Hormone imbalances are a fairly common cause of fertility problems in men. Of hormone issues, Low testosterone (or hypogonadism) gets the most press. It is fairly common for testosterone levels to drop as men age and testosterone replacement therapy has gained popularity in helping men feel active and youthful. However, when you are trying to conceive, getting the right balance of hormones can be a little more involved.
The male endocrine system revolves around ensuring that there is enough, but not too much testosterone. As a quick refresher to high school sex ed, here is how hormones are produced. In the brain, the pituitary gland produces luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH travels through the blood to the testicle where it stimulates production of Testosterone, which is a steroid, by leydig cells. Testosterone is soaked up by sertoli cells to feed baby sperm. Leftover testosterone goes into the blood stream, where it is put to use building muscles and growing your 5 o’clock shadow. (see our bio lesson on hormones for more details). When there is enough testosterone around, sertoli cells secrete inhibin, which in turn tells the brain to stop producing FSH.
If semen analysis comes back abnormal, most urologists will perform a physical exam and request a simple blood test to measure Testosterone and FSH (occasionally they will also measure LH as well, but usually it is unnecessary). It is best to take the test in the morning when blood testosterone levels are at their peak. See our article on hormone testing for more details.
What can go wrong?
There are a variety of ways that men’s hormones can get out of balance. These are the most common, although sometimes Testosterone and FSH can’t tell the whole story. There are certain conditions for which it is useful to gather information about additional hormones include thyroid stimulating hormone (TSH), luteinizing hormone (LH), and estrodiol (a form of estrogen).
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Primary Hypogonadism: Low T, High FSH
Primary hypogonadism, sometimes referred to as hypergonadotrophic hypogonadism, occurs when the brain is sending a signal to the testicle to produce testosterone, but for one reason or another, the testicle is unable to produce sufficient testosterone. Often this is due to some form of testicular failure which can come from injury, infection, toxins, genetic conditions, or congenital defects. If, indeed, the tissue of the testicle is damaged, there is little that medicine can do to repair or restore function.
Genetic Disorders Several genetic disorders can reduce testicular function and lower T levels. Some of the most common disorders include Klinefelter Syndrome,which happens when men receive an extra X chromosome and have XXY rather than just XY. Another common issue known as Y Chromosome Microdeletion (YCM) happens when key genes responsible for testosterone or sperm production are deleted from the Y Chromosome. See a full list of genetic disorders that can impact fertility.
Cryptorchidism: when balls go AWOL: Poor descent of the testicle is one of the most common birth defects in baby boys, affecting 3% of full-term babies and up to 30% of premies. Often the testicle will descend on its own during the first year of life (usually during the first 3 months), however sometimes surgery is required. When the testicles don’t descend, fertility is at risk. This is due to keeping the testicle in the body longer, which overheats the cells responsible for producing sperm and permanently cooks the ball.
Infection & Injury: “Protect the family jewels” has an element of truth to it. Injury to the testicle can destroy tissue needed for sperm production. A cheap shot below the belt isn’t likely to do it, but if you somehow injure yourself and the pain doesn’t subside, it is a good idea to go to the ER; Sometimes blood flow to the testicle can get cut off and cause irreversible damage. Infections such as mumps, gonorrhea, and syphilis, among others, can also cause severe damage. Often these can be treated with medication. Take home point: if it hurts or it’s weird and it doesn’t go away, it’s a good idea to see a doctor, even if its embarrassing. Your balls will thank you.
Testicular atrophy: Are my balls shrinking?
Testicular atrophy, or shrinking balls, are most commonly associated with steroid use, but there are a number of other reasons that a man’s testicles would begin to atrophy. The most common reason is age. Atrophy is a natural part of aging. As we get older blood doesn’t circulate quite as well and some of our less critical tissues (such as muscles) begin to shrink. Another common cause is leading a sedentary lifestyle. This lifestyle results in the body beginning to atrophy, and in extreme cases this can include testicular mass, creating a negative feedback loop: smaller testicles reduce testosterone production, which in turn increases fatigue, further reducing physical activity and increasing atrophy.
Steroids & Testosterone Replacement Therapy: High T, Low FSH
The most common way to boost testosterone is to use anabolic steroids or testosterone replacement therapy. These drugs are part of a family of drugs known as androgens. They all work on a similar principle: they are pumped into the bloodstream either inter-muscularly (via shot) or trans-dermal (with patch or gel), and bind to androgen receptors throughout the body, and enhance all the secondary sex characteristics (such as hair growth, muscle mass, etc). However, they do not pass into the testicle and therefore do nothing to help with sperm production. In fact, they have the opposite effect. When the brain senses that there are high levels of testosterone in the blood, it assumes the testosterone is coming from the testicle. The brain then shuts off production of FSH, which stimulates the production of testosterone in the testicle. So while the body enjoys the benefits of high serum testosterone, the testicles are stranded and begin to shrink.
If you have low T and have been on TRT but are now finding a drop in sperm count, pick your ego off the floor, there is a good chance that you can boost your sperm count. The first step is getting off the testosterone medication. Next, you need to figure out the causes of your low T. Lastly, there are a variety of medications that can help boost testosterone levels in sperm friendly ways. There are also a whole host of natural ways to boost testosterone.
Secondary Hypogonadism: Low T, Low FSH
Secondary hypogonadism occurs when there is a problem with the pituitary gland or the signaling pathway, that suppressed production of follicle stimulating hormone or luteinizing hormone, or both, which in turn suppresses testosterone production. The good news is that this form of hypogonadism is much easier to treat. Medications such as Gonal-f, Menopur or hCG which were originally developed to treat female infertility have proven to be very effective at resolving low T issues when there is a signalling problem. Many urologists have limited experience with endocrine issues. They may not be aware of medications to restore hormone levels and want to prescribe a testosterone, which will not be helpful for all the reasons mentioned above. Ask them to look into FSH or LH based medications.
Genetics: There are a number of known genetic conditions that can impair the production of key reproductive hormones. Most of these conditions are relatively rare (1 in 10,000), but are still worth knowing about. Kallman Syndrome is a condition that causes a late onset of puberty and is charactized by a complete lack or severely impaired ability to smell. It dramatically reduces the production of GnRH, the hormone responsible for stimulating the production of LH and FSH. Other genetic disorders that can lead to hormone imbalances include: Prader-Willi Syndrome, Pasqualini Syndrome, Congenital adrenal hyperplasia
Got Prolactin?: The role of prolactin in men is not understood very well. Some scientific literature suggests that in small quantities prolactin helps the testicle produce testosterone. However, in large quantities it can inhibit production of GnRH and increase the production of stress hormones. Both of these things can suppress testosterone production. The most common cause of hyperprolactinemia, or elevated prolactin, are pituitary adenomas, which are small non-cancerous tumors that can sometimes grow on the pituitary gland. Pituitary adenomas can cause infertility, erectile and sexual dysfunction, and gynaemastia (man boobs). They are often not diagnosed until they have grown large enough to cause headaches or vision problems. If you are having trouble getting to the root of hormonal imbalances it may be a good idea to check prolactin levels to ensure that there aren’t problems with the pituitary gland. Read more…
Effects of Medications or Toxins
There is a lot of speculation and research going on to discover the effects of environmental toxins on male fertility. The studies are rather difficult to conduct and so much of the hard evidence remains inconclusive. However, there is quite a bit of anecdotal evidence that various medications and environmental toxins – certain forms of plastics, pesticides, building materials – can impact reproductive hormones.
Aromatase Disorders: Testosterone / Estrogen Imbalance
Aromatase is an enzyme responsible for converting testosterone into estrogen. Traditionally, aromatase disorders have been fairly rare and caused by genetic conditions that can lead to both deficiency or an excess of aromatase. However, more and more men are experiencing hormonal imbalances due to excessive aromatase. Here are a list of the most common reasons:
If you suspect you may have issues with excessive aromatase activity, you may want to ask your doctor to check your testosterone to estrogen ratio. If estrogen excedes testosterone, you may benefit from using aromatase inhibitors.
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