TRT induced Azoospermia fertility protocol question

[optimizely]

Hey guys,

I’m a 30-year-old male who was on testosterone replacement therapy (TRT) for eight years. I’ve been completely off T for four months now and have been taking Clomid 25 mg daily and HCG 1,500 IU every Monday, Wednesday, and Friday. Recently, I’ve just increased my HCG dosage to 2,000 IU. My last semen analysis still showed azoospermia. My fertility was fine before I started TRT, and have no varicocele.

My Testosterone is 430, FSH is 16.7, and LH is 6.8.

My question is, would dropping the Clomid and taking exogenous FSH accelerate spermatogenesis? Since my FSH levels are normal and responding to the Clomid, would that be pointless?

Thanks!

 

[Cataceous]

With those numbers I wouldn't bother switching to exogenous FSH. It seems doubtful it would help. If you've seen the research then you know that the time to return of spermatogenesis is highly variable. If I'm remembering correctly, some men didn't see it until well into the second year. Patience is key. I would consider dropping the hCG, as that's recommended in the typical recovery protocols.

Dr. Saya's fertility ranking:

A *very* generalized ranking of relative fertilities (with top being most fertile):

1. Clomid/SERM treatment
2(A). HCG + HMG (or lyophilized FSH)
2(B). Baseline no treatment (no HPTA suppression via TRT, AAS, HCG mono, etc) - assuming no significant degree of primary/secondary/tertiary dysfunction.
3(A). HCG monotherapy (does in fact result in HPTA suppression, especially at higher doses, but *may* move up to #2 in select cases of SECONDARY/TERTIARY hypogonadism)
3(B). TRT + HCG (as we know many men are still able to maintain adequate fertility to conceive)
4. TRT/AAS with no concurrent HCG.

 

[optimizely]

Thanks. I’ll have to consider dropping the HCG then. I was under the impression Dr. Lipshultz’s protocol was to stop TRT and run HCG and Clomid for 3 months and if no sperm then switch to HCG and FSH for fastest return of spermatogenesis.

Clomid monotherapy makes the most logical sense if both LH and FSH return to normal limits since it doesn’t suppress the HPTA. I just thought HCG somehow made spermatogenesis happen faster.

 

[Cataceous]

...
Clomid monotherapy makes the most logical sense if both LH and FSH return to normal limits since it doesn’t suppress the HPTA. I just thought HCG somehow made spermatogenesis happen faster.

There are not rigorous studies comparing the protocols, so we're relying on educated guesswork. Most likely any reasonable protocol will work when given enough time. But that includes no treatment as well, since most men do recover eventually. It's reasonable to suspect that hCG is useful earlier in the recovery, and particularly when starting from a state of testicular atrophy. This may allow for simultaneous recovery of the hypothalamus and testicles. Without hCG the recovery is likely to be more sequential, going from upstream to downstream: hypothalamus -> pituitary -> testicles. Each gland needs stimulation from the upstream gland in order to start recovering.

Later in the recovery process, using hCG may be more hindrance than help. As noted by Dr. Saya in the post above, HCG can be suppressive. Therefore it is somewhat working against the clomiphene. In your case you have a good level of LH, which is the hormone hCG is supposed to augment. The implication is that the additional stimulation of hCG may not be that useful for fertility, as you may already have a good level of intratesticular testosterone. Worse, because hCG has a considerably longer half-life than endogenous LH, side effects are common, especially ones related to excess estrogen.