Does low testosterone impact fertility?

When someone is diagnosed with low testosterone (low T), they may question what it means for their reproductive future. Testosterone is the primary male sex hormone responsible for various important bodily functions. These functions include:

  • The development of the penis and testes
  • The growth of facial, pubic, and body hair
  • The regulation of sex drive (libido) and mood 
  • The growth of muscle and bone mass 
  • The production of sperm and red blood cells

Individuals diagnosed with low T may wonder how the condition could impact their fertility, what forms of low T treatments are available, and whether or not assisted reproduction or fertility preservation are viable options.

Fortunately, several treatments are available for people diagnosed with low T who wish to preserve their fertility. By working closely with their healthcare provider, people diagnosed with low T can find treatment protocols that best meet their needs.

What is low T in people with testes?

Testosterone is produced in the testes via a negative feedback loop within the hypothalamic-pituitary-gonadal (HPG) axis. This means that testosterone production is inhibited when sufficient testosterone levels are detected. Most people with testes produce adequate levels of testosterone throughout their lives for their bodies to carry out several functions of testosterone throughout their lives. However, if an issue arises within the HPG axis or there is a physical problem affecting the testes, the testes may not produce adequate testosterone levels.

Does low T cause infertility?

The process of sperm production, known as spermatogenesis, requires the testes to produce adequate testosterone levels. While some people with low T may still have enough sperm to achieve pregnancy, many people with low T face infertility due to diminished sperm production, decreased libido, or erectile dysfunction.

How is low T diagnosed?

The American Urological Association recommends healthcare providers make a diagnosis and consider treatment of low T, also known as hypogonadism, when total testosterone levels in the blood fall below 300 ng/dl on two separate occasions and the patient exhibits signs and/or symptoms of low T, such as:

  • Decreased libido
  • Reduced nocturnal erections
  • Erectile dysfunction
  • Decreased volume of ejaculate
  • Male factor infertility
  • Decreased energy
  • Decreased cognition
  • Reduced muscle mass
  • Reduced strength
  • Increased adiposity/body fat
  • Gynecomastia (growth of glandular breast tissue)
  • Loss of body and facial hair
  • Decreased bone mineral density
  • Hot flashes and/or profuse sweating
  • Sleep disturbances
  • Depressed mood
  • Increased anxiety
  • Anemia

What are some of the causes of low T?

Some people with testes may have risk factors that increase their chances of being diagnosed with low T. Chronic conditions such as obesity, type 2 diabetes, hypertension, metabolic syndrome, and stress (both acute and chronic) often present alongside low T levels. Testicular damage and/or genetic conditions such as Klinefelter syndrome can also cause both low T and decreased sperm count. Certain medications and drugs, including opioids, alcohol, marijuana, and chemotherapy, can also decrease testosterone.

Ironically, another cause of low T is synthetic, or exogenous, testosterone use, also known as testosterone replacement therapy (TRT). As stated above, testosterone production is regulated via a negative feedback loop. Then, when circulating testosterone levels drop, the body is signaled to produce testosterone. However, when a person with testes undergoes TRT through synthetic applications of testosterone, including gels, creams, or injections, their body responds as if it is producing sufficient quantities of testosterone on its own and subsequently may decrease or discontinue its production of testosterone.  

Aging was also once thought to be a typical physiological cause of low T production in people with testes. In fact, about 40% of people with testes over the age of 45 experience low T, and the number increases to 50% when they reach their 80s. Additionally, recent studies suggest this age-related decline in testosterone levels may be exacerbated by co-occurring chronic medical conditions such as obesity, smoking, and taking certain prescription medications rather than solely from aging itself. It is common for testosterone levels to decrease by 1-2% per year with aging; however, this does not always result in testosterone levels that are below normal levels.

Common myths and misconceptions about low T and fertility

 Searching for scientifically sound information on low T and fertility can leave a person feeling frustrated as they attempt to wade through pages of unclear and outdated information, often published by companies selling testosterone supplements and boosters. A trusted healthcare provider can help people with suspected low T find accurate and up-to-date information relevant to their clinical situation.

Myth #1: Taking supplemental synthetic testosterone (testosterone replacement therapy or TRT) will cure infertility in people diagnosed with low T.

Fact: Although TRT can help with issues such as low libido and erectile dysfunction, synthetic testosterone can suppress the body’s natural sperm production and lead to azoospermia, a condition in which no detectable levels of sperm are found in semen. This may be reversible once the TRT is discontinued. However, this is not guaranteed.

Myth #2: Lifestyle changes alone cannot correct low T or low sperm count. 

Fact: Research shows that weight loss is associated with increased testosterone levels and that the most positive results came from weight loss resulting from an increase in vigorous physical activity.  

Myth #3: Testosterone “boosters” sold online and in vitamin shops will increase testosterone levels.

Fact: Limited human studies have evaluated testosterone boosters, and no studies to date have proven that these boosters definitively increase testosterone levels in people with low T. In fact, a recent study found additional ingredients in many supplements, including medications for erectile dysfunction, weight loss, and steroids, which are potentially harmful to some people with certain medical conditions.

Which healthcare providers help people with symptoms of low T?

People who suspect they may be dealing with low T should contact a provider to schedule an appointment for evaluation and testing. Their doctor may then refer them to a urologist or reproductive endocrinologist for further specialized care.

What treatment options are available to people with low T who wish to preserve their fertility?

 Pharmaceuticals such as human chorionic gonadotropin (hCG), selective estrogen receptor modulators (SERMs) including clomiphene citrate or tamoxifen, and aromatase inhibitors (AIs), including anastrozole and letrozole can be used alone or in combination to treat low T in people wishing to preserve fertility.

For people with low T due to testicular damage or genetic conditions, non-pharmaceutical family-forming options may include surgical retrieval of sperm from the testes, assisted reproductive technologies such as intracytoplasmic sperm injection (ICSI), or using donor sperm.

Resources for Carrot members 

Carrot offers access to vetted, inclusive providers specializing in low T treatment. Members have unlimited access to chats with specialized Carrot Experts who can help them understand what low T is and provide information on the various treatment, family-forming opinions, and available resources through the Carrot benefit.

Members can also now access personalized hormone replacement therapy (HRT) prescriptions to effectively and safely manage low T symptoms when necessary. 

If you’re a Carrot member looking to learn more about low T, sign in to your account to learn more about your options.

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