequency of administration may be later needed.

5. He recommends to monitor both testosterone and estradiol levels to assess response to treatment after 2 - 3 weeks after change in dose of HCG as well as periodic intervals during chronic administration. He claims that salivary testing will better reflect the true free levels of both estrogens and testosterone. (Pharmasan.com and others) Most insurance companies do not pay for salivary testing. Blood testing is the standard way to test for testosterone and estradiol.

6. Except for reports of antibodies developing against HCG (he mentions that he has never seen this problem), the claims that there are no adverse effects of chronic HCG administration.

Dr. Shippen's book was published in the late 90's. I know of no physician that uses his protocol. I have no opinion on its validity. The idea that testicular function can be improved with cycles of HCG in men with low testosterone caused by sluggish yet functioning Leydig cells is an interesting concept that needs to be studied. I guess that since this protocol requires very close monitoring, many doctors have avoided using it. The off label nature of the protocol's use of HCG can also make it expensive for patients who will have to pay cash for its use and monitoring.

Source: Testosterone: A Man's Guide
 

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Defy Medical TRT clinic doctor

Nelson Vergel

Founder, ExcelMale.com
Concomitant Intramuscular Human Chorionic Gonadotropin Preserves Spermatogenesis in Men Undergoing Testosterone Replacement Therapy

Tung-Chin Hsieh, Alexander W. Pastuszak, Kathleen Hwang and Larry I. Lipshultz*,†

From the Division of Urology, University of California-San Diego (TCH), San Diego, California, Scott Department of Urology, Baylor College of
Medicine (AWP, LIL), Houston, Texas, and Department of Urology (KH), Brown University School of Medicine, Providence, Rhode Island

Purpose: Testosterone replacement therapy results in decreased serum gonadotropins and intratesticular testosterone, and impairs spermatogenesis, leading to azoospermia in 40% of patients. However, intratesticular testosterone can be maintained during testosterone replacement therapy with co-administration of low dose human chorionic gonadotropin, which may support continued spermatogenesis in patients on testosterone replacement therapy.

Materials and Methods: We retrospectively reviewed the records of hypogonadal men treated with testosterone replacement therapy and concomitant low dose human chorionic gonadotropin. Testosterone replacement consisted of daily topical gel or weekly intramuscular injection with intramuscular human chorionic gonadotropin (500 IU) every other day. Serum and free testosterone, estradiol, semen parameters and pregnancy rates were evaluated before and during therapy.

Results:
A total of 26 men with a mean age of 35.9 years were included in the study. Mean followup was 6.2 months. Of the men 19 were treated with injectable testosterone and 7 were treated with transdermal gel. Mean serum hormone levels before vs during treatment were testosterone 207.2 vs 1,055.5 ng/dl (p <0.0001), free testosterone 8.1 vs 20.4 pg/ml (p = 0.02) and estradiol 2.2 vs 3.7 pg/ml (p = 0.11). Pretreatment semen parameters were volume 2.9 ml, density 35.2 million per ml, motility 49.0% and forward progression 2.3. No differences in semen parameters were observed during greater than 1 year of followup. No impact on semen parameters was observed as a function of testosterone formuation. No patient became azoospermic during concomitant testosterone replacement and human chorionic gonadotropin therapy. Nine of 26 men contributed to pregnancy with the partner during followup.

Conclusions:
Low dose human chorionic gonadotropin appears to maintain se-men parameters in hypogonadal men on testosterone replacement therapy. Concurrent testosterone replacement and human chorionic gonadotropin use may preserve fertility in hypogonadal males who desire fertility preservation while on testosterone replacement therapy.

RESULTS

A total of 31 consecutive hypogonadal men who desired fertility preservation were identified for study


TRT:

* AndroGel® (5 gm daily) in 2 patients and Testim® (5 gm daily) in 5.
† Testosterone enanthate (200 mg weekly) in 2 patients and testosterone cypi- onate (200 mg weekly) in 17.


In 26 of these men complete data were available on semen parameters and serum hormone quantitation before and after TRT. The average ± SD age of our cohort was 35.9 ± 9.5 years. Men were followed a mean of 6.2 ± 4.9 months and up to 18 months (table 1). Of the men 19 men were treated with injectable T formulations, while 7 used transdermal gels. All men received intramuscular HCG (500 IU) every other day.

In the cohort mean serum hormone levels before vs during treatment were T 207.2 ± 99.2 vs 1,055.5 ± 420.9 ng/dl (p <0.0001), FT 8.1 ± 3.9 vs 20.4 ± 13.5 ng/dl (p = 0.02) and E 2.2 ± 1.0 vs 3.7 ± 2.6 ng/dl (p = 0.11), supporting the efficacy of TRT in these men. Mean pretreatment semen parameters were volume 2.9 ± 1.4 ml, density 35.2 ± 29.6 million per ml, motility 49.0% ± 10.4%, FP 2.3 ± 0.3 and TMS count 84.6 ± 82.4 million.

To ascertain the effects of exogenous TRT and HCG on semen parameters the men were followed at 2 to 4-months intervals with semen parameters and hormonal assessment compared to pretreatment parameters. A statistically significant decrease in se- men volume was observed at 1 to 2 months of followup (p = 0.04). This small difference was not observed at any other followup point. Furthermore, no statistically significant differences were noted in other semen parameters at any followup time. No significant differences were observed in semen parameters between the injectable and transdermal TRT groups. Taken together, these data indicate that concomitant HCG therapy in the setting of TRT is effective for preserving semen parameters.
 

Excel Male

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This study provide groundwork for Lipshultz's study of HCG+ TRT

The Journal of Clinical Endocrinology & Metabolism 90(5):2595-2602
Printed in U.S.A. Copyright © 2005 by The Endocrine Society
doi: 10.1210/jc.2004-0802

Low-Dose Human Chorionic Gonadotropin Maintains Intratesticular Testosterone in Normal Men with
Testosterone-Induced Gonadotropin Suppression


Andrea D. Coviello, et al


In previous studies of testicular biopsy tissue from healthy men, intratesticular testosterone (ITT) has been shown to be
much higher than serum testosterone (T), suggesting that high ITT is needed relative to serum T for normal spermato-
genesis in men. However, the quantitative relationship between ITT and spermatogenesis is not known. To begin to
address this issue experimentally, we determined the dose-response relationship between human chorionic gonadotro-
pin (hCG) and ITT to ascertain the minimum dose needed to maintain ITT in the normal range. Twenty-nine men with nor-
mal reproductive physiology were randomized to receive 200 mg T enanthate weekly in combination with either saline pla-
cebo or 125, 250, or 500 IU hCG every other day for 3 wk. ITT was assessed in testicular fluid obtained by percutaneous fine
needle aspiration at baseline and at the end of treatment.

Baseline serum T (14.1 nmol/liter) was 1.2% of ITT (1174 nmol/ liter). LH and FSH were profoundly suppressed to 5% and 3% of baseline, respectively, and ITT was suppressed by 94% (1234 to 72 nmol/liter) in the T enanthate/placebo group. ITT increased linearly with increasing hCG dose (P < 0.001). Posttreatment ITT was 25% less than baseline in the 125 IU hCG group, 7% less than baseline in the 250 IU hCG group, and 26% greater than baseline in the 500 IU hCG group. These results demonstrate that relatively low dose hCG maintains ITT within the normal range in healthy men with gonadotropin suppression. Extensions of this study will allow determination of the ITT concentration threshold required to maintain spermatogenesis in man. (J Clin Endocrinol Metab 90: 2595-2602, 2005)
 
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