Fertility Considerations in Testosterone Replacement Therapy

Introduction to Fertility Preservation

The American Urological Association recommends that sperm count should be checked before initiating testosterone replacement therapy (TRT) in men interested in future fertility, as exogenous testosterone typically suppresses spermatogenesis and may cause azoospermia 1
Men interested in preserving fertility should undergo testicular examination to evaluate size, consistency, and descent, and serum follicle-stimulating hormone (FSH) should be measured to assess underlying reproductive health 1
Consider semen analysis before starting TRT, especially if fertility is a concern, to assess baseline fertility status 1

Elevated FSH levels in testosterone deficient men (hypergonadotropic hypogonadism) typically indicates impaired spermatogenesis, and patients with severe oligospermia or non-obstructive azoospermia should be offered reproductive genetics testing (karyotype and Y-chromosome microdeletion analysis) 1

Baseline semen analysis is recommended before starting TRT for all men interested in future fertility, and follow-up semen analyses should be performed every 3-6 months for men actively trying to conceive, or annually for men with future fertility interests 1
The long-term impact on fertility must be discussed before starting treatment, and this discussion should be documented in the medical record 1

Sperm cryopreservation before starting TRT is a preferred method for preserving fertility, and should be discussed with all postpubertal males before starting TRT, as even limited sperm samples can be used with intracytoplasmic sperm injection (ICSI) 2
Selective estrogen receptor modulators may be considered as an alternative to TRT for men wishing to preserve fertility 1

Men on TRT who later wish to conceive should discontinue testosterone well in advance of planned conception, as recovery of spermatogenesis after TRT discontinuation is highly variable in terms of time course and degree 1
Prior TRT may negatively impact spermatogenic response to gonadotropin therapy, especially in men with severe hypogonadism, highlighting the importance of careful fertility planning and management 1

Delayed fertility preservation, such as sperm banking, should be avoided, as quality may be compromised after even a single treatment, emphasizing the need for timely fertility assessment and preservation strategies 2