Treatments for Low Testosterone

Testosterone (T) is an “androgen”, one of the hormones that give men their “male” characteristics. Androgens are essential for developing the male reproductive organs (penis, prostate, seminal vesicles, vas deferens, and epididymis) when baby boys develop in the womb.

The body stops making sex hormones a few months after birth and restarts at puberty, and testosterone is the primary male hormone essential for sexual function and fertility.

Low testosterone (low T) is a significant cause of male infertility, but sperm production relies on more than one hormone, which makes it essential that each case is carefully assessed before a treatment option is chosen.

Androgens change how the body works by stimulating the androgen receptors (ARs) found in all male sex organs. Testosterone (T) and its derivative, dihydrotestosterone (DHT), which is 2.4x more potent than T, are the two most important androgens. The testes need high androgen levels to make the ARs stimulate testicular function and produce sperm.

However, about 1.7% of infertile men have AR gene mutations that prevent them from responding to testosterone. ^[i] (which is in addition to other causes of Androgen Insensitivity Syndrome).

There’s a natural variation in normal T levels, and in non-obese American and European men aged 19 to 39, they’re: ^[ii]

Percentile	T level ng/dL
5th	303
50th (average)	531
95th	852

Testosterone levels naturally fall with age, and the average male T level in age groups are:

Age	T level ng/dL
19-39	507
40-49	461
50-59	446
60+	446

Although testosterone falls with age, it’s not the most significant factor affecting T levels in men wishing to become fathers. The falls in male T concentrations in the last 30 years far outweigh the age issue, and it may not be due to specific health or lifestyle trends. ^[iii] Exposure to man-made endocrine-disrupting chemicals (EDCs) in the womb and adulthood is changing male fertility. There are many benefits to maintaining healthy testosterone levels:

• Greater muscle mass
• Less body fat (especially abdominal fat)
• More psychological vigour and resilience
• Better general well-being

Men with testosterone deficiency have a variety of symptoms:

• Low libido
• Fatigue
• Greater fat mass
• Osteoporosis
• Erectile dysfunction

 

Testosterone replacement therapy (TRT)

Testosterone replacement therapy (TRT) significantly increases the survival rates of hypogonadal men, ^[iv] which is crucial because testosterone deficiency is associated with a range of morbidities:

• Major depressive disorder ^[v]
• Type 2 diabetes ^[vi]
• Obesity ^[vii]
• Metabolic syndrome ^[viii]
• Cardiovascular disease ^[ix]
• Cognitive decline ^[x]

Low T also significantly reduces the quality of life and increases the risk of mortality in men: ^{[xi] [xii]}

• Men with the lowest total testosterone levels are 40% more likely to die in 12 years than other men (after controlling for age, obesity, and lifestyle).
• Severe “late-onset hypogonadism” (LOH) raises men’s mortality risk five-fold, even after controlling for age, BMI, current smoking, and general health.

However, TRT use is controversial because it’s associated with an increased risk of exacerbating pre-existing medical conditions, which is why TRT is contraindicated for men with:

• Any existing prostate disease
• Elevated hematocrit concentrations
• High CVD risk
• Obstructive sleep apnoea

The US FDA and the Endocrine Society of Australia only recommend TRT for cases of “classic” or irreversible Androgen Deficiency (AD) rather than “functional”, age, or comorbidity-related AD.

Androgen receptors (ARs) don’t distinguish between T made in the testes or given as a supplement, and healthy sperm production requires low levels of follicle-stimulating hormone (FSH) and luteinising hormone (LH). ^[xiii]

High testosterone levels suppress GnRH production from the hypothalamus and will ultimately inhibit LH/FSH production in the pituitary. Without FSH and LH involved in sperm production, men are infertile.

The 2013 European Association of Urology Guidelines on Male Infertility clearly state that:

“Testosterone suppresses pituitary production of LH and FSH; therefore, replacement therapy should not be given for infertility”. ^[xiv]

Despite this clear guidance, up to 25% of urologists have used T replacement therapies to treat male fertility, ^[xv] and many sources continue to recommend it as a fertility treatment. Straight-line thinking doesn’t work well in this situation.

 

Self-medication

Unsurprisingly, many men take T supplements to increase muscle mass and improve their fertility. Around 1.3% of men attending infertility clinics admit taking T to treat hypogonadism and infertility (88% had azoospermia). However, not all men admit to T use, so any men with LH below 0.06 IU/L should be asked about external T exposure.

Stopping T replacement therapy is the appropriate first step for these men wanting children:

• 50% normalise their T levels within six months
• 95%–98% normalise their T levels in 15–18 months
• 65 to 94% recover the ability to make sperm. ^{[xvi] [xvii]}

Strategies that increase male testosterone production and concentrations and avoid the potential TRT risks are highly desirable and revolve around herbal options.

 

Herbal options for low male testosterone

Herbal products are increasingly popular due to several factors; they’re seen as effective, with a long history of traditional use and are relatively safe, with few records of serious side effects.

Sales have increased yearly for over a decade, and about US$8.8 billion of products were sold in 2018. Studies show some herbs are effective treatments for many male fertility conditions, even when they don’t raise testosterone. ^[xviii] Herbs can improve the function of the hypothalamus-pituitary-testes axis, immune health and elevate T levels. We have formulated the most compelling herbs in a unique blend. The herbs with the most robust research to support beneficial effects on sex hormones are:

Herb	Testosterone	Luteinizing hormone (LH)	Follicle-stimulating hormone (FSH)	Prolactin	Adrenaline & noradrenaline	SHBG
Trigonella foenum-graecum	Improved	Possible improvement				Improved
Withania somnifera	Improved	Improved	Improved	Improved	Improved
Tribulus terrestris	Inconclusive	No change
Mucuna pruriens	Inconclusive	Improved	Improved	Improved	Improved
Eurycoma longifolia	Improved	Improved