current protocol for preserving testicular function with TRT

[aaghabegian]

What's the current protocol for preserving testicular function with TRT

 

[Cataceous]

Various options for increasing testosterone while preserving testicular function:

Treatment	Pros	Cons
Conventional TRT + hCG	Effective, usually preserves fertility, higher testosterone levels if needed	Cost, sometimes extra injections, often excess aromatization, upstream HPTA suppression (LH/FSH/GnRH/kisspeptin)
Conventional TRT + hCG + FSH/hMG	Effective, best option for fertility with conventional TRT, higher testosterone levels if needed	Greater cost, sometimes extra injections, often excess aromatization, upstream HPTA suppression (LH/FSH/GnRH/kisspeptin)
hCG monotherapy	Effective, usually preserves fertility	Cost, often excess aromatization, often upstream HPTA suppression (LH/FSH/GnRH/kisspeptin)
hCG + FSH/hMG	Effective, good for fertility	Cost, often excess aromatization, often upstream HPTA suppression (LH/FSH/GnRH/kisspeptin)
Testosterone nasal gel monotherapy	Preserved HPTA function and fertility, bio-identical testosterone	Cost? Unpleasant delivery, less dosing flexibility, 2-3 daily doses
Testosterone buccal troche monotherapy	Preserved HPTA function and fertility, bio-identical testosterone	Not well characterized for TRT, finding appropriate doses may be complicated, 2-3 daily doses
Enclomiphene monotherapy	Preserved or enhanced HPTA function and fertility, good lab numbers likely, simple oral delivery	Mixed subjective results, uncertainty about long-term effects of non-endogenous drug
Oral testosterone + enclomiphene	Convenience of oral delivery, possible subjective improvement over enclomiphene monotherapy	Cost? Uncertainty about long-term effects of non-endogenous drug enclomiphene
Conventional TRT + gonadorelin + enclomiphene	Partial HPTA preservation, higher testosterone levels if needed	Multiple daily injections for best results. Uncertainty about long-term effects of enclomiphene
Micronized testosterone suspension, 2-3 daily microdoses	Possible preserved HPTA function and fertility, bio-identical testosterone	Not well characterized, multiple daily injections, speculative
Conventional TRT + enclomiphene + cistanche extract	Possible preserved HPTA function and fertility, higher testosterone levels if needed, simple oral add-on	Not characterized, speculative, uncertainty about long-term effects of non-endogenous drugs
Kisspeptin-10 monotherapy	More HPTA preservation, similar to endogenous hormone	Not well characterized, speculative
Gonadorelin (GnRH) monotherapy	Bio-identical hormone, partial HPTA preservation	Multiple daily injections

 

[aaghabegian]

Thank you for your through and prompt response. What's the recommended dosing of hCG with conventional TRT?

 

[Cataceous]

Usually there's a minimum of 250 IU hCG twice a week up to a maximum of maybe 500 IU three times a week. Around 750-1,000 IU per week in divided doses is typical.

 

[aaghabegian]

Thanks a million.
Is hCG monotherapy worth trying in a 34-year-old who is quite symptomatic with T levels around 300? He is interested in potentially preserving fertility?
Would the dosing be the same as above?

 

[Cataceous]

...
Is hCG monotherapy worth trying in a 34-year-old who is quite symptomatic with T levels around 300? He is interested in potentially preserving fertility?
Would the dosing be the same as above?

HCG monotherapy is a reasonable choice given the concerns about fertility. Anecdotes tend to disfavor it with respect to subjective results. This may be due to the potential for excess aromatization. But some guys seem happy with it. Let me throw in Dr. Saya's fertility ranking to give you an idea of where some of these treatments stand:

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

​

1. Clomid/SERM treatment​

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2(A). HCG + HMG (or lyophilized FSH)​

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2(B). Baseline no treatment (no HPTA suppression via TRT, AAS, HCG mono, etc) - assuming no significant degree of primary/secondary/tertiary dysfunction.​

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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)​

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3(B). TRT + HCG (as we know many men are still able to maintain adequate fertility to conceive)​

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4. TRT/AAS with no concurrent HCG.​

Usually dosing for hCG monotherapy is higher than what I mentioned above for use with TRT. In these cases 1,000 IU per week would be about the lowest I've heard about. Doses easily range into the thousands or more. I don't think there's any harm in a low-and-slow approach to dosing. Higher doses are likely to be better for fertility, but subjective results may then deteriorate. Guys have been known to temporarily tolerate higher doses and not feeling great until a pregnancy is achieved. But for the longer term it's important to feel decent.

When it is available and practical I would favor a fast-acting testosterone product, such as nasal gel, buccal troches and possibly suspension. These are likely to ameliorate the symptoms of hypogonadism with the fewest side effects and least hormonal disruption.

 

[aaghabegian]

thank you so much