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Strategy for clinicians

To maintain fertility in men with hypogonadism prescribed testosterone, Lipshultz said, clinicians should first insist on a semen analysis before beginning testosterone treatment.

“Patients need to realize that 2% of all men are sterile,” Lipshultz said. “We need to know where the individual is before we introduce testosterone because our endpoint may not be able to be any better than pre-treatment level.”

If the man desires a future pregnancy, the clinician should prescribe hCG concurrent with testosterone therapy, typically at 500 U subcutaneous three times per week or 1,500 U once weekly if the patient wishes only to prevent testicular atrophy. The patient should cycle off of testosterone twice yearly, at a rate of 3,000 U three times per week for 4 weeks, adding 25 mg daily clomiphene therapy during that period, Lipshultz said. However, for men desiring a pregnancy, 3,000 U hCG three times per week should be prescribed in addition to clomiphene therapy. Clinicians should check the patient’s follicle-stimulating hormone (FSH) level and conduct a semen analysis after 4 months for men desiring pregnancy; if the FSH level is not sufficiently elevated, the clinician should discontinue clomiphene and instead introduce FSH concurrent with the hCG, he said.

“To date, we have not had any patients who did not return to baseline,” Lipshultz said, referring to the regimen. – by Regina Schaffer