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Testosterone Therapy and Fertility: What Charleston Men Planning a Family Should Know First
For Charleston men weighing TRT and fertility, the short answer is that outside testosterone works like a contraceptive. In a World Health Organization trial of 271 fertile men on weekly testosterone injections, 157 (58%) had no sperm, and the trial's cumulative rate at 6 months was 65% [1]. Sperm production often resumes after stopping, but at a pace no one can promise [7]. The time to plan for children is before the first dose.
By Ashley Harwyn, PA-C, ABAAHP | Published | Last updated

The best recovery numbers come from men who took testosterone-based hormonal contraceptives in trials. Across 1,549 of those men in 30 studies, sperm returned to 20 million per mL in 67% within 6 months and 90% within 12 months [2]. They were healthy volunteers on a planned course. In a study of men who became infertile after testosterone use, longer use predicted slower recovery [15].
The drug is common. The authors of a 2015 study put the number of U.S. men taking testosterone at about 3 million, and said many of reproductive age did not know its effect on fertility [4]. In a 2010 survey of 387 American Urological Association members, 25% said they would give testosterone to infertile men trying to conceive [5]. The authors called it "a medication known for its contraceptive potential" [5]. In June 2026, FDA requested testosterone label updates [3]. Neither of the two updates it listed concerns sperm or fertility [3].
Your family timeline and TRT
Shows which evaluation steps and questions apply. It does not take lab values, diagnose, or predict recovery.
When might you want children?
Within 12 months
- Guideline
- The Endocrine Society's 2018 guideline recommends against starting testosterone in men planning fertility in the near term. [8]
- Before any treatment
- Get a semen analysis. Avoid ejaculation for 2 to 7 days first, and expect two or more samples within a week or two (MedlinePlus). [22]
- Ask your clinician
- Which fertility-sparing options apply to me, and should I bank sperm first?
In 1 to 3 years
- Guideline
- The 2018 guideline abstract does not define near term in months, so raise your timeline at the visit. [8]
- Recovery data
- In contraception trials, 90% of men recovered to 20 million sperm per mL within 12 months of stopping. In a study of men infertile after testosterone use, longer use predicted slower recovery (Liu 2006; Kohn 2017). [2] [15]
- Options to discuss
- Using hCG or clomiphene to protect sperm is off-label, and enclomiphene is not an FDA-approved drug. [12] [13] [21]
- Before any treatment
- Get a semen analysis. Avoid ejaculation for 2 to 7 days first, and expect two or more samples within a week or two (MedlinePlus). [22]
Not planning children
Unsure
- Guideline
- The 2018 guideline abstract does not define near term in months, so raise your timeline at the visit. [8]
- Before any treatment
- Get a semen analysis. Avoid ejaculation for 2 to 7 days first, and expect two or more samples within a week or two (MedlinePlus). [22]
- Ask your clinician
- Which fertility-sparing options apply to me, and should I bank sperm first?
General information from published studies and FDA labeling read November 2026. It is not medical advice and does not check your hormones or fertility. Your clinician decides.
Key takeaways
- Outside testosterone can stop sperm production. In the WHO trial of 271 fertile men on weekly 200 mg injections, 157 (58%) had no sperm, and the trial's cumulative rate at 6 months was 65% [1].
- The Endocrine Society recommends "against starting T therapy in patients who are planning fertility in the near term" [8].
- In contraception trials, sperm returned to 20 million per mL in 67% of men by 6 months and 90% by 12 months [2]. Among 66 men treated for infertility after testosterone, 30% had not reached the study's recovery mark at 12 months [15].
- Using hCG or clomiphene to protect sperm is off-label, and enclomiphene is not an FDA-approved drug [12] [13] [21].
- The recovery table below sets the contraception-trial numbers beside the studies of men who actually used testosterone, and names the population behind each one.
Section 01 / How it works
How outside testosterone shuts down sperm production
Testosterone from a shot or a gel lowers LH and FSH, the two pituitary hormones that drive the testicles. The body's own testosterone production drops. Testosterone inside the testicles falls sharply, and sperm production is impaired [7]. The authors of a 2013 study put the rate of azoospermia on testosterone replacement at 40% of patients [6].
Two terms make the rest of this guide easier. Azoospermia means no sperm in the semen. In the WHO trial, a man counted as azoospermic only after three semen samples in a row showed none [1]. Secondary hypogonadism is low testosterone that starts in the pituitary or hypothalamus, not the testicles. The hCG label covers selected cases in men, described as hypogonadism "secondary to a pituitary deficiency" [21].
The form of testosterone does not make it fertility-safe. In two phase III trials, men on testosterone gel saw LH and FSH fall over 16 weeks [10]. Their sperm production dropped markedly [10]. In a separate 12-man study, gel failed to raise sperm counts above 20 million per mL in all 5 men who used it for 3 months [11]. A gel is not a fertility-sparing form of TRT.
It also happens fast. On weekly 200 mg testosterone enanthate injections, WHO trial men took a mean of 120 days to reach zero sperm [1]. That is about four months.
A 2025 review in Nature Reviews Urology states it plainly: "Exogenous testosterone is contraindicated in men trying to conceive" [7]. That is a review's conclusion, not a guideline. The same review raises the possibility that newer short-acting forms, oral testosterone undecanoate and nasal testosterone gel, only partly suppress the hormone system and partly preserve sperm production. That is not yet an established option [7].
Section 02 / Guidelines
What clinical guidelines tell men on testosterone who want children
The Endocrine Society's 2018 guideline on testosterone therapy is direct. Its task force recommends "against starting T therapy in patients who are planning fertility in the near term" [8]. Near-term fertility plans sit in the same sentence as breast or prostate cancer and untreated severe obstructive sleep apnea, as reasons not to start testosterone [8].
That recommendation is about starting. The guideline abstract does not define near term in months [8]. So how soon is too soon? The honest answer is a conversation with your clinician, not a number.
The same guideline asks for a firm diagnosis first. It recommends diagnosing hypogonadism only in men with symptoms and signs of deficiency and consistently low testosterone [8]. It recommends confirming the result with a repeat fasting morning test [8]. When deficiency is found, it recommends more evaluation to find the cause [8].
Other expert sources point the same way. The 2025 Nature Reviews Urology authors call outside testosterone contraindicated for men trying to conceive [7]. A 2017 study of 66 men treated for infertility after testosterone use closed with a warning. The authors wrote that physicians should "be cautious in pursuing long-term T therapy, particularly in men who still desire fertility" [16].
Three sources, three formats, one direction. If children are a near-term goal, starting testosterone is the step to question first.
Planning a family and thinking about TRT? Book a men's health evaluation and bring your timeline with you. Read about testosterone replacement therapy at Solcara, or call 843-981-0870.
Section 03 / Recovery data
Recovery after stopping: what the trial data show and what they do not
The largest recovery dataset comes from contraception trials in healthy volunteers. In 1,549 such men, sperm reached 20 million per mL in 67% within 6 months, 90% within 12, 96% within 16 and 100% within 24 [2]. A study of 66 men who became infertile on testosterone found that 3 in 10 had not reached its recovery mark at 12 months, even with treatment [15].
- 6 months: 67% recovered
- 12 months: 90%
- 16 months: 96%
- 24 months: 100%
Here is that contraception-trial timeline. The right-hand column is our arithmetic from the published figures.
| Time after stopping | Men recovered to 20 million per mL | Men not yet recovered (our arithmetic) |
|---|---|---|
| 6 months | 67% | 33% |
| 12 months | 90% | 10% |
| 16 months | 96% | 4% |
| 24 months | 100% | 0% |
Men recovered to 20 million per mL
6 months
67%12 months
90%16 months
96%24 months
100%A study of 66 men who became infertile on testosterone found that 3 in 10 had not reached its recovery mark at 12 months, even with treatment. [15]
The contraception numbers should not be quoted to a man on long-term TRT as a promise.
Source: Liu PY et al., The Lancet 2006, PMID 16650651. Date range: 30 studies published 1990 to 2005. Denominator: 1,549 men. [2]
Those 1,549 men were aged 18 to 51, had normal hormone levels at the start, and came from 30 studies published from 1990 to 2005 [2]. The next table sets that dataset beside studies of men who actually used testosterone.
| Study | Who was studied | Recovery measure | Result | What it does not tell you |
|---|---|---|---|---|
| WHO Task Force, 1990 [1] | 157 of 271 healthy fertile men who reached azoospermia on weekly 200 mg testosterone enanthate | Median time from azoospermia to 20 million per mL | 3.7 months | A planned contraception course, not years of TRT |
| Liu, 2006 [2] | 1,549 healthy men in 30 studies | Chance of reaching 20 million per mL | 67% by 6 months, 100% by 24 months | Volunteers with normal hormones at baseline |
| Wenker, 2015 [17] | 49 men with azoospermia or severe oligospermia while on testosterone | Return or improvement of sperm on hCG-based therapy | 47 of 49 (95.9%), average 4.6 months | A case series with no comparison group |
| Kohn, 2017 [15] | 66 men with infertility after testosterone use | Total motile count above 5 million within 12 months, on hCG plus a SERM | 70% | Retrospective, one academic clinic |
| Rajmil, 2024 [18] | 13 studies of anabolic steroid users | Return of normal sperm production | May take over a year to normalize | Steroid misuse, not prescribed TRT |
The two groups disagree on age. In the contraception trials, older men recovered faster, as did men with shorter treatment and shorter-acting testosterone, though the authors call these effects minor [2]. In the infertility study, older age and longer testosterone use predicted slower recovery [15]. These are different men: healthy volunteers in one, men already infertile after testosterone in the other. The contraception numbers should not be quoted to a man on long-term TRT as a promise.
Starting point showed a gap. In the Kohn study, 64.8% of men with no sperm reached the recovery mark at 12 months [16]. Among men who still had a few sperm (cryptozoospermia), 91.7% did, yet the authors report that this difference did not predict a failure of recovery [16]. Our arithmetic: 20 of the 66 men, about 3 in 10, had not reached it a year into treatment [15].
The case series has a gap of its own. The Wenker authors called for studies comparing hCG-based therapy with unaided withdrawal of testosterone, which their report did not include [17].
Section 04 / Options and FDA status
Fertility-sparing options a clinician may discuss, and their FDA status
Four approaches come up when a man wants testosterone support and future children: hCG alongside testosterone, clomiphene, enclomiphene, and freezing sperm before starting. None of the three drugs is FDA-labeled for protecting sperm during TRT [12] [13] [21]. Clomiphene's label covers women only [13], and FDA advisers voted 8 to 4 against adding enclomiphene to the list of substances pharmacies may compound from [12].
| Option | What it is | FDA status for this use | Best evidence cited here | What drives the cost |
|---|---|---|---|---|
| hCG with testosterone | An injected hormone that keeps testosterone up inside the testicles during TRT [6] | Labeled for selected hypogonadotropic hypogonadism in males, prepubertal cryptorchidism and ovulation induction; use alongside TRT is off-label [21] | 26 men on 500 IU every other day: none became azoospermic and 9 contributed to a pregnancy; retrospective, no control group [9] | A second injectable drug, every other day in the study [9] |
| Clomiphene citrate | An oral drug used off-label for low testosterone in men [14] | Approved only for ovulatory dysfunction in women desiring pregnancy [13] | 120 men treated more than 3 years: 88% reached normal testosterone; the outcome was testosterone, not fertility [14] | An oral drug plus testosterone and estradiol checks, since estradiol rose on treatment [14] |
| Enclomiphene citrate | One of the two isomers that make up clomiphene [13] | Not an FDA-approved drug; FDA advisers voted 8 to 4 in 2022 against adding it to the 503A bulks list [12] | Two 16-week phase III trials: sperm concentration stayed in the normal range, unlike testosterone gel [10] | No FDA-approved product to price against [12] |
| Sperm banking before TRT | Freezing semen samples before the first dose | A procedure, not a drug | The studies cited here did not test it | The number of samples stored and the years of storage |
Of the options here, hCG has the most direct evidence for men who stay on testosterone. A 2013 study followed 26 hypogonadal men, mean age 35.9, on testosterone plus hCG at 500 IU every other day [9]. No man became azoospermic, and 9 of 26 contributed to a pregnancy [9]. Mean follow-up was 6.2 months, the review was retrospective, and no group went without hCG [9].
Enclomiphene works by a different route. It raises the body's own LH and FSH instead of replacing testosterone [10]. In a 12-man study of men coming off testosterone gel, enclomiphene raised sperm counts in 7 of 7 men at 3 months [11]. At 6 months it was 6 of 6 [11]. In two phase III trials of overweight men aged 18 to 60 with secondary hypogonadism, it kept sperm concentration in the normal range for 16 weeks [10].
Enclomiphene citrate is not an FDA-approved drug [12]. In 2022, FDA proposed that it not be placed on the 503A bulks list, and its Pharmacy Compounding Advisory Committee voted 8 to 4 against it [12]. Several members who voted no cited a lack of clinical efficacy evidence [12]. This article makes no claim about its current compounding status.
Sperm banking does not depend on how a man's body responds later. The guideline abstract cited here does not address sperm banking before TRT [8], so treat it as a question to raise, not a rule. For program pricing, see what TRT costs in Charleston.
Section 05 / Before treatment
What a pre-treatment evaluation in Charleston should include
A man who wants children and is considering TRT should have a fertility baseline before the first dose. That means a confirmed testosterone diagnosis, a search for the cause, a semen analysis, and a frank history that includes any past steroid use. The Endocrine Society recommends confirming low testosterone with a repeat fasting morning test [8].

- Confirm the diagnosis. The Endocrine Society recommends diagnosing low testosterone only with symptoms and signs plus consistently low levels [8]. A repeat fasting morning total testosterone test confirms it [8].
- Look for the cause. The guideline recommends more evaluation to find why testosterone is low [8]. Secondary hypogonadism is the condition the enclomiphene trials studied, and selected cases of it are what the hCG label covers in men [10] [21].
- Get a semen analysis before treatment. Avoid ejaculation for 2 to 7 days beforehand. Counts vary from day to day, so you may need two or more samples within a week or two [22].
- Read the result against current reference values. The 2021 WHO-collated lower reference values are 16 million sperm per mL, 30% progressive motility and 4% normal forms [19]. They come from more than 3,500 fertile men in 12 countries [19]. They are not a hard line between fertile and subfertile men [19].
- Disclose any past anabolic steroid use. One center reviewed 6,033 men seen for low testosterone [20]. Prior steroid use was the most common cause of profoundly low testosterone (50 ng/dL or less), at 43% of those cases [20]. In a later survey of 382 men on TRT, 20.9% reported past steroid use [20].
- Bring your family timeline. Say whether you want children within 12 months, in 1 to 3 years, not at all, or are unsure. Ask which fertility-sparing options apply to you, and whether to bank sperm first.
The cost drivers of this workup are the semen analysis, which may be repeated [22], a repeat morning testosterone test [8], and a second drug if hCG is added [9]. For more to bring up, see these questions to ask a men's clinic. Couples planning together can also ask about fertility care. This guide covers FDA labeling and published research, not any state's rules. Outside South Carolina, check your state medical board's rules and your own clinician.
Section 06 / Questions
TRT and Fertility Questions Answered
Does TRT make you infertile?
It can, while you take it. In the WHO trial of 271 fertile men on weekly 200 mg testosterone enanthate, 157 (58%) had no sperm, and the trial's cumulative rate at 6 months was 65% [1]. Contraception trials found the effect reversible: 90% of men were back to 20 million per mL within 12 months [2]. In a study of 66 men treated for infertility after testosterone, older men and longer users recovered more slowly [15]. No one can guarantee recovery for a specific man.
How long does it take for sperm to come back after stopping TRT?
In contraception trials, the median time to reach 20 million per mL was 3.4 months, and 96% of men got there within 16 months [2]. A study of men treated for infertility after testosterone used a different recovery measure. On hCG plus a SERM, 70% reached a total motile count above 5 million within 12 months [15]. A review of anabolic steroid users found that "sperm production may take over a year to normalize" [18].
Can you take hCG with testosterone to keep fertility?
Some clinicians pair low-dose hCG with testosterone for this purpose, which is off-label [21]. In one retrospective study of 26 men on 500 IU every other day, no man became azoospermic and 9 contributed to a pregnancy [9]. Mean follow-up was 6.2 months, with no control group [9]. That is evidence hCG can help. It is not proof it works for every man.
Is enclomiphene FDA approved?
No. Enclomiphene citrate is not an FDA-approved drug [12]. In 2022, FDA's Pharmacy Compounding Advisory Committee voted 8 to 4 against adding it to the 503A bulks list [12]. It is one of the two isomers in clomiphene, whose FDA-approved label covers only ovulatory dysfunction in women [13].
Should I bank sperm before starting testosterone?
If children are a real possibility, discuss it before the first dose. The Endocrine Society guideline abstract cited here does not address banking before TRT [8]. The case rests on the recovery data: among men treated for infertility after testosterone, 30% had not reached the study's recovery mark at 12 months [15]. A semen analysis first measures the quantity and quality of what there is to store [22].
Section 07 / Bottom line
Bottom line: protect the option before you start
Testosterone therapy and fertility pull in opposite directions during treatment. In the WHO trial, outside testosterone stopped sperm completely in 157 of 271 fertile men (58%), a cumulative rate of 65% at 6 months [1]. The Endocrine Society recommends against starting it when fertility is a near-term plan [8].
Recovery after stopping is real but uneven. Contraception volunteers recovered on a predictable curve [2]. In a study of men who became infertile after testosterone use, 3 in 10 had not reached the recovery mark at a year, and older men and longer users recovered more slowly [15].
The options that try to keep sperm during treatment are off-label or unapproved [12] [13] [21], and the hCG evidence cited here is small and retrospective [9]. So the order matters. Confirm the diagnosis, get a semen analysis, decide about banking, then decide about testosterone.
Solcara Health sees patients at 496 Bramson Ct in Mount Pleasant and at The Longevity Club, 163 Rutledge Ave in downtown Charleston. To plan TRT around a family timeline, call 843-981-0870 or book online.
References
- [1] World Health Organization Task Force on methods for the regulation of male fertility. Contraceptive efficacy of testosterone-induced azoospermia in normal men. The Lancet. October 1990. PMID 1977002. https://pubmed.ncbi.nlm.nih.gov/1977002/
- [2] Liu PY, et al. Rate, extent, and modifiers of spermatogenic recovery after hormonal male contraception: an integrated analysis. The Lancet. April 2006. PMID 16650651. https://pubmed.ncbi.nlm.nih.gov/16650651/
- [3] U.S. Food and Drug Administration. Testosterone Information. Content current as of June 23, 2026. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/testosterone-information
- [4] Wenker EP, Dupree JM, Langille GM, et al. The Use of HCG-Based Combination Therapy for Recovery of Spermatogenesis after Testosterone Use. The Journal of Sexual Medicine. June 2015. PMID 25904023. https://pubmed.ncbi.nlm.nih.gov/25904023/
- [5] Ko EY, Siddiqi K, Brannigan RE, Sabanegh ES. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. The Journal of Urology. March 2012. PMID 22264467. https://pubmed.ncbi.nlm.nih.gov/22264467/
- [6] Hsieh TC, Pastuszak AW, Hwang K, Lipshultz LI. Concomitant intramuscular human chorionic gonadotropin preserves spermatogenesis in men undergoing testosterone replacement therapy (background figure). The Journal of Urology. February 2013. PMID 23260550. https://pubmed.ncbi.nlm.nih.gov/23260550/
- [7] Naelitz BD, Momtazi-Mar L, Vallabhaneni S, et al. Testosterone replacement therapy and spermatogenesis in reproductive age men. Nature Reviews Urology. October 2025. PMID 40346275. https://pubmed.ncbi.nlm.nih.gov/40346275/
- [8] Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism. May 2018. PMID 29562364. https://pubmed.ncbi.nlm.nih.gov/29562364/
- [9] Hsieh TC, Pastuszak AW, Hwang K, Lipshultz LI. Concomitant intramuscular human chorionic gonadotropin preserves spermatogenesis in men undergoing testosterone replacement therapy (results). The Journal of Urology. February 2013. PMID 23260550. https://pubmed.ncbi.nlm.nih.gov/23260550/
- [10] Kim ED, McCullough A, Kaminetsky J. Oral enclomiphene citrate raises testosterone and preserves sperm counts in obese hypogonadal men, unlike topical testosterone: restoration instead of replacement. BJU International. April 2016. PMID 26496621. https://pubmed.ncbi.nlm.nih.gov/26496621/
- [11] Kaminetsky J, Werner M, Fontenot G, Wiehle RD. Oral enclomiphene citrate stimulates the endogenous production of testosterone and sperm counts in men with low testosterone. The Journal of Sexual Medicine. June 2013. PMID 23530575. https://pubmed.ncbi.nlm.nih.gov/23530575/
- [12] U.S. Food and Drug Administration. Final Summary Minutes of the Pharmacy Compounding Advisory Committee Meeting, June 8, 2022 (approved August 19, 2022). https://www.fda.gov/media/161293/download
- [13] U.S. Food and Drug Administration, Drugs@FDA. CLOMID (clomiphene citrate) prescribing information, NDA 016131. 2012. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/016131s026lbl.pdf
- [14] Krzastek SC, Sharma D, Abdullah N, et al. Long-Term Safety and Efficacy of Clomiphene Citrate for the Treatment of Hypogonadism. The Journal of Urology. November 2019. PMID 31216250. https://pubmed.ncbi.nlm.nih.gov/31216250/
- [15] Kohn TP, Louis MR, Pickett SM, et al. Age and duration of testosterone therapy predict time to return of sperm count after human chorionic gonadotropin therapy. Fertility and Sterility. February 2017. PMID 27855957. https://pubmed.ncbi.nlm.nih.gov/27855957/
- [16] Kohn TP, et al. Age and duration of testosterone therapy predict time to return of sperm count after human chorionic gonadotropin therapy (azoospermia subgroup and conclusion). Fertility and Sterility. February 2017. PMID 27855957. https://pubmed.ncbi.nlm.nih.gov/27855957/
- [17] Wenker EP, et al. The Use of HCG-Based Combination Therapy for Recovery of Spermatogenesis after Testosterone Use (results). The Journal of Sexual Medicine. June 2015. PMID 25904023. https://pubmed.ncbi.nlm.nih.gov/25904023/
- [18] Rajmil O, Moreno-Sepulveda J. Recovery of spermatogenesis after androgenic anabolic steroids abuse in men. A systematic review of the literature. Actas Urologicas Espanolas (English edition). March 2024. PMID 37567343. https://pubmed.ncbi.nlm.nih.gov/37567343/
- [19] Campbell MJ, Lotti F, Baldi E, et al. Distribution of semen examination results 2020: A follow up of data collated for the WHO semen analysis manual 2010. Andrology. May 2021. PMID 33528873. https://pubmed.ncbi.nlm.nih.gov/33528873/
- [20] Coward RM, Rajanahally S, Kovac JR, et al. Anabolic steroid induced hypogonadism in young men. The Journal of Urology. December 2013. PMID 23764075. https://pubmed.ncbi.nlm.nih.gov/23764075/
- [21] U.S. National Library of Medicine, DailyMed. Chorionic Gonadotropin kit (Fresenius Kabi USA), prescribing information: Indications and Usage. April 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f93b2baa-03ac-4650-b35a-20b818d712d6
- [22] U.S. National Library of Medicine, MedlinePlus. Semen Analysis. Last updated June 10, 2025. https://medlineplus.gov/lab-tests/semen-analysis/

The information in this article is for educational purposes only and does not constitute medical advice. Consult a qualified healthcare provider before making any medical decisions. It does not create a provider-patient relationship. Talk with a licensed clinician about your own situation before starting, stopping or changing any treatment. Solcara Health, 496 Bramson Ct, Ste 120, Mount Pleasant, SC 29464 and 163 Rutledge Ave, Ste 202, Charleston, SC 29403. 843-981-0870.

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