What is the best dose of HCG? Dr Saya presents two case studies.

[Vince Carter]

Dr. Saya - Thanks so much for this post. These results seem to mirror my results when changing hCG dose. I initially used 500iu twice per week. However, by day three I noticed a definite diminished effect on how I felt, and testicular volume. I tried changing to daily injections of 150iu, thinking that would work much better, but that quickly lost its effect. I might feel a little effect for a few hours, but after a couple weeks my testicles steadily got smaller, and the effects were almost nonexistent. I changed a few months ago to 350iu every M/W/F, which seemed to get better, but then I still felt very diminished effects by Monday morning. I recently switched to 350iu every M/W/F, with an additional 200iu "bump" on Sunday morning, which seems to be working much better for me at the moment.

I am a Defy patient, and am extremely primary. Before starting TRT my FSH/LH were very high, with a testosterone level of only 180. I'm starting to believe that the level of being primary hypogonadal plays a very big role in the effectiveness of hCG dosing amounts and injection schedule. To be honest, I would probably feel a lot better if my hCG dosing levels would mirror my pre-TRT LH levels (pretty high), but I try to stay pretty close to what I'm being prescribed.

I've been formulating in my own head how some of us don't care for or actually dislike HCG, and if it's related to primary or secondary HypoG.

 

[Dr Justin Saya MD]

Dr. Saya - Thanks for a very interesting study that so far no other MD has covered in such detail. When are you writing your book? Great Stuff!

"When are you writing your book"...LOL, once my 4 little ones are gone to college and I have TIME...thanks to you (and others) for your kind words. Glad it's appreciated.

 

[dallas101346]

How do these graphs change if the person injects IM?

 

[Dr Justin Saya MD]

How do these graphs change if the person injects IM?

Good question. This graph -- http://m.humrep.oxfordjournals.org/content/18/11/2294/F1.expansion -- courtesy of PeakT and Kierkegaard (over on the peaktestosterone forum) suggests the peak may be a little higher with hCG via IM (although likely much less pronounced at our dosages 150iu/500iu vs 10,000iu). This was also for females (shouldn't make a difference with the pharmacokinetics however). Interestingly, peak hCG serum levels achieved tend to be HIGHER the LEANER a person is (obese = lower peak serum levels comparatively for both SQ and IM). Once again, likely not as pronounced at our lower dosages, but interesting nonetheless.

 

[Dctrscot]

Dr. Saya, that is a great bit of research albeit a small N. It has generated one apparent question for me though. Is constant stimulation of the leydig cells considered optimum or desirable? Meaning if endogenous LH is secreted with a 20 min 1/2 life, what is the time frame of stimulation on the cells? That answer I do not know but if the smaller dose kind of "turns them on then they go off until the switch goes again" , wouldn't the smaller dose more closely mimic natural in vivo LH? I guess it begs the original question.....Is constant stimulation what we desire? Thanks again. This is a GREAT piece.

 

[JPB]

The long half life of hCG compared to pulsatile LH rhythms means you cannot even come close to mimic the natural pattern even with a lower dose or more frequent inj pattern.

 

[maxadvance]

The long half life of hCG compared to pulsatile LH rhythms means you cannot even come close to mimic the natural pattern even with a lower dose or more frequent inj pattern.

What long half life? 24-36 hours is long? Dr Saya's graph of just his control group refutes everything you just said, not to mention the new thread on the subject

 

[Dctrscot]

That was the exact question...the pulsatile nature of LH and its stimulation on the testes. Am I to assume the leydig cells are CONSTANTLY stimulated from a substance with a 20 min 1/2 life?

 

[Dr Justin Saya MD]

Dr. Saya, that is a great bit of research albeit a small N. It has generated one apparent question for me though. Is constant stimulation of the leydig cells considered optimum or desirable? Meaning if endogenous LH is secreted in a 15 to 20 minute window daily, what is the time frame of stimulation on the cells? That answer I do not know but if the smaller dose kind of "turns them on then they go off until the switch goes again" , wouldn't the smaller dose more closely mimic natural in vivo LH? I guess it begs the original question.....Is constant stimulation what we desire? Thanks again. This is a GREAT piece.

Thanks for your comments, Dctrscot! An important point of clarification is that, although LH does have a short half-life AND is secreted in a pulsatile nature, it is NOT only secreted in a 15-20 minute window daily. If this were so, with the short half-life we would expect to find LH levels of 0 for the majority of the day...which we really NEVER see for males except those already on TRT. LH is secreted more so in the AM hours, but is indeed secreted throughout the rest of the day as well. Here is a good study on the diurnal variation:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681273/#__abstractid251532title

Thus, endogenous LH levels are really NEVER zero in a normal male and, consequently, there IS CONSTANT STIMULATION of the leydig cells in a normal male throughout the day (albeit at varying levels). The only concern with very small HCG doses (even on a daily basis) is that there *may* be periods where the HCG level (read LH level) is close to zero (or much lower than "normal" LH levels) and the testes go "under-stimulated" during this time. Now in a clinical context, this is probably most relevant when it comes to fertility/atrophy considerations, but an important thought nonetheless.

 

[Dctrscot]

If your are chasing serum concentrations of hcg to match LH, I agree it's impossible. My question is the effect on testes given the "pulsatile" delivery of hcg on a daily, eod basis.

 

[Dr Justin Saya MD]

The long half life of hCG compared to pulsatile LH rhythms means you cannot even come close to mimic the natural pattern even with a lower dose or more frequent inj pattern.

In the literal sense...this is true and indisputable.

But thinking of it from a different angle gives a different perspective.

Now LH indeed has a very short half-life AND is secreted in a pulsatile nature...BUT these pulses are many and frequent throughout the day (yes, more in the AM but throughout the day nonetheless) to the extent that at ANY time during the day an LH serum level is checked it will typically fall in the "normal" range of ~1.8mIU/mL - 8mIU/mL. Diurnal variation can be seen here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681273/#__abstractid251532title

Contrast this with an HCG injection which has a much longer half-life, but is also only injected ONCE. Now if you compare this to a SINGLE LH PULSE it will be a drastically and distinctly different pattern. However, if you compare the pattern of the single HCG injection with the CUMULATIVE PATTERN of the MANY LH PULSES throughout the day...the pattern or "area under the curve" becomes much more similar (i.e. more constant and continual stimulation from both). Hope this makes sense.

 

[Dr Justin Saya MD]

If your are chasing serum concentrations of hcg to match LH, I agree it's impossible. My question is the effect on testes given the "pulsatile" delivery of hcg on a daily, eod basis.

Answered that in the previous post:

" The only concern with very small HCG doses (even on a daily basis) is that there *may* be periods where the HCG level (read LH level) is close to zero (or much lower than "normal" LH levels) and the testes go "under-stimulated" during this time. Now in a clinical context, this is probably most relevant when it comes to fertility/atrophy considerations, but an important thought nonetheless."

 

[Dr Justin Saya MD]

That was the exact question...the pulsatile nature of LH and its stimulation on the testes. Am I to assume the leydig cells are CONSTANTLY stimulated from a substance with a 20 min 1/2 life?

From a SINGLE LH pulse - no, they are not continually stimulated...but from the multitude of LH pulses throughout the day - yes, they ARE continually stimulated.

To confirm, just draw LH levels on a male patient (not on TRT and without secondary hypogonadism) throughout the day...if you ever find a reading of zero I'll give you my first born lol.

 

[Dctrscot]

GREAT Dr. Saya. Thank you so much for clarification! I absolutely think this could be one if not the most hotly contested and questioned subjects in trt. Kudos for this initial study and positioning yourself as the tip of the spear to identifying optimal and standard hcg dose for the trt patients.

 

[Dr Justin Saya MD]

GREAT Dr. Saya. Thank you so much for clarification! I absolutely think this could be one if not the most hotly contested and questioned subjects in trt. Kudos for this initial study and positioning yourself as the tip of the spear to identifying optimal and standard hcg dose for the trt patients.

Absolutely, my friend. I view this area of medicine as more of a brotherhood...we are all in this together to push forward and advance.

 

[trthcg05]

Dr. Lipshultz did a vericocelectomy on me way back in 2001. I am glad I know him! I had pain in my testicle for 2 years and he cured it. I lived in Houston at the time, and I did my homework to find the best doctor alive to do the surgery. It was successful. It's a small world. Now I am on TRT pellets and nobody will give me HCG. I live in Louisiana. I'd like to use Defy, but if I need to drive to Houston and see Dr. Lipshultz, I will. I am at the point where I need to restart after the pellets wear off and get HCG quickly. I am shrinking dramatically, and me and the wife still want kids. I wasn't informed of any side effects or any possible fertility issues. I definitely wasn't told my anxiety would go sky high and I would feel much, much worse. I was promised rainbows and boundless happy energy. My Dr. actually told me I'd grow more hair! Everything was going to get better, she said. The TRT has had horrible side effects. They are wearing off, but it was a VERY rough few months! High panic level anxiety at night. Weight gain, hair loss and soreness. Can you advise over the phone or on this board? I am in search of new care.

Also, my old labs prove I am secondary. I also have a 2 and a 4 year old child, and we want more. My LH is now <.02 as of 1/20/2016

TRT should have been a last resort... IMHO

Thanks for your time and attention...

-RC

 

[Dr Justin Saya MD]

Trthcg05 -

I replied to one of your other thread posts. I can help you with a restart regimen. The pellets should be just about dissolved completely by now. Contact my office to get the process started.

 

[JPB]

The primary issue with hCG in a fair number of people is not just determining the dose and schedule to provide near continuous stimulus but also the dose that minimizes estrogen related sides. That is the conundrum. I think it is fair to hypothesize that the properties of hCG (vs. LH) invariably result in the body's comparably greater ramping up of intratesticular aromatase activity.

 

[Dr Justin Saya MD]

I think it is fair to hypothesize that the properties of hCG (vs. LH) invariably result in the body's comparably greater ramping up of intratesticular aromatase activity.

The main property of hCG to keep in mind here that differs from endogenous LH is that the hCG is NOT subject to the normal negative feedback mechanism for control (as it is administered exogenously), whereas the endogenous LH is subject to the negative feedback mechanism. Thus, aromatization is kept on a "tighter leash" with the negative feedback of E2 with endogenous LH.

 

[CSI007]

Dr Saya,

I have a question regarding aromatization and HCG. If I start out on the very low end with my E2 (my values are very low end of "normal") does this lessen the likelihood of needing another drug to combat high levels of E2 as my T rises?

Please see my thread here:https://www.excelmale.com/forum/showthread.php?6424-Low-T-and-elevated-fasting-blood-sugar/page2