Low testosterone: testing, treatment and the fertility trade-off

Testosterone declines slowly with age. Truly low levels can cause fatigue, low libido, loss of muscle, low mood and anemia. But these symptoms have many causes, so the diagnosis needs proper testing, not a single result from a clinic advertisement.

Getting the diagnosis right

• Two early-morning blood tests on different days, because levels peak in the morning.
• LH and FSH to tell whether the problem is in the testicles or the pituitary, and prolactin when indicated.
• A look at sleep apnea, weight, alcohol, opioids and other medications, all of which lower testosterone.

Testosterone therapy and fertility

This is the point many testosterone clinics skip. Taking testosterone switches off your own production and usually stops sperm production. For men who may want children, that can be a serious problem, and recovery after stopping can take many months. Men who want to preserve fertility are often treated instead with medications that make the body produce more of its own testosterone, such as clomiphene or hCG.

If you do start testosterone

• Expect regular blood counts. Testosterone thickens the blood, and a high hematocrit raises clot risk.
• Expect PSA monitoring and a check of how you feel at three to six months.
• Gels, injections and pellets all work. They differ in convenience and in how steady the levels are.

Questions to ask

• Have I had two morning tests, and what were my LH and FSH?
• Will this affect my fertility, and what are the alternatives?
• How will you monitor my blood count and PSA?