TRT and Fertility: a GP referrer’s guide
Testosterone replacement therapy (TRT) can be transformative for men with confirmed testosterone deficiency, but it is also a common, preventable cause of male-factor subfertility. Exogenous testosterone suppresses hypothalamic–pituitary LH/FSH, reducing intratesticular testosterone and impairing spermatogenesis—clinically presenting as oligospermia or azoospermia.¹² Contemporary guidelines are consistent: do not start or continue exogenous testosterone in men with current or future fertility goals, particularly if conception is planned in the near term.³⁻⁵
1) Does the patient want children and when?
Ask every reproductive-age man prior to prescribing TRT:
Child-wish (yes/no/unsure) and timeframe (0–6 months, 6–12 months, >12 months)
Partner factors (age, known infertility), prior paternity, contraception plans
If fertility is desired now or soon, avoid TRT and consider early referral to a reproductive urologist/andrologist or endocrinologist.³⁻⁵
2) Baseline work-up that streamlines specialist care
Before initiating TRT (or at first review if already started):
Confirm biochemical deficiency with two morning total testosterone results (plus free T when indicated), and add LH/FSH ± prolactin to help define primary vs secondary hypogonadism.³
If fertility is relevant: arrange baseline semen analysis and counsel explicitly that TRT can suppress sperm production.⁵
Review reversible contributors (obesity, OSA, medications/opioids, acute illness) and cardiovascular/metabolic risk as part of holistic management.³
3) If a man on TRT wants to conceive
For most men, the fertility-safe starting point is cease exogenous testosterone and refer. Guideline statements emphasise that exogenous testosterone should not be prescribed to men interested in current or future fertility.⁵
Recovery of spermatogenesis is variable and influenced by duration of exposure, baseline testicular reserve, and any prior anabolic steroid use.
Early referral is particularly important when there is azoospermia/severe oligospermia, testicular atrophy, prolonged TRT exposure, history of cryptorchidism/chemo, or partner age >35.⁵
4) Fertility-preserving options (specialist-led)
When fertility is a priority, aim to stimulate endogenous testosterone and spermatogenesis rather than replace testosterone. In men with secondary hypogonadism desiring conception, the best-supported approach is gonadotropin therapy (hCG ± FSH) under specialist care.⁶⁻⁸ In selected cases, SERMs (e.g., clomiphene/enclomiphene) or aromatase inhibitors may be used to increase endogenous gonadotropin drive or optimise the testosterone:oestrogen balance, though evidence is more variable and monitoring is required.³⁹
GP take-home
TRT is not a fertility treatment; it commonly suppresses sperm production.¹²
Ask about fertility before prescribing; document timeframe.³⁻⁵
If fertility is desired: avoid TRT, order axis labs ± semen analysis, and refer early.⁵⁻⁸
References
Lee JA, et al. Indications for the use of human chorionic gonadotropic hormone for the management of infertility in hypogonadal men. Transl Androl Urol. 2018.
Chung E, et al. Management of male infertility with coexisting sexual dysfunction and hypogonadism. World J Mens Health. 2023.
Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018.
European Association of Urology. Sexual & Reproductive Health Guidelines—Male hypogonadism (testosterone therapy contraindicated when fertility desired). EAU Guidelines (web).
Brannigan RE, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline (2020; amended 2024). American Urological Association (guideline/PDF).
Behre HM, et al. Clinical use of FSH in male infertility. Front Endocrinol. 2019.
Khera M, et al. Male hypogonadism: recommendations from the Fifth International Consultation on Sexual Medicine. Sex Med Rev. 2025.
European Urology. Update on male hypogonadism (fertility issues; gonadotropin therapy for secondary hypogonadism). 2025.
Scovell JM, et al. Testosterone replacement therapy versus clomiphene citrate in managing symptoms of hypogonadism in men. Sex Med Rev. 2018.
