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Key points

• All men starting on long-acting and intermediate-acting testosterone replacement therapy should be counselled on the well-characterized risk of hypothalamic–pituitary–gonadal (HPG) axis suppression and the resultant infertility.

• Spermatogenesis might be maintained in men receiving short-acting testosterone formulations (including topical testosterone gel, nasal testosterone gel and oral testosterone), as these agents promote incomplete inhibition of the HPG axis.

• Most men recover spermatogenesis after cessation of exogenous testosterone; however, restoration of sperm production might take months or years and fail to achieve baseline levels depending on the duration and degree of supratherapeutic administration.

• Men with underlying HPG-axis dysfunction exposed to exogenous testosterone might experience particularly protracted and uncertainr ecovery of sperm production that may be supported with medical therapies.

• Surgical sperm retrieval and assisted reproductive technology might be appropriate in men with persistently diminished sperm production following testosterone exposure.