Testosterone, Clomid & HCG: Men’s Health, Sperm Count and Fertility Explained

In part 2 of this conversation, Dr. Chhaya Makhija continues her discussion with urologist and men’s health expert Dr. Justin Dubin, shifting the focus from diagnosing low testosterone to what treatment actually looks like.

Dr. Dubin walks through how physicians approach testosterone therapy and what factors matter when deciding if it’s the right option. The conversation also touches on common misconceptions about testosterone, concerns about heart health and prostate cancer, and the growing influence of social media on how younger men think about testosterone therapy.

They wrap up with a discussion on HCG therapy, which may help stimulate natural testosterone production and support fertility in certain cases.

There isn’t a one-size-fits-all approach to treatment. Understanding the options and having open conversations with your physician can help patients make informed decisions about their health. 

About The Guest

Dr. Justin Dubin is a Urologist who specializes in Men's Health including sexual medicine and male infertility in South Florida. Justin grew up in Wayne, NJ and graduated from Johns Hopkins University with a degree in Biology. He attended Rutgers Robert Wood Johnson for medical school then completed his training in Urology at the University of Miami followed by his Andrology fellowship at Northwestern University.  

Dr. Dubin is passionate about men’s health and education with the goal of improving both the lives of men and their partners. He has published multiple papers on both male infertility and sexual health, has been quoted in the NY Times, Insider, GQ, The Cut, USA Today, and Men’s Health and is the current co-host of the men’s health podcast Man Up: A Doctor’s Guide to Men’s Health through which he hopes to destigmatize men's health topics and motivate men to improve their overall lives.

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Transcript

SPEAKER_05 0:00

Number one, true or false, testosterone therapy permanently boosts fertility.

SPEAKER_00 0:05

False.

SPEAKER_05 0:06

Number two, can testosterone therapy suppress sperm production?

SPEAKER_00 0:11

That is true.

SPEAKER_05 0:13

All testosterone formulations are equally effective.

SPEAKER_02 0:17

I would say it depends.

SPEAKER_05 0:20

Testosterone injections, gels, pills, which one is the most commonly used formulation?

SPEAKER_03 0:26

Injections by far are the most common.

SPEAKER_05 0:29

Are oral testosterone pills universally recommended? Welcome to Hormones and Hope, a podcast where we bridge science and wellness to help transform your health. I'm your host, Dr. Chaya Makija, or you can call me Dr. Chaya, a triple board certified endocrinologist and lifestyle medicine physician and founder of Unified Endocrine and Diabetes Care. Each week we dive into the powerful intersection of clinical medicine and real-life lifestyle strategies to help you feel stronger, live longer, and show up as your most vibrant self inside and out. So let's get empowered. Hi everyone, I have Rumroll here for you, this time for Dr. Dubin, as this is our part two discussion. And if you haven't tune in to the part one, which is all about what is men's health from a leading expert, uh urologist Dr. Dubin, and what does low testosterone mean? You know, what tests you need to discuss with their physicians and how to make a diagnosis. Um, and then come tune into this part two episode where we learn everything about testosterone and the right way to use it, to discuss it with your physician and just more in in terms of what's beyond testosterone that's available for you. So, welcome, Dr. Dubin.

SPEAKER_04 1:48

Thanks for having me. I'm excited to be back for part two. This this was really fun to part one. So I'm excited to be part of this again.

SPEAKER_05 1:54

Great. You know, I love the simplification, and I'm like trying to now get ready as to how you're going to explain the use of testosterone and the and the biochemistry of how it can change men's health. So same story here. We start our uh rapid fire with you, Dr. Dubin, and then uh we get into our deep dive nuanced QA. So you're ready? I'm ready. Okay, it's all about testosterone. Uh number one, true or false? Testosterone therapy permanently boost fertility.

SPEAKER_00 2:25

False.

SPEAKER_05 2:26

Number two, can testosterone therapy suppress sperm production?

SPEAKER_00 2:31

That is true.

SPEAKER_05 2:33

All testosterone formulations are equally effective.

SPEAKER_02 2:38

I would say it depends.

SPEAKER_05 2:40

Yeah. Testosterone injections, gels, pills, which one is the most commonly used formulation?

SPEAKER_03 2:47

Injections by far are the most common.

SPEAKER_05 2:50

Thank you. Are oral testosterone pills universally recommended?

SPEAKER_03 2:55

I think so, yes.

SPEAKER_05 2:57

Uh number six, testosterone therapy increases cardiovascular risk in men.

SPEAKER_02 3:02

No.

SPEAKER_05 3:03

One reason men should avoid low-T clinics without proper evaluation.

SPEAKER_04 3:09

One reason they they don't most of these practices from our study, they don't really understand the guidelines and or have not advised appropriately with the risks of taking testosterone.

SPEAKER_05 3:21

Thank you. So this was great. There were some clear answers, but uh I think the treatment needs to be broken down so that as an individual who is dealing with this condition and needs some form of replacement therapy or a discussion, I think they should have a lot of clarity now. So we know what hypogonadism is, and we also know the off-label treatment relevant to clomophin uh in individuals with hypogonadism, most of them being secondary hypogonadism in part one. So if you can tell us when or what kind of patient, even if it's a patient scenario, that you would start initiating this discussion for testosterone therapy, in what scenario? So low testosterone, you've already looked at their other secondary causes or primary causes. You have a diagnosis and they have symptoms, of course. How do you initiate that discussion?

SPEAKER_04 4:14

So I think first off, if someone's coming to me, I diagnosed them with low testosterone. We talked about the diagnosis, sign symptoms, low T times total T, three less than 300 times two. Obviously a little bit of gray there. But when I'm having the conversation about them being an eligible candidate for taking real deal testosterone replacement therapy, I think about the risks associated with testosterone, and that will help guide me, right? So when we think about the risks of taking testosterone, the biggest one I always think about is it causes infertility. Now I think a lot of people don't understand that because you're like, wait, you need testosterone to create sperm. We talked about that pretty much the pathway is linked with sperm. So why would taking testosterone kill your sperm? Well, it's because we have to go back to that HPG axis. And so we talked about how FSH, LH send a signal to the testicle, the testicle makes sperm and testosterone, and then there's a feedback loop of estrogen and inhibiting B and all these things that can tell the brain that they're making enough testosterone. Well, when you take exogenous testosterone, which is testosterone replacement therapy, testosterone from outside your body, that's not being made by your testicles, but it your body and your brain is still getting the feedback loop. And so your brain is saying, oh wow, we're making enough testosterone. We don't need to make anymore. So it stops the signal of FSH to FSH and LH and your pituitary to be made. FSH and LH become pretty much zero, which means your testicle is no longer making testosterone and it's no longer making sperm. It can your testicles can atrophy after a while, and they may not recover the ability to make testosterone. They typically do recover the ability to make sperm. That's a story for another day. So taking testosterone is two things. One, it's something that kills your sperm, it causes infertility. About 60% of men, only after four months of taking testosterone, have no sperm in their ejaculate. It also is something that when I put someone on it, you're on it for life. You're not a 21-year-old gym rat who's trying to do these cycles of TRT or anything. When I put you on this medication, you are on it for life. And that's a really important thing that I stress to my patients. I make sure that they are have no longer have desire for fertility or want any more kids or want any kids. And two, I want them to understand that they're committing themselves to a lifetime use of a medication. The other things that we talk about for risk is that testosterone can increase your red blood cell thickness. Testosterone is an anabolic steroid, right? It adds, that's how I think about it, adds it builds. So it's going to increase your bone health. It's going to increase your muscle development, your metabolism, your focus, your energy, your libido. Hopefully improve your erections. But it also increases your red blood cell proliferation. Theoretically, if your blood gets too thick, that can be putting you at risk for a clot, like a DVT or heart attack. Now, that's a controversial thing that we do know it increases your hematocrit, but we don't really know anymore. There was a lot of bad papers a long time ago saying that it caused heart attacks and stroke. And the most recent trial, the Traverse trial, which was published about three years ago in the New England Journal of Medicine, was a randomized trial that showed that it did not increase. They took patients with high risk for a heart attack or had heart attacks and strokes, and it did not increase the risk of heart attack and stroke. So, to the point that they've, I think they've pulled back the black box warning on that because of the traverse trial. So it does not cause heart attack or stroke, which means that I'm never worried if you have a history of heart attack or stroke to put you on this. There are still some nuances to that, of course, that we don't have to get into. So the other thing is prostate cancer. This is the other controversial thing that is always important. We always thought that taking testosterone, or people thought, not we always thought, there is an inherent link between testosterone and prostate cancer. When men have aggressive prostate cancer, they can be given ADT, which is antigen deprivation therapy, to remove all the testosterone in their body, which helps treat prostate cancer. So inherently, people thought taking testosterone can worsen your prostate cancer, can cause prostate cancer, cause recurrence of prostate cancer, or spread of prostate cancer. What we've discovered is that's simply not true. Obviously, though, if someone has active aggressive prostate cancer and they probably need to be on androgen deprivation therapy, I'm not giving them testosterone. But I will tell you, men with low-risk prostate cancer, they're on things, something called active surveillance. There's a lot of good data suggesting these people can be put on testosterone safely and monitored closely. Now, I'm not saying and recommending every single person who's a provider do that. You have to be comfortable, you have to understand the data, but it is something that we do. I treat a lot of men who have been cured of prostate cancer with testosterone replacement therapy. So there is a gray area, but it's not a complete contraindication to give it. So people that I think are the true purest form of not who should not get testosterone are people who want future fertility. That's kind of my stop end gap. And that's kind of my my breakdown and how I actually counsel patients on the risks and benefits through that conversation we just had.

SPEAKER_05 9:51

Yes. Again, it's uh simplified, and you know, you highlighted the fertility aspect of it. And thank you for sharing about a young generation. You know, when I started my own practice, I went before being in a larger group setting. I, my first four or five constipations were coming from TikTok of young kids between 18 to 25. And uh, you know, they pull out a form and it was low testosterone. What was the source of referral? TikTok.

SPEAKER_04 10:23

Yeah, their looks maxing, as the as the say, their looks maxing, claviculars out there telling them all to take uh TRT and everything. But yeah, no, it's out there. We did a study on TikTok and and Instagram. We looked at men's health topics, testosterone, male infertility, peronies disease, rectile dysfunction, semen retention, and all the data is horrible on TikTok and Instagram. It's mostly not provide given by providers. Someone's trying to sell you something. So, you know, you have to go. I'm glad that they went to you. Honestly, kudos to them to actually finding uh uh an endocrinologist and a doctor to actually get information from instead of just buying some stuff. So I actually give those those guys credit, but you're right. It is something that is uh grossly being exaggerated out there, and and people are making profit out of it for sure.

SPEAKER_05 11:12

Yeah. Since you say that, I wanted to share, you know, uh, this was also shared in part one that Dr. Dubin has his own podcast, Man Up Podcast, and it's on Man Up. So for men's health, if you're looking for resources, just go tune into his podcast. He's got diverse, like so many topics, and uh I usually let my patients know about the education of plethora that's out there in uh several episodes. So don't miss out on that one for sure. So thank you, Dr. Dubin. You know, I think you mentioned this at the introduction or when we were chatting about, you know, men not or the the the sense of uh being ashamed of, oh, I have erectile dysfunction or oh low libido can't happen to me, or how will I discuss this with my physician or even my spouse? That should be out there. Like we need to get those inhibitions out and those dias out when uh there are exchanges between the physician and the patient, or even with the couple and the physician. So thank you. So, testosterone, you've told us, you know, the specific things which need to be eliminated or looked at when you're bringing this about in the discussion. And then in the rapid fire, you mentioned that injections are the most common formulations. So can you enlighten us with more insights on what are the formulations which are approved, what are available, and then what are the usual go-to-ones or any pros and cons with either of those?

SPEAKER_04 12:37

So when we're talking about injections, there's traditionally two forms of injections that I that we recommend. The most common really is testosterone sipionate, which the half-life is about seven to eight days. And it's it's given in vials traditionally. And I think it's really important to understand the half-life of these medications because they really dictate how you use them. So personally, I think when you have testosterone sypionate, the best way to do it is to inject it on a weekly basis. You we just heard the half-life is seven to eight days. So, why is that important? Because if I inject on a Sunday, and by you ask your patients, they will feel by that next Sunday, they feel much lower than they did before. And it's because that half-life is about that time frame. And that's why, like a lot of people come to me and they're on the appropriate dosage. They're on about, you know, I do 100 milligrams a week, is where I start. Now, everyone is different. We can lower it, we can raise it. That's traditionally how I like to start. But a lot of patients come to me, they're on testosterone stipulate, but they're not happy with how they feel. And I ask them how they're taking it. And their provider often says, is doing it one injection, 200 milligrams every two weeks. Now, although that is equivalent, if you understand the pharmacology here, you're gonna be blasted off to the moon for that first week, and you're gonna be coming down pretty hard on the second week that you just don't feel even keeled. And I think then if you understand the half-lives, getting to that steady state of where guys are able to keep a consistent level of testosterone for the most part is important. And that's why I encourage people injecting once a week with testosterone sipionate. Now, the other one that a lot of younger people like to do, a lot of bodybuilders tend to do is test ananthate. Now, test ananthate you can still get pretty much anywhere. And honestly, the truth is both of these can be injected, I am or sub Q, realistically, but IM is in your muscles, sub Q is like in your fat, in your belly. Test ananthate actually it has a half-life of about four to five days, and people therefore take it about twice a week. Some people think it may have like less water retention. To me, every one of my patients who's on it, I feel like they're the same as the other patients that are on sypionate. But some people like to take that medication instead, and I'm happy to provide it. But the the gold standards typically testosterone sipionate, not an enanthate. The other option is also testosterone enanthate, which is actually an auto injector called zyastead. That's subcutaneous as well into your belly. Some people don't like needles, so they take that injection, and that's once a week, and that dosage can be adjusted as well. But uh the enanthate in the non-uh commercialized version, I do twice a week. For the zyaste, I do once a week. That's the recommended way to do it. So those are the most common injections. Sipionate's usually the best one, in my opinion, just because of how cheap it is. You can get it quite easily, quite readily, and especially using coupons like good RX. I usually don't recommend patients go through the insurance process. It's very painful. Just use the coupons. So that's the injections. Tell me what else you want to know.

SPEAKER_05 16:00

Now comes gels. You know, I have a bunch of patients with secondary hypochonatism because of a pituitary tumor. It's resected, and that led to hypochonatism, and they just somehow do better with the gels as compared to injections. Now, these are um not necessarily older, but 60 plus individuals. So tell us more about gels, and the last would be the pills because they're more recent.

SPEAKER_04 16:24

Yeah, so androgel, which is the testosterone gel, I think that you need a dear a specific kind of patient. They they have other contraindications that I think are are you have to be aware of when you're counseling patients. First off, anyone who works outside sweats a lot, I never recommend androgel because how it works. Well, androgel is absorbed, you know, through your skin. Uh, you typically put it on, it's in the clicking machine, you put it on your shoulders, so it's absorbed pretty much directly into, you know, the muscle of your body there. That's why you don't want to put it on you anywhere with a lot of fat, so it's more readily absorbed. But you typically do it once a day. I say however you prefer. I think I would prefer to do it in the in the morning, but some people like to do it at night because you, you know, your testosterone levels are highest actually when you wake up. So some people feel like they get that boost in the morning when they wake up, but I'd rather just do it in the morning. But another, another, but that's here or there. I typically recommend they do it after they shower, right? So if you shower in the morning, you dry yourself off, put it on, you're good to go for the day. Same thing at night. But if you sweat a lot, you work outside, you're not gonna be absorbing the medication as well. So I don't think it's a good option for you. If you're very overweight, where you have like a lot of fat even on your shoulders, probably not gonna absorb well. Not a good option for you. Another thing that we don't think about enough that I always ask is are you around, especially here in Florida, you know, California, you probably have it too. A lot of people were shirtless a lot, right? Because the weather's pretty good. So I always ask, are you around children? Do you have the young kids that you carry? Do you have grandkids that you carry or hold? And sometimes if you're shirtless, because remember, the biggest concern here and the biggest risk is not to you, it's to your to the other people around you. Transference. Now, the data on transference shows that it's pretty much like less than 2%, but I like 0% when it comes to giving, putting a potential child at risk for getting testosterone exposure. You see it once in a while in the news, a baby girl develops like clitoral, clitoromegaly, or they develop like body hair, or a kid develops pre-pure pues into puberty at a very young age because of these kinds of things. So anyone who's around young children or or you know, taking care of young children, I never give them this thing. But for other people who don't like injections, are willing to do something on a daily basis, I think it's a great option. Uh any thoughts or comments on that before we move on to the next thing?

SPEAKER_05 18:56

No, I love that. You broke it down because it's not the uh the medical condition that justifies injections versus andra gel or any testosterone gel, but it is actually these, you know, daily routine. What is your 24-7 hour look like, your environment that matters in terms of the formal sense?

SPEAKER_04 19:14

Yeah, and especially in a place like Miami where everyone's sweating, everyone's hot. A lot of people work outside. So I tend to switch people off of gels a lot of the times and get better effects. The next one, actually, I want to, before we get to the oral, there's other options as well, right? You have testapel, which is the the pellets they can go in your butt. And those are for long term. They take they last about three to six months. They're a slow release in your body. You get a little procedure, it takes about 15, 20 minutes in the office. Personally, I'm not a big fan of them. I think that you have to have a special patient for that. I think the ideal patient for that is someone who's either in like a nursing home who can't care for themselves or can't care for themselves or can't do injections or isn't able to care for themselves on a regular basis, that really just needs a testosterone anyway. I think those are good candidates for that. But I think younger guys really shouldn't be on it because the truth is you're sore for a couple of days, a couple of weeks, and I feel like you're not getting a better regulation of your hormone levels. I prefer to keep a more steady state with injections or gels or oralty. So, you know, just because it provides value. But there is value for certain patients, a specific kind of patient that is a good candidate for this. Now, I have people come in and say, I just want the pellets. I don't want to think about it. I just want to come in every six months and just know I'm I'm being treated. And I think that's very reasonable. I'll never argue with that. But it's kind of my last resort a lot of the times, unless it's a specific kind of patient. There's something else called long-term injections of ED. It's much less commonly seen just because insurance is a problem to get it approved. That's you're done. You're you inject, I think, every 10 weeks. But you know, you're probably not going to be able to get access to that. It was a struggle for me. I was giving it to patients, but who actually like the medication. It's not the medic problem with the medication, it's just insurance problems getting it approved. And then the last one, as you said, is oral testosterone. And I think oral testosterone is really on the up and up. There's three different brands, but they all pretty much do the same thing: Talando, Kaiser Trex, and Jotenzo. They're all commercial brands, so they can run a little bit more expensive. How they work is when we were trained, the guidelines really said you shouldn't be taking any oral testosterone because originally it was a first pass through the liver. It would cause liver injury. And over the last 10 years, though, they've refined this and it is not any issues anymore. It's it's no risk to your liver. It they are great oral medication options for people who either don't want it taken, don't like injections, aren't good candidates for gels, or just prefer oral medications in general. The medication usually peaks around five to six hours after taking it. So you have to take it twice a day. You take it once in the morning, once usually at lunchtime or at night, depending on how you want. If you need, like instead of a coffee boost, you know, I tell my patients you can time that however you want to do it. Like around 3 p.m., you can get a little nice boost with the second testosterone. Important for this though, you need to have fatty food with it. So you can't take it on an empty stomach. It needs to be taken with food to help it absorb into your body. One of the actual benefits of this is we discussed one of the risks of taking testosterone is polycythemia, which is increasing red blood cells or increasing your blood thickness. This is actually the only testosterone option that does not increase your red blood cell thickness. So on occasion, you have patients who are very sensitive from testosterone. Their blood thickness goes too high, and we don't want to put them at risk for other issues. So for those patients, this is a really excellent option that is usually approved through insurance because we've shown they've failed other options that don't work for them. And this is a great option for those patients who we need to control their hematocrit, their hemoglobin levels, and you're getting the impact of the testosterone without getting that rush of the increased hematocrit. And people say, why is that? Well, it's shorter acting, and so it goes more in rhythm with your physiology. When you're injecting, which usually has the highest risk of polycythemia, you have to remember you're giving your body a huge spike of testosterone, which is like a big punch saying you got to go do this, and it really stimulates your red blood cells. Whereas if you have this slow physiological increase in testosterone, you're probably less likely to get that. You know, there's also some data showing that the oral testosterones are actually the only ones to improve your free testosterone by potentially decreasing your SHPG. And that we talked about SHBG a lot, a little bit last time in the last episode, but in general, it's very hard to lower SHBG. We really don't have many interventions on doing so. And this is actually potentially one of the things that can improve your testosterone by improving your not only your total T, your free T, and low by lowing your SHPG. So these are all really good options. The oral T, because it's the newest, is the most expensive and typically the hardest one to get approved. So you have to understand that, and you might have to be willing to pay$200 a month for the medication, which for some people is worth it. Some people, you know, you can go get a vial of testosterone in Sipinate at Good RX for three months worth for like 35 bucks. So like the price differential is huge. But the important thing is we have a buffet of options to really cater to you, your needs, and what's going to work best for you.

SPEAKER_05 24:58

Wow. I didn't know about the the sex hormone binding globin and the oldest strong. So that's that's Yeah.

SPEAKER_04 25:04

I'm like 90% sure that's true.

SPEAKER_05 25:08

No, that's amazing because there are these uh individuals where you're trying to, you know, like really pull your hair that how do I get attacked uh S's the sex hormone binding globulin? Beautiful. This is going to be our last piece, Dr. Dubin. He's given us like gems and uh lots of pearls in this world of men's health, is the use of etc injections. Male patient is desiring fertility, but they've been exposed to either testosterone injections for treatment of hypogonadism or they are needing the support of etc injections to help with fertility.

SPEAKER_04 25:42

So let's talk about HCG. Uh human chorianogonadotropin. This is what a lot of people associate with a pregnancy test, right? So when women get pregnant, they release HCG. So they pee into the pregnancy test and it tests positive for HCG. And you're like, what are men doing injecting HCG into their body? Well, HCG is very interesting because it's structurally very similar and recognized by our body as LH. So it will activate LH, the luteinizing hormone receptors. And from our conversations, we now recall that LH is the hormone that stimulates the testicle to make testosterone. And that's very important because unlike CERMS, which we talked about, clomid and clomophene, that tell your body to make more LH and FSH to tell your testicle make testosterone, you're bypassing that and you're injecting directly a medication that can tell your testicle to naturally make testosterone. So HCG is actually a really great option for men who want to preserve their fertility. And it is an option in addition to clomid and clomaphine as well. And sometimes it's in combination with. Now, the half-life of this medication is about 24 to 36 hours. So you're usually injecting it twice to three times a week. I usually do about 1,500 units to start Monday, Wednesday, Friday if it's by itself, 500 units Monday, Wednesday, Friday if it's with testosterone. This is an important concept because when we're talking about testosterone, if you add HCG, you're actually giving your testicles the ability to preserve their size and preserve their function, potentially by making testosterone and sperm. Now, I know it doesn't really make sense. And I'll be honest, I don't think we 100% understand why, but we do know that HCG, although it's only stimulating the LH receptors, there is some kind of cross-reactivity where it is also stimulating your Sertoli cells in your testicles to continue to make sperm. And maybe that's just because your testosterone levels in your testicle are so high and good that you're able to make sperm or at least preserve your sperm. But this is a really valuable thing for guys who are either on testosterone, who want to come off of it for fertility purposes, or want to find a way to preserve their testicle size or their fertility while on testosterone. Now, the important thing here is nothing's guaranteed in this life. And I say this every time a patient asks, Can I want to preserve my fertility, but I want to be on T. Can I go on HCG as well as T? And I say, yes, we can do that. But everyone responds differently. I cannot predict how your body is going to respond. You may preserve your testicle size, but you may not preserve your fertility. Or you may preserve your fertility, but it's going to dramatically decline, right? And maybe someone who was able to conceive naturally now will only have to be able to conceive through IVF. Have I seen that? Absolutely, I have. But there are people who are able to have kids with just on testosterone, right? But when we're talking about the odds, I really prefer to not keep people on testosterone and just give them either clomid and clomiphene or a combination of HCG with those or just HCG. Now, very interesting study came out about a year or two ago where they randomized guys who are already on T who wanted to recover their fertility. They put one group on HCG in addition to the testosterone they were taking, and they took the other guys off and just put them on HCG and clone it. And the recovery rates were actually the same, believe it or not, of sperm, which means that HCG with testosterone is potentially a viable option for sperm recovery. Now, is it my choice? No. But you also have to understand that some people really, after being on testosterone for so long, their testicles have atrophied that they don't respond to enclomophene or HCG on them. And they're miserable. And, you know, I've had these patients, they've been on it even if for two years their testicles took a hit, and we're giving them all the clomid, all the HCG. I'm giving them other medications that we don't need to talk about to improve their symptoms. And they're just holding on until they get sperm to bank and then go back on. But, you know, if I can get you off it, I can. But some people just need that extra boost. I've had guys who we took off everything, their sperm came back completely normal. They said, I want to be on TNH CG, and their sperm declined and it dropped like 95%, and we took them off again. It's a game that if the patient's willing to play, I'm always willing to learn with you. But I always think that it's a caveat that you have to understand what the best route is and what the optimal route is. But there's also a reality of the situation. So understanding these things and understanding that there are different pathways for different people is important. But there is always an ideal pathway if you can find it.

SPEAKER_05 31:02

Amazing. You know what's amazing to me is clinicians, experts as yourself, and then the education that comes along with giving that the buffet option that you talk about, uh, and the education of going to the evaluation is such a key piece in that relationship of patient-physician and how you're approaching their care.

SPEAKER_04 31:25

Yeah, I think we're really lucky in the space that I have, is for almost everything that I do, there's not just one option. There's so there's autonomy in you and your body and how you want to proceed with how you want to take a medication, what you want to take, what your goals are. And I think that is a real key to having a patient buy in. Because sometimes if you say, hey, you're taking this, and they're like, Well, what are the other options? And you know, you you've seen patients, I've seen patients. Well, no one told me I could do this. And it's like, yes, you can do that. And they're like, Well, I would have loved to have done this. I would have listened to the doctor, I would have used this medication if I knew that this was an option. But when you're providing just one route that where there's many, I think a lot of people won't buy in. So, like giving the options, allowing them to really buy into their care because they think that's the best path for them, I think really makes a big difference at the end of the day.

SPEAKER_05 32:23

It does. And to my friends, people, audience, uh tuning in, take this as your library of resources. You know, the two episodes that Dr. Dubin really dived deep into what is hypoginatism, what is low testosterone, the workup and the clinical evaluation and just the walkthrough to every treatment option that you have. You literally could listen to both of them and then educate yourself. And it could also be having a discussion with whichever physician or clinician you're seeing who uh who's taking care of you, or you need to ask specific questions. You have all the answers of these two episodes. I love it, Dr. Dubin, and uh I really appreciate and uh it feels like it's an honor to have an expert as yourself. Break it down for your best health.

SPEAKER_01 33:10

Oh no, that's just I'm just a guy. I'm just a guy who writes others.

SPEAKER_05 33:16

Yes, that's being humble. But thank you so much. It's a privilege to have such specialist in communities where it's far, you know. I don't know how many miles that would be, what, fourteen hundred, fifteen hundred miles away. But you're you're spreading probably more, yeah. This is like half of United States. I think it's double.

SPEAKER_01 33:37

Yeah, I think it's double. Yeah, I think it's like three thousand. I was gonna say like three thousand, four thousand, yeah.

SPEAKER_05 33:42

Yeah, that'll give you three thousand something. Yeah, so I really appreciate it, and thank you so much for joining us and breaking everything down and simplifying it.

SPEAKER_04 33:51

My pleasure. Thanks for having me. This was really fun.

SPEAKER_05 33:54

Thanks for hanging out with me on hormones and hope. If you've loved this episode, do me a favor, hit subscribe, share it with someone you care about, and drop a review if you're feeling generous. Want more tools to support your hormones and health? Head over to unified endocrine care.com. We've got free guides, resources, and more waiting for you. Until next time, stay curious, stay kind to your body, and keep your hormones happy.