The treatment of hypogonadism in men of reproductive age

Objective: To review the mechanisms of T replacement therapy's inhibition of spermatogenesis and current therapeutic approaches in reproductive aged men. Design: Review of published literature. Setting: PubMed search from 1990-2012. Patient(s): PubMed search from 1990-2012. Intervention(s): A literature review was performed. Main Outcome Measure(s): Semen analysis and pregnancy outcomes, time to recovery of spermatogenesis, serum and intratesticular T levels. Result(s): Exogenous T suppresses intratesticular T production, which is an absolute prerequisite for normal spermatogenesis. Therapies that protect the testis involve hCG therapy or selective estrogen receptor (ER) modulators, but may also include low-dose hCG with exogenous T. Off-label use of selective ER modulators, such as clomiphene citrate (CC), are effective for maintaining T production long term and offer the convenience of representing a safe, oral therapy. At present, routine use of aromatase inhibitors is not recommended based on a lack of long-term data. Conclusion(s): Exogenous T supplementation decreases sperm production. Studies of hormonal contraception indicate that most men have a return of normal sperm production within 1 year after discontinuation. Clomiphene citrate is a safe and effective therapy for men who desire to maintain future potential fertility. Although less frequently used in the general population, hCG therapy with or without T supplementation represents an alternative treatment. (Fertil Steril (R) 2013;99:718-24. (C) 2013 by American Society for Reproductive Medicine.)