Vitality Unleashed: The Functional Medicine Podcast

TRT: The Muscle-Building Baby Blocker

• Dr. Kumar from LifeWellMD.com • Season 1 • Episode 102

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The quiet revolution happening in men's health has a hidden consequence few are talking about. Testosterone replacement therapy (TRT) is exploding in popularity, with projections showing 6.5 million American men may have hypogonadism by 2025. But as we reveal in this eye-opening episode, the fertility implications of this treatment deserve urgent attention.

We break down the startling statistics: worldwide testosterone sales increasing 12-fold in just over a decade, and US spending quadrupling in less than ten years. This massive uptick correlates with concerning trends in male fertility clinics, where approximately 7% of men seeking help have a history with TRT. Even more troubling is the knowledge gap we uncovered – many men (and sometimes even their doctors) don't fully grasp how profoundly these treatments affect reproductive function.

The science is fascinating and alarming. Your body's sperm factory requires intratesticular testosterone concentrations 50-100 times higher than blood levels, but external testosterone creates negative feedback that essentially shuts down this critical production. It's a cruel irony – the treatment that makes you feel better simultaneously pauses your reproductive system without obvious symptoms.

Hope exists in recovery strategies we explore in depth. Most men return to normal fertility within 6-24 months after stopping treatment, though individual factors significantly impact timelines. We investigate preservation options like human chorionic gonadotropin (HCG), which can maintain fertility during TRT, and alternative approaches like SERMs and aromatase inhibitors. For forward-thinking men, we discuss the importance of sperm cryopreservation before starting therapy.

Like many complex health decisions, managing testosterone and fertility requires weighing short-term benefits against long-term goals. Listen now to gain crucial insights that could protect your reproductive future while addressing hormone needs. Your future family plans may depend on it.

Disclaimer:
The information provided in this podcast is for educational purposes only and is not intended as medical advice. Always consult with a qualified healthcare professional before making changes to your supplement regimen or health routine. Individual needs and reactions vary, so it’s important to make informed decisions with the guidance of your physician.

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Stay Informed, Stay Healthy:
Remember, informed choices lead to better health. Until next time, be well and take care of yourself.

Speaker 1:

Welcome back to the Deep Dive. Today we're digging into some really important source material. It's all about a topic a lot of men are curious about, maybe even dealing with, but perhaps don't fully grasp the fast-growing use of testosterone replacement therapy, trt, and how it directly impacts male fertility.

Speaker 2:

Yeah, it's quite striking when you look at the research we've gathered, the sheer scale of the increase in TRT use is well significant. We're seeing projections that suggest as many as what 6.5 million men in the US might have symptomatic hypogonadism by 2025.

Speaker 1:

6.5 million Wow.

Speaker 2:

And that naturally leads to a big jump in TRT prescriptions.

Speaker 1:

That's a massive number. It really makes you think about the downstream effects. So our mission today is, to you know, cut through the noise. We want to give you a clear, really well-informed perspective on this complex relationship between TRT, other anabolic agents and a man's ability to conceive.

Speaker 2:

Exactly. We need to look at how these treatments actually affect the body.

Speaker 1:

Right, and what factors influence whether fertility comes back and, crucially, what strategies are actually out there to preserve it or maybe restore it later on? We've pulled some really compelling stuff from a recent comprehensive review focused on understanding and managing the suppression of spermatogenesis. Ok, so let's talk scale, because when you look at the numbers, it's pretty eye opening. Something that jumped out at me was this huge increase in worldwide sales of testosterone preparations, like a 12-fold increase between 2000 and 2011.

Speaker 2:

12-fold. It's staggering.

Speaker 1:

And here in the US, spending quadrupled just between 2007 and 2016 is just a massive shift.

Speaker 2:

And if you connect those dots, this huge trend in TRT use. It's happened alongside more men showing up with infertility issues. Often these men have a history of using TR. Trend in TRT use it's happened alongside more men showing up with infertility issues. Often these men have a history of using TRT. There was a UK study, for example, that found that about 7% of men seeking help for infertility were either currently using TRT or had used it in the past. That's not insignificant 7%.

Speaker 1:

And it's not only TRT right. We also need to talk about anabolic androgenic steroids, cray-a, the kind often used for muscle building.

Speaker 2:

Yes, those also have a detrimental effect on spermatogenesis, definitely.

Speaker 1:

What seems particularly concerning from the research, though, is how awareness seems to vary so much, even among doctors sometimes, about these adverse effects on fertility.

Speaker 2:

That's a really critical point. I mean, if clinicians themselves aren't always fully aware, how can we possibly make sure that men thinking about these therapies are getting the full picture about the fertility side of things before they start?

Speaker 1:

Exactly. It highlights a potential gap in understanding, both for the public and maybe even within the medical community sometimes.

Speaker 2:

It really does.

Speaker 1:

Okay. So this rising use, plus maybe rising infertility connected to it, it leads to the basic question how? How do these external hormones mess with something as fundamental as making sperm? Let's peel back the layers on the mechanism. It boils down to something called the hypothalamic pituitary gonadal axis, the HPG axis.

Speaker 2:

Right. The HPG axis is essentially the command center for male fertility. Think of it like this your hypothalamus up in the brain makes GNRH. That tells the pituitary gland to release two key hormones luteinizing hormone, lh, and follicle-stimulating hormone, fsh.

Speaker 1:

Okay, LH and FSH.

Speaker 2:

LH then travels down and tells the latex cells in the testes hey, produce testosterone. But crucially it's intratesticular testosterone ITT, the concentration inside the testes. And this ITT needs to be way, way higher, like 50 to 100 times higher than the testosterone just floating around in your blood. That high level is needed for sperm maturation 50 to 100 times higher.

Speaker 1:

Wow Okay.

Speaker 2:

And FSH. That stimulates the Sertoli cells, which are like the nurse cells for sperm. They're vital for facilitating the whole process of spermitogenesis.

Speaker 1:

Okay, so that's the natural process. Now here's the kicker right. This is where TRT or ASS come in Exogenous testosterone, the stuff from outside your body. It throws a wrench in the works by creating a negative feedback loop.

Speaker 2:

Precisely. Your body naturally monitors testosterone and estrogen levels in the blood. When they're high enough, they send a signal back to the brain saying OK, we're good, Slow down production. That suppresses GNRH, which in turn suppresses LH and FSH.

Speaker 1:

So the natural production line slows down.

Speaker 2:

Exactly Now. When you introduce external testosterone, whether it's TRT or AAS, it basically floods that system and slams the brakes on that natural production pathway. Your brain thinks there's plenty of testosterone, so it shuts down the signals the LH and FSH, which means? Which means the testes don't get the signal to produce their own high concentration ITT. So intertesticular testosterone levels plummet, Even though your blood levels might be fine or even high from the therapy. Studies show, ITT has to drop quite significantly, maybe over 80%, before you see a decline in sperm production. But that suppressed level is still often higher than normal blood levels.

Speaker 1:

Okay, let me see if I've got this. The key thing is, your body's own sperm factory needs this super-concentrated testosterone inside the testes. But external TRT shuts that internal factory down because it tricks the brain into thinking there's already enough testosterone system-wide. So you might feel good on TRT.

Speaker 2:

You might feel much better symptom-wise.

Speaker 1:

But inside the testes where sperm are made, the essential ingredient. That high ITT is just gone.

Speaker 2:

Or drastically reduced.

Speaker 1:

Pretty much. Yes, it's effectively put on pause.

Speaker 2:

And it's not just direct testosterone. We saw in the research that other things affecting hormones and it's not just direct testosterone we saw in the research that other things affecting hormones, like DHT, dihydrotestosterone, can play a role too.

Speaker 1:

Medications like finasteride used for hair loss affect DHT.

Speaker 2:

And those are five alpha reductase inhibitors, and they can impact sperm parameters too, though thankfully the sources said recovery usually happens after stopping them. But it just shows how interconnected and delicate this hormonal balance is it really does.

Speaker 1:

It's a finely tuned system.

Speaker 2:

Which naturally brings us to probably the biggest question for a lot of guys If you've been on TOT or maybe used to KAS in the past, can your fertility actually recover? Okay, so the good news, generally speaking, is yes, natural recovery of spermatogenesis does typically happen after stopping these agents, for the vast majority of men.

Speaker 1:

Okay, that's reassuring.

Speaker 2:

But and this is a big but the timeframe for that recovery is highly variable. It really depends on several individual factors. It's definitely not a one-size-fits-all situation.

Speaker 1:

Right. The research mentioned a meta-analysis. This was on men who took testosterone as a potential male contraceptive, so they actually had normal hormone levels to start with. They were eugonatal.

Speaker 2:

Correct. That's an important distinction.

Speaker 1:

For those men the chances of getting back to a decent sperm count, say 20 million per milliliter, were pretty good over time, about 67 percent at six months after stopping, 90 percent by 12 months and apparently 100 percent by 24 months.

Speaker 2:

Yes, those were the findings for that specific group.

Speaker 1:

But it's important to flag, like you said, that men who start TRT because they are hypogonadal with low T might have a different starting point right, their baseline could be different, which might affect recovery.

Speaker 2:

That's a reasonable assumption. Yes, yeah. Their underlying condition might play a role. And, yes, their underlying condition might play a role.

Speaker 2:

Now, for KERI-S users, the washout period the time it takes for the drugs to clear is thought to be similar to TRT, maybe around four months, but one study we looked at showed the average time for sperm concentration to recover in previous AS users was longer, about 10.4 months. And, interestingly, other hormone markers, things like FSH and inhibin B, which reflect testicular function. They took much longer to get back to normal, like 19 months for FSH and 31 months for inhibin B on average.

Speaker 1:

Wow, 31 months. So even if sperm production restarts, the underlying system might still be recovering for quite a while longer.

Speaker 2:

Exactly. It suggests a deeper, more prolonged impact on the hormonal axis itself.

Speaker 1:

So okay, recovery isn't just about stopping. It's a process and the timeline is really individual. What are the main things that affect how quickly someone bounces back?

Speaker 2:

Well, the research points to a few key factors. Using TRT or NAS for a longer duration or using higher doses, that tends to mean a longer recovery time.

Speaker 1:

Makes sense.

Speaker 2:

Older age higher doses that tends to mean a longer recovery time Makes sense. Older age, both when starting or stopping the therapy, is also linked to slower recovery and maybe obviously if someone had pre-existing fertility issues or just generally poor testicular function before starting, their recovery might be longer or potentially incomplete. Okay, any other factors? Yes, the sources mentioned Asian ethnicity being associated with potentially longer recovery in some studies and also pre-therapy testicular volume, basically the size of the testes before treatment, can also play a role.

Speaker 1:

So stopping the drugs is step one, absolutely critical. But it's not necessarily a magic bullet, especially if you were on them for a long time or maybe started when you were a bit older. We also saw mentors of newer things SARMs Selective Androgen Receptor Modulators.

Speaker 2:

Yes, sarms, they're being researched for different things.

Speaker 1:

They can also suppress spermatogenesis. It seems, though the studies mentioned, recovery was observed after stopping those too. It just reinforces the idea, doesn't it? Anything that messes significantly with your hormones can potentially impact fertility.

Speaker 2:

It really does, which is why understanding the available strategies is so important Strategies to help recovery or, even better, to preserve fertility from the start. Especially if you're considering TRT or maybe you've already used it, making informed choices here is just crucial.

Speaker 1:

Okay, let's get practical, actionable tips. If fertility is on your mind, what should you be talking about with your doctor or specialist?

Speaker 2:

Right, first things first. If you're actively trying to conceive, the clear guidance from the sources is avoid TRT and AAS or specialist Right, first things first. If you're actively trying to conceive, the clear guidance from the sources is avoid TRT and AAS. Or if you're currently using them, stop immediately, under medical supervision, of course.

Speaker 1:

Okay, stop the offending agent. What next?

Speaker 2:

Beyond just stopping, there are active treatments, hormonal stimulation agents that can help kickstart the system again. One major one is human chorionic gonadotropin, or HCG, hcg HCG basically mimics LH. It directly stimulates the testicles to ramp up that all-important intratesticular testosterone, the ITT, and that promotes sperm production. It can also help with the low T symptoms while the natural system recovers.

Speaker 1:

What kind of dose are we talking?

Speaker 2:

about. Typical doses are around 1,500 to 3,000 international units, usually injected two or three times a week. What's really interesting is that some studies suggest using low-dose HCG alongside. Trt can actually help maintain ITT levels and preserve semen quality.

Speaker 1:

Ah, so that could be a preservation strategy for men who need TRT but also want kids.

Speaker 2:

Potentially. Yes, it's a key option to discuss for preserving fertility. While on TRT, then there's recombinant FSH or RFSH.

Speaker 1:

FSH that acts on the other cells, the Sertoli cells.

Speaker 2:

Exactly. It's often added if EFCG alone isn't quite doing the trick. Fsh needs decent ITT levels to work effectively, so it's usually used with HGG. The combination hCG plus RFSH has shown pretty high success rates in getting spermatogenesis going again.

Speaker 1:

Okay, hCG, maybe RFSH, what else?

Speaker 2:

Then you have selective estrogen receptor modulators, or CIRMs, things like clomiphene citrate, often called clomid or tamoxifen. How do?

Speaker 1:

they work.

Speaker 2:

They work higher up. They block estrogen's negative feedback effect on the pituitary gland. By blocking estrogen's signal, they trick the pituitary into releasing more LH and FSH.

Speaker 1:

Ah, indirectly boosting the natural signal.

Speaker 2:

Correct Now. Clomiphene is widely used off-label for male infertility, but the results, honestly, are a bit mixed according to the sources and it can have side effects, headache, mood changes, rarely more serious things like blood clots. We also saw a note that one part of clomiphene, something called N-clomiphene, might be better at preserving sperm counts.

Speaker 1:

Hmm, interesting nuance. Any other drug classes?

Speaker 2:

The last main group mentioned were aromatase inhibitors, or AIs. These drugs stop the conversion of testosterone into estrogen. Less estrogen means less negative feedback, which again can indirectly boost LH and FSH.

Speaker 1:

So another way to tweak the feedback loop.

Speaker 2:

Yes, they're also used off-label for male infertility, typically considered if a man's testosterone to estrogen ratio is low. But the evidence for using them specifically after TRT or AAS cessation seems limited, and often they're used alongside HCG, not usually on their own. In that context, Okay.

Speaker 1:

So it seems like stopping is step one, but then there's this whole toolkit of potential medical options to actively manage the recovery. It really drives home how important good counseling and an individualized plan are right from the start.

Speaker 2:

Absolutely. The research really hammers this point home. Counseling men about these fertility effects before they even start TRT or AAS is so, so important. It's a critical proactive step.

Speaker 1:

What other proactive things can be done?

Speaker 2:

Well, another crucial one is discussing sperm cryopreservation, sperm freezing. Doing this before starting TRT or AAS is a really valuable safety net, especially for guys who might already have some testicular issues, maybe like Klinefelter syndrome, or if there's a zoospermic, meaning no sperm in the ejaculate to begin with.

Speaker 1:

Right. It could save them needing more invasive procedures later.

Speaker 2:

Exactly. It could prevent the need for surgical sperm retrieval down the line which leads to the final option Surgical sperm retrieval, ssr, combined with assisted reproductive techniques, rt, like IVF or ICSI. So if stopping TRTAS and trying the hormone stimulation drugs doesn't work, yes, for men who remain azuspermic after all that, or maybe for couples who just don't have a lot of time biologically, then SSR retrieving sperm directly from the testes combined with IVF-ICSI, might be the necessary path to conception.

Speaker 1:

Wow, okay, this deep dive has really really shown a light on that critical link between these hormone therapies and male fertility. It seems clear that, yeah, recovery is often possible, which is good news, but it's absolutely not guaranteed, not a quick fix, and it really depends heavily on the individual person and their history.

Speaker 2:

That's the core message really, and it really depends heavily on the individual person and their history. That's the core message really the absolute necessity of having an open, thorough, informed conversation with your health care provider, talking through all the options for managing fertility. You know whether that's looking at alternatives like HCG instead of TRT if having kids is a priority soon.

Speaker 1:

Right.

Speaker 2:

Or being proactive about sperm freezing before you even start treatment. Just understanding these strategies is paramount for your long term health picture and, you know, future family plans.

Speaker 1:

It leaves you wondering, doesn't it? With TRT use growing so rapidly, what does this mean for male fertility trends overall in the coming years? And, more personally, how can you, as a man, navigate this? How do you balance maybe feeling better right now with potential long-term impacts on your ability to have a family? Definitely something to mull over until our next deep dive.