Chairman of Urology
Weill Cornell Medical Center
Former President, ASRM
Director, Male Reproductive Medicine
Mount Sinai Medical Center
Hormone imbalances account for around 10% of all male factor infertility cases, and can manifest themselves in myriad ways, ranging from sexual dysfunction to low sperm concentration. Generally speaking, hormone imbalances are both detectable and correctable.
As we alluded to in the last lesson’s discussion of azoospermia, hormones are regulated in the brain. The hypothalamus detects hormone levels in the body, and messages to the pituitary gland (also in the brain), to begin producing hormones at the necessary levels. The pituitary produces Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH), amongst others.
LH impacts the testes' ability to produce testosterone, which dictates libido and erectile function, while FSH (along with testosterone) regulates sperm production. To complete the loop, the hypothalamus measures the body’s level of these hormones, and determines which signals to send to the pituitary to produce more, or less, of each.
Typically, a blood draw (done in the morning as levels change during the day) accurately detects hormone levels and this is where the ranges typically fall:
If a hormone imbalance is detected, your urologist should be focused in determining the root cause. For instance, an elevated prolactin level can indicate risk of a pituitary tumor. When there is an FSH or LH deficit, it’s customary to prescribe hormones that mimic the function of naturally-made FSH and LH.
The hormone testosterone helps incite the testicles to produce sperm. After age 30, testosterone levels in men drop 1% per year. In turn, as men get older many suffer depleted energy levels, diminished sex-drive, and fat begins to replace muscle. One result is that many men resort to testosterone replacement therapy (TRT) to reverse the trend.
TRT has such a negative impact on male fertility that it’s been looked at as a possible form of male birth control. Artificially-raised levels of testosterone signal to the hypothalamus, and thus the pituitary, that there’s no need to produce hormones like LH or FSH. When those levels drop, so too does the testes’ ability to produce sperm.
But 20 - 25% of urologists get this wrong and actually believe exogenously-taken testosterone improves male fertility. More knowledgeable urologists will want to taper a man off hormone therapy, rather than pull him off all at once, since a dramatic drop in testosterone levels raises the risk of depression.
In 2016, clinicians at Baylor treating azoospermatic men who used testosterone noticed that treated men recorded better outcomes if they ended their testosterone use at a younger age or used testosterone for a shorter period.
All the same, some men simply cannot live happily off of testosterone and with a depleted energy level or sex drive. It’s worth noting that when men take clomiphene citrate (clomid) and aromatase inhibitors this often raises the level of serum testosterone without affecting sperm parameters. However, this is an off label use of these medications.