Taking testosterone replacement for hypogonadism due to pituitary disease? Read this.

From Lewis S Blevins, Jr. MD –  I see a lot of men who are concerned about taking testosterone replacement for hypogonadism due to pituitary disease. Their concerns are primarily related to whether exogenous testosterone will suppress sperm production and decreased fertility and diminish testicular size. Let’s address these concerns.

First, men with hypogonadism due to hypopituitarism are usually already infertile or have diminished fertility. Their testicles are already diminished in size and most of this is due to decreased sperm production and diminished intratesticular fluid.

Remember….. disordered LH and FSH production lead the hypogonadism in the first place.

Exogenous testosterone Is often used to restore testosterone levels to normal. It can result in improved fertility in some men. It may, however, and especially if doses are higher than they should be, suppress LH and FSH production which will lead to decreased testosterone production by the testicles, if there was any, and perhaps diminished sperm production, if there was any sperm production in the setting of hypogonadism. THESE ARE REVERSIBLE.

Yes. Read it again. These are reversible changes. Just as LH and FSH suppression by oral contraceptives in women is reversible.

Of course, after testosterone discontinuation, in the man with pituitary disease, testosterone levels fall, LH and FSH levels don’t rise, and sperm production does not increase. This is as a result of the pituitary disorder and not prior treatment with testosterone.

Fertility, when it is desired, is usually restored by the administration of hCG, which acts like LH, as an every other day injection. Some men require the injection of FSH as well. Again, pretreatment with testosterone does not decrease the likelihood of subsequent responses to hCG and FSH.

My advice: If you’re man with hypogonadism due to pituitary disease the best form of testosterone replacement is exogenous testosterone. When you are interested in fertility then it is fine to use hCG and, if necessary, FSH. While I have a few patients who use hCG as a stimulus to endogenous testosterone production I do not favor this approach because it is expensive, is often not covered by insurance, requires injections every other day, and often results in elevated testosterone and estrogen levels as well as their attendant consequences.

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