The treatment of hypogonadism in men of reproductive age

ObjectiveTo review the mechanisms of T replacement therapy's inhibition of spermatogenesis and current therapeutic approaches in reproductive aged men.DesignReview of published literature.SettingPubMed 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.