How to Improve Sperm Quality, LH, FSH and Testosterone in Infertile Men

[Nelson Vergel]

Improving Testosterone, LH, FSH and Sperm Quality in Men Who Stopped TRT or Anabolic Steroids? Main Therapies.

Note: AI's are not recommended due to extreme decreases in estradiol that may have negative health consequences in men.

hCG plus FSH doses used in several studies:

Reference:

Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use

The use of hormone stimulation in male infertility

The use of hormone stimulation in male infertility (2023) Daniel Foran, Runzhi Chen, Channa N. Jayasena, Suks Minhas and Tharu Tharakan Abstract Infertility affects 15% of couples worldwide and in approximately 50% of cases, the cause is secondary to an abnormality of the sperm. However...

www.excelmale.com

Semen Analysis Optimum Parameters

Here is a sample semen analysis report (optimum ranges) that I was able to obtain from a friend. Infertility testing: In an evaluation of a man's fertility, each aspect of the semen analysis is considered, as well as the findings as a whole. Semen from a man can vary widely from sample to...

www.excelmale.com

 

[Nelson Vergel]

Getting Off Testosterone or Anabolics? You May Want to Read this HPTA protocol

 

[Sides]

HCG, HMG (mixed FSH and LH), and FSH worked for me, and restored my fertility after 27 years on testosterone and other anabolic steroids. My wife is currently pregnant, and our baby girl is due to be born on November 29. And I am 51 years old, and have been using test for more than half my life. It worked for me, and will work for most men, barring any pre-existing fertility issues.

 

[lt84]

I hope it is OK to reply to this thread; I'm not a super frequent user of EM so I apologize if this is not acceptable.

My husband was on combo therapy that included testosterone, clomid, anastrazole and HCG for six months. This got his test levels through the roof, but it still zeroed out his sperm count. His LH/FSH levels were normal before starting any therapy (although his test was sitting at 130 before treatment). After six months on the combo therapy, test was at 930 and FSH/LH were both 0 as expected.

He discontinued combo therapy in June and began HCG monotherapy in early July after the zero sperm count (as we are trying to conceive). He has been taking 1500IU every three days. He just got bloods and another SA done and the results were LH .6 and FSH .7. Sperm was 3.9 mil/ml. Test is currently 320 total, so still low, but better than his 130 baseline. He actually says he feels better now at 320 than he did on combo therapy at 930.

So.... does HCG screw up the HPT axis? Should his LH/FSH be so low while just on HCG? We have an appointment on Monday with our andrologist and I'll be taking in print outs of the studies and suggestions you've cited above. I want to make sure I'm fully informed before I request FSH be added to his regimen, because I am not sure if the HCG is what is keeping his LH and FSH so low in the first place. His baseline before therapy of LH/FSH was definitely normal, so I'm certain we aren't talking about testicular damage.

Thanks for any input-- the stuff you post has been absolutely invaluable to us so far, Nelson. Our andrologist is hesitant to use FSH so I want to go in knowing completely about what i'm talking about.

 

[Nelson Vergel]

does HCG screw up the HPT axis?

Yes, it shuts down LH and FSH. Not a good product to use alone. Have him use hCG plus FSH or HMG. Empower Pharmacy has the lowest prices for either (by prescription)

Fertility | Compounding Pharmacy - Empower Pharmacy

As you can tell from the table above, 1500 IU of hCG plus 75-150 IU of FSH three times per week worked pretty well for most men in those studies.

 

[lt84]

Excellent. THANK YOU! We are currently using Empower. Hoping she will add FSH (or even better, HMG since it mimics both LH and FSH, right?) on Monday. Bringing your screen shots above with us. Ty ty ty as always.

 

[Nelson Vergel]

Excellent. THANK YOU! We are currently using Empower. Hoping she will add FSH (or even better, HMG since it mimics both LH and FSH, right?) on Monday. Bringing your screen shots above with us. Ty ty ty as always.

Just print this paper instead (attached).

 

[Sides]

Excellent. THANK YOU! We are currently using Empower. Hoping she will add FSH (or even better, HMG since it mimics both LH and FSH, right?) on Monday. Bringing your screen shots above with us. Ty ty ty as always.

lt84, HMG (mixed FSH and LH) is a great product, and I used it myself in my fertility protocol, as my doctor at first refused to prescribe FSH. But your husband will need to use HCG (which is an LH analogue) along with FSH or HMG.

Although there is both LH and FSH in HMG, there is not sufficient LH in HMG to maintain high enough levels of intra-testicular testosterone for optimal spermatogenesis. Plus injected LH has a very short half-life in the body, only a few hours. So that is why we use HCG, along with either HMG or FSH, for regaining fertility. Your husband will need both HCG and either HMG or FSH to get his sperm count up to the highest possible quantity and quality.

So have your doctor continue to prescribe HCG, and add either FSH or HMG. But if she prescribes HMG, remember you are only using the HMG for it's FSH, to stimulate the Sertoli cells of the testicles, as there is not enough LH in it to stimulate the Leydig cells of the testicles for maximum benefit.

Although I personally used HMG, optimally I would just stick with FSH and HCG just to keep things simple. But my case and others show that either FSH or HMG will work.

From the paper Nelson gave you above:

"FSH given alone or in combination with testosterone has proven unsuccessful at inducing spermatogenesis or maintaining spermatogenesis in those previously induced with hCG/FSH (hCG 1500 IU and HMG 150 IU both subcutaneous and 3 times per week), confirming the need for maintenance of elevated ITT.46 However, long-term use of hCG alone can induce spermatogenesis in up to 70% of patients, with a greater effect seen in men with initial testis length >4 cm, but further improvement is appreciated with the addition of FSH (HMG) suggesting a timelier recovery with both gonadotropins.47 The success of inducing spermatogenesis with a combination of hCG and FSH is supported by several studies (Table 1).41,42,45,48–53 In these data, most begin by stimulating endogenous testosterone production with trial of hCG alone with doses ranging from 1500 to 5000 IU 2–3 times per week titrated according to serum testosterone levels. Most experts treat with hCG alone for 3–6 months after which a certain number of cases will result in spermatogenesis induction. In those without adequate spermatogenesis induction, treatment proceeds with the addition of FSH with doses ranging from 75 to 400 IU 2–3 times per week titrated according to semen analysis results. Success defined as induction of spermatogenesis with >1–1.5 × 106 ml−1 sperm was reported to occur in 44%–100% of patients treated for 6–144 months.52 Pregnancy rates, when reported, were observed in 40%–75% of patients usually at sperm concentration levels below “normal.”42,51,54 Factors predicting success include larger baseline testis volume, previous natural gonadotropin exposure (normal puberty), and repeated treatment cycles whereas previous exogenous testosterone exposure and cryptorchidism portend a slower response although these findings are variable.42,55 It is important to consider these data are in men with HH due to classic causes and not patients with previous TRT/AAS use in whom better outcomes can theoretically be expected given the likelihood of normal pubertal development and HPG axis function at some point before TRT/AAS exposure."

 

[Juice7]

Great info Nelson and Sides, I just wanted to clarify as I can’t see it stated anywhere. Are the gonadotrophins administered after stopping T injections or could I maintain T injections on the protocol?

 

[Nelson Vergel]

Great info Nelson and Sides, I just wanted to clarify as I can’t see it stated anywhere. Are the gonadotrophins administered after stopping T injections or could I maintain T injections on the protocol?

Great question.
These FSH plus hCG or hMG protocols are done without testosterone.

Before starting them, and if you are on TRT, I would try hCG (500 IU three times per week) plus TRT. I would test my sperm quality 8 weeks later and see if TRT + hCG works (it's cheaper). If it does not, I would stop TRT and start FSH + hCG. Then wait 8 weeks and retest. Depending on the results, your doctor will adjust the dose of either product.

Some doctors would rather have you stop TRT, then start Clomid, and then test 8 weeks later. But some guys do not feel sexual on Clomid. However, Clomid provides the cheapest way to attempt to increase sperm quality. But, like everything, it seems to work better in younger men.

 

[Sides]

Great info Nelson and Sides, I just wanted to clarify as I can’t see it stated anywhere. Are the gonadotrophins administered after stopping T injections or could I maintain T injections on the protocol?

Either way works. The traditional old-school way is to stop T injections, then start the HCG and HMG or FSH. However, this means that you will have low T for a while, perhaps a long time, while your body regains the ability to make it's own T, and libido, erectile function, and sperm count will be adversely effected.

I, and many other men, have done the protocol and stayed on testosterone injections the whole time. I stayed on 200-300mg of testosterone throughout the whole protocol, and successfully regained my fertility and got my wife pregnant. I know that the late great Dr John Crisler advocated the same thing, staying on T injections while adding in HCG and HMG. And staying on testosterone has not adversely effected other men I know, who have also successfully regained their fertility while staying on T.

 

[Nelson Vergel]

I, and many other men, have done the protocol and stayed on testosterone injections the whole time. I stayed on 200-300mg of testosterone throughout the whole protocol, and successfully regained my fertility and got my wife pregnant.

Good to know. Most fertility doctors would make you stop TRT if you use FSH (or hMG)

 

[Sides]

Good to know. Most fertility doctors would make you stop TRT if you use FSH (or hMG)

LOL don't I know it. That's just one reason why I have a very low opinion of most fertility doctors, including my own. And I've been on test for 27 out of my 51 years, long before the days of modern-day test replacement, since 1992 when we used to have to order from mail-order pharmacies overseas. NOBODY makes me do anything...except possibly my wife LOL.

I had researched the subject myself, learned from guys like Dr Crisler and Greg Palumbo and Mike Arnold, and knew it could be done without going off of testosterone, adding in HCG and HMG. But although I showed my doctor the paper you provided above from the Asian Journal of Andrology, along with other articles on the subject, he still refused to prescribe me HMG or FSH, so I had to buy those products myself on the black market. He was shocked when my sperm count ended up so high by the time of our IVF procedure in October 2018, as he never thought the whole thing would work.

Sadly, often the advice you can find on the online forums and boards such as this one, is much better than the advice you will get from your own doctors, both for fertility and for TRT in general. It's up to each individual person to educate themselves as much as possible, because you can't depend on your doctors to be up on the latest research. I'm grateful to people like you for starting online forums like this one, and I've learned a lot in my time here. Now it's up to me to keep telling what I know, so that other people can find out and learn from my experiences, the good and the bad.

 

[Juice7]

Thanks Sides, I've been following your posts for time now and can't express enough gratitude to you for sharing your experience and insights. It really does give hope to the rest of us who are on TRT and concerned about fertility. I'm planning on starting a family early next year so I'm hoping you'll still be around then to field any questions!

And Nelson your content on TRT and Fertility has been the most informative I've been able to find on the internet.

Considering the Gonadotrophins bypass the HPTA, my thoughts were that you would expect the same results regardless of whether exogenous T was present or not? Or does the exogenous T impact the effectiveness of the Gonadotrophins?

If you were stopping the T shots altogether, wouldn't you be better off just to switch to Clomid instead of running HCG & HMG considering where I am you are probably looking at $15 for a month of Clomid vs $1,500 for the gonadotrophins? Or is the protocol aimed more at those with permanently suppressed pituitaries that wouldn't respond to clomid at all?

 

[Sides]

Considering the Gonadotrophins bypass the HPTA, my thoughts were that you would expect the same results regardless of whether exogenous T was present or not? Or does the exogenous T impact the effectiveness of the Gonadotrophins?

If you were stopping the T shots altogether, wouldn't you be better off just to switch to Clomid instead of running HCG & HMG considering where I am you are probably looking at $15 for a month of Clomid vs $1,500 for the gonadotrophins? Or is the protocol aimed more at those with permanently suppressed pituitaries that wouldn't respond to clomid at all?

I believe the answer to your question, as it is for so many things in life, is "it depends." In this case, it mostly depends how old you are, and how long you have been using testosterone and had your HPTA suppressed.

Clomid and stopping T is certainly much cheaper, but I don't believe it is nearly as effective as running HCG and HMG or FSH, especially if you have been on T for a long time.

Look at this study:

Age and Duration of Testosterone Therapy Predict Time to Return of Sperm Count after hCG Therapy

66 men who had been using testosterone for years were instructed to stop using testosterone and were treated using 3000iu of HCG per week, and either Clomid or Nolvadex. 46 of those men (70%) eventually reached a total motile sperm count of over 5 million, the generally accepted minimum sperm count for IUI.

So getting off T, and using HCG and Clomid does work. But the degree to which it works depends on the age of the man, and the length of time that the man has been on testosterone.

Look at Figure 1 of the study. Someone like me, who is over 50 years old, and has been on testosterone for over 10 years, would only have a 15.6% chance of reaching 5 million sperm count by six months, and a 34.1% chance of reaching 5 million sperm count in one year, if they stopped using T and started using HCG and Clomid/Nolvadex.

I'm 51 years old, and I've been using testosterone and other anabolic steroids for over 27 years now. And in only eleven months, I reached a sperm count of 31 million per ml, and successfully impregnated my wife. And I never stopped using T at all, and I only used HMG for the last 4 months of my 11 month protocol.

So in my own experience, either I am an extreme statistical outlier, or T + HCG + HMG/FSH is greatly superior to stopping T and just using HCG plus Clomid.

Clomid is cheap, but in my opinion not nearly as effective as using HCG + HMG/FSH.

 

[lt84]

Saw the fertility doctor yesterday and she refused FSH/HMG. She said he is doing fine on HCG monotherapy but increased him from 1500IU/3x/week to 2000IU/3x/week. She also wants to add 50mg of Clomid every other day to his regimen. Sigh.

In the fertility world, they will absolutely not advise continuing TRT while trying to conceive (which I've learned is absolutely silly, but since hubby says he's feeling pretty good on the HCG, I'm not arguing with it). I am a bit concerned about him starting the Clomid again; it seems like a pretty high dose too. Doc basically said she reserves FSH/HMG for severe cases where there is complete azoospermia without resolve whatsoever in six months of other tried therapy.

Should we move forward with adding the Clomid at this point or just opt for the HCG monotherapy? I will say that under the scope, I've noticed a significant increase in sperm (we check with a home microscope... cool stuff) in the last ten days... like just after he had his last SA. I really just want him to feel good and continue making more sperm. I don't want him to feel like crap and I worry the Clomid will mess with how good he's been feeing. He's open to doing it or not; so he's not much help.

Also, @Sides, he was only on TRT for 7 months... so maybe the HCG+Clomid isn't a terrible option sperm wise? I just don't want the poor guy feeling like **** in the meantime. He's so "whatever you say dear" that I want to make sure we are making the best choice.

 

[Sides]

Saw the fertility doctor yesterday and she refused FSH/HMG. She said he is doing fine on HCG monotherapy but increased him from 1500IU/3x/week to 2000IU/3x/week. She also wants to add 50mg of Clomid every other day to his regimen. Sigh.

In the fertility world, they will absolutely not advise continuing TRT while trying to conceive (which I've learned is absolutely silly, but since hubby says he's feeling pretty good on the HCG, I'm not arguing with it). I am a bit concerned about him starting the Clomid again; it seems like a pretty high dose too. Doc basically said she reserves FSH/HMG for severe cases where there is complete azoospermia without resolve whatsoever in six months of other tried therapy.

Should we move forward with adding the Clomid at this point or just opt for the HCG monotherapy? I will say that under the scope, I've noticed a significant increase in sperm (we check with a home microscope... cool stuff) in the last ten days... like just after he had his last SA. I really just want him to feel good and continue making more sperm. I don't want him to feel like crap and I worry the Clomid will mess with how good he's been feeing. He's open to doing it or not; so he's not much help.

Also, @Sides, he was only on TRT for 7 months... so maybe the HCG+Clomid isn't a terrible option sperm wise? I just don't want the poor guy feeling like **** in the meantime. He's so "whatever you say dear" that I want to make sure we are making the best choice.

My first thought is, if it was me, I would find a new doctor who is more open-minded to new research and different approaches. A doctor is just another person with an opinion, hopefully an informed and educated opinion, but still just some guy (or woman) with an opinion. They are human beings, and get things right or wrong, and make mistakes just like the rest of us. So always keep in mind that you can go to another fertility doctor and get their opinion on your situation.

However, if your husband was only on TRT for 7 months, perhaps he will recover well with Clomid and HCG. Some men do respond well to Clomid. So you could wait and see how he responds to Clomid and HCG. He did have low test (130) in the beginning, which was the whole reason for getting on TRT in the first place. So if his total testosterone is 320 now, and he feels better than he did at 930, that is an improvement of sorts. But as you are looking to conceive, the most important variables are going to be his LH and FSH, and his semen analysis. As long as the total motile sperm count goes up, that's the important thing. But of course, you want your husband to feel good as well. So if his libido and energy go up, and his sperm counts go up, then HCG/Clomid would be a good choice for you. But that requires waiting and giving it a try.

It depends how quickly you want to conceive, or how long you are willing to wait and give HCG/Clomid a chance. Maybe it will work for him, maybe not. It wouldn't have worked for me, but our situations are different. Again, if it were me, I would find another doctor willing to prescribe HMG/FSH, or I would buy it myself on the black market and use it regardless of what the doctor says. But I'm not you or your husband. I've been using test for 27 years; he only used test for 7 months. So you have to do the right thing for your personal circumstances, and do what you feel comfortable doing.

 

[Juice7]

Sides I’m keen to understand the HCG and Clomid treatment approach. Doesn’t HCG suppress LH secretion, while Clomid increases it, meaning they could be confusing the pituitary? In the same way that Test and Clomid don’t work together?

I had a zero count after being on T along for a couple of years. Went on Clomid Mono for 3 months and got up to 180m but felt like absolute shit so banked a couple of loads and went back on. Now I’m on T and HCG and tested 6 months in I was down to 50m and low volume. I’m about to restest after a year so hopefully it’s still around 50m otherwise the doc is happy to script me GonalF. I’m tossing up biting the bullet and going in Clomid to achieve pregnancy or stay on and use FSH. Cost vs crash/feeling shit is something I’m still considering

 

[Sides]

Sides I’m keen to understand the HCG and Clomid treatment approach. Doesn’t HCG suppress LH secretion, while Clomid increases it, meaning they could be confusing the pituitary? In the same way that Test and Clomid don’t work together?

I had a zero count after being on T along for a couple of years. Went on Clomid Mono for 3 months and got up to 180m but felt like absolute shit so banked a couple of loads and went back on. Now I’m on T and HCG and tested 6 months in I was down to 50m and low volume. I’m about to restest after a year so hopefully it’s still around 50m otherwise the doc is happy to script me GonalF. I’m tossing up biting the bullet and going in Clomid to achieve pregnancy or stay on and use FSH. Cost vs crash/feeling shit is something I’m still considering

Juice7, you are correct that HCG supresses secretion of LH. But that's OK on a HCG + Clomid treatment, because HCG is an analogue of LH and acts the same way as LH in stimulating the Leydig cells to produce high levels of intra-testicular testosterone. In this case, Clomid acts to stimulate the secretion of FSH, which stimulates the Sertoli cells to produce more sperm. So HCG + Clomid is a viable approach that works for many men.

As I showed with the study above, I don't believe that HCG + Clomid works nearly as well as HCG + HMG/FSH, but of course it would be much less expensive. Clomid is dirt cheap, while HMG and FSH are expensive. But I also believe they are much more effective, so they may be worth the extra expense. I know that they certainly were worth the expense for me.

In your case, you did very well on Clomid monotherapy, with a sperm count of 180 million, so that's a well-proven and viable option for you. But as you noticed, Clomid makes many men feel terrible. I know in my case, all it did for me was make me feel bad and raise my SHBG. So Test + HCG + FSH may be worth it to you, even with the extra cost, just so you feel better.

You are lucky to have a doctor who is willing to prescribe you FSH. If you decide to go that route, in most cases insurance won't pay for the FSH, as they don't pay for many fertility meds for men. If that is the case, I would recommend FSH from Empower Pharmacy, a compounding pharmacy in Texas, rather than name brand Gonal-F. I had to buy Gonal-F for my wife when we were going through our IVF procedure, and even with a discount from the fertility pharmacy, a 900iu pen of Gonal-F cost me $714, if I remember correctly. On the other hand, a 1200iu vial of FSH from Empower Pharmacy only cost me $325. I know the price has gone up slightly since then, and Empower now has 1500iu vials of FSH instead of 1200iu vials, but Empower still has the best prices you will find on fertility meds here in America.

FSH INJECTION | Compounding Pharmacy - Empower Pharmacy

And according to this study in the April 2018 issue of the Journal of Urology, compounded FSH from Empower Pharmacy was just as effective as name-brand Gonal-F, at a fraction of the price ($2.20 average price per unit for Gonal-F, versus $0.20 per unit for compounded FSH from Empower.)

American Urological Association

At that price for FSH from Empower, I would definitely consider Test + HCG + FSH over Clomid monotherapy, just because you will feel much better. Print out the links and show them to your doctor, and see what she thinks.

 

[Dr Justin Saya MD]

Juice7, you are correct that HCG supresses secretion of LH. But that's OK on a HCG + Clomid treatment, because HCG is an analogue of LH and acts the same way as LH in stimulating the Leydig cells to produce high levels of intra-testicular testosterone. In this case, Clomid acts to stimulate the secretion of FSH, which stimulates the Sertoli cells to produce more sperm. So HCG + Clomid is a viable approach that works for many men.

As I showed with the study above, I don't believe that HCG + Clomid works nearly as well as HCG + HMG/FSH, but of course it would be much less expensive. Clomid is dirt cheap, while HMG and FSH are expensive. But I also believe they are much more effective, so they may be worth the extra expense. I know that they certainly were worth the expense for me.

In your case, you did very well on Clomid monotherapy, with a sperm count of 180 million, so that's a well-proven and viable option for you. But as you noticed, Clomid makes many men feel terrible. I know in my case, all it did for me was make me feel bad and raise my SHBG. So Test + HCG + FSH may be worth it to you, even with the extra cost, just so you feel better.

You are lucky to have a doctor who is willing to prescribe you FSH. If you decide to go that route, in most cases insurance won't pay for the FSH, as they don't pay for many fertility meds for men. If that is the case, I would recommend FSH from Empower Pharmacy, a compounding pharmacy in Texas, rather than name brand Gonal-F. I had to buy Gonal-F for my wife when we were going through our IVF procedure, and even with a discount from the fertility pharmacy, a 900iu pen of Gonal-F cost me $714, if I remember correctly. On the other hand, a 1200iu vial of FSH from Empower Pharmacy only cost me $325. I know the price has gone up slightly since then, and Empower now has 1500iu vials of FSH instead of 1200iu vials, but Empower still has the best prices you will find on fertility meds here in America.

FSH INJECTION | Compounding Pharmacy - Empower Pharmacy

And according to this study in the April 2018 issue of the Journal of Urology, compounded FSH from Empower Pharmacy was just as effective as name-brand Gonal-F, at a fraction of the price ($2.20 average price per unit for Gonal-F, versus $0.20 per unit for compounded FSH from Empower.)

American Urological Association

At that price for FSH from Empower, I would definitely consider Test + HCG + FSH over Clomid monotherapy, just because you will feel much better. Print out the links and show them to your doctor, and see what she thinks.

Sides - your advice and insight in this thread is on point. If remaining on TRT, then HCG + FSH would be more effective than HCG + clomid (due to the competing negative feedback from TRT). If OFF of TRT, then clomid is typically quite effective from a fertility perspective.