Advice needed on TRT / Treatment options

Hi Everyone,

I just wanted to say thanks in advance for anyone who reads this message and provides a thoughtful response. I'll try my best to keep this very concise to reduce length. I am currently working with a nutritionist and endocrinologist to address low t symptoms and blood tests. First and foremost, my most recent bloods are as follows:

Total test = 323 on scale of 241-827 NG/DL
Free test = 35 on scale of 46-224 pg/mL
FSH = 1.6 on scale of 1.6-8 MIU/ML
LH = 1.8 on scale of 1.5 - 9.3
Prolactin = 5.8 on scale of 2-18 NG/ML
IGF/1 = 170 on scale of 53-331 NG/ML
Cortisol = 16.6 on scale of 4.0-22.0 MCG/DL

As shown, my total test is within range, albeit on the lower end, and my free test actually dips below normal. FSH and LH are as low as they can possibly get within the normal range. However, what is truly normal for a 33 year old?

Supporting information: Although I am able to perform sexually, my libido is essentially non-existant. Sensation and climax are very dull. I am not "fat" but a layer of stubborn fat sits around my waist despite working out regularly and eating a relatively good diet. I suffer with depression, anxiety and fatigue. I took a 16 week cycle of testosterone enthanate in 2012 and again in 2013 (each cycle consisted of approx two 225mgs injections per week for a total of 450mgs weekly.) Each cycle followed by a month of Nolvadex 40mg I believe (or possibly 40/40/20/20... I can't recall precisely.

Ultimately, I do not know if this was pre-existing or if the cycles are the cause the decline in the hpta hormones because I, unfortunately, do not have previous blood tests to use as a baseline. I have an MRI scheduled for this Friday to look for pituitary tumor. I guess I am looking for general input or advice on treatment. I feel that these markers are significantly low for my age, not to mention my symptoms. I would aggressively pursue HRT but I am interested in preserving any ability I have to have children. Are there any treatments that I should be looking into considering that I don't don't want to impose further damage on my ability to have kids. This is all rather depressing so looking for any help you guys can provide. Thanks again.

One other measurement that may be relevant is TSH Reflex... 1.15 miu/ml. I think that is associated with thyroid and falls somewhere in the "normal" range...

There are treatment plans that will not hamper your fertility , in fact a proper trt regimen will include hCG which if I remember correctly many guys on this forum have gotten their wives pregnant while on trt . You are on the right track as far as ruling out possibilities . The more knowledgeable members can look at your blood work and give you more info. Your fsh and lh are at the border low, estradiol and shbg were not tested.

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Originally Posted by Beethoven

There are treatment plans that will not hamper your fertility , in fact a proper trt regimen will include hCG which if I remember correctly many guys on this forum have gotten their wives pregnant while on trt . You are on the right track as far as ruling out possibilities . The more knowledgeable members can look at your blood work and give you more info. Your fsh and lh are at the border low, estradiol and shbg were not tested.

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Thanks Beethoven. Is there a lot of information out there to support the HCG / TRT method for maintaining fertility? Is it successful in a high percent of people or is it a hit and miss kind of thing?

Im surprised that SHBG and estradiol were not on the bloodwork order. Im assuming that we'd be interested to see if the SBHG level is high? What impact does estradiol have? Do either of these measures (sbgh / estradiol) tie into the low FSH and LH?

Last question... could relationship, work and life stress lead to such low FSH, LH and subsequently testosterone? I've had a lot of all three for the past half year. I'm assuming the answer is that it can have an affect, but to this degree?

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Originally Posted by strife2981

Thanks Beethoven. Is there a lot of information out there to support the HCG / TRT method for maintaining fertility? Is it successful in a high percent of people or is it a hit and miss kind of thing?

Im surprised that SHBG and estradiol were not on the bloodwork order. Im assuming that we'd be interested to see if the SBHG level is high? What impact does estradiol have? Do either of these measures (sbgh / estradiol) tie into the low FSH and LH?

Last question... could relationship, work and life stress lead to such low FSH, LH and subsequently testosterone? I've had a lot of all three for the past half year. I'm assuming the answer is that it can have an affect, but to this degree?

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To be brief, high estradiol can make you feel as crappy as low T. Good to keep tabs on it.

As far as I know, reports of the success of hCG treatment on fertility has been anecdotal - at least from what I have observed on this forum. You'd have to do further research on this yourself. But there is also hMG - which has FSH and LH in it (along with a little hCG). This directly stimulates the Sertoli cells in the testes responsible for sperm production. But because it's much more expensive than hCG, most take it short term - when you're going for pregnancy. This is commonly used in fertility clinics and would be something to consider down the line - if you need it. But you have nothing to lose by taking hCG and everything to gain. My position is this: You want to have the best life possible. If you need TRT, go for it. The worry about pregnancy may not even be a reality. When the time comes, just keep on trying - and enjoy the experience.

You're taking the right action to find out what is causing your symptoms. If you decide to start on TRT, the best option is to treat with hCG - not only to maintain fertility but to have a better quality of life. You WILL feel much better taking it.

If I remember correctly, Kel has provided us with a study not too long ago concerning HCG and fertility on trt. Can't remember but what 2sox said is right on. Quality of life s the most important thing. I will check for that article. And yes, stress and all that do have its effect, although I think yours is probably more physical.

Are you referring to this one B?

Concomitant intramuscular human chorionic gonadotropin preserves sp... - PubMed - NCBI

Op, shbg will follow estrogen. Meaning if E rises so will shbg. With low T I doubt very much you have high E or shbg at this time. You appear to be on the right path obtaining an MRI to search for adenomas as they can wipe out T production and cause various other issues as well. Do not rule out thyroid issues either if you have not looked into this area. Hypothryoidism causes hypogonadism. Do not judge this by TSH alone.

Any other medication / drug usage?
Any head or testical trauma?

If all avenues are exhausted looking for a cause then a consideration would initially be clomid therapy, imho. Cessation of the clomid later on would then allow you to assess whether your pituitary will maintain higher values once stimulation via serms has stopped.

Outcomes of clomiphene citrate treatment in young hypogonadal men. - PubMed - NCBI

Ah yes, that's it. Glad I wasn't mis remembering . I hate it when that happens . Lol. I was searching the past threads and found quite a few guys on trt that got their significant other pregnant . Thanks a bunch .

Thanks for all of your responses 2Sox, Beethoven and KelKel. All of the advice and information is greatly appreciated. It's at least somewhat comforting to know that HCG and HMG are potential options in the event that I need to go the HRT route. Man, I wish I had already had kids because if that were the case, I'd not even think twice.

I learned today that the MRI will be applied to my insurance deductible meaning that I will be paying around $700 out of pocket to have that test done. A real bummer, as though the issue alone was not bummer enough. Assuming that the MRI and thyroid test come back negative, is there any other diagnostic tests that should be considered or would it then be time to consider one of the treatment options?

KelKel, to answer your question about head injury and drug use. Addressing head injury first... I was knocked out in 2005 after a friend and I were attacked by a group of 10 guys. It's a long story but I received 30 stitches in the back of my head. I don't remember what occurred in the immediate moments before I was knocked out (most likely concussed) . I've also been in 2 car accidents. One where I hit the steering wheel with my face and bit through my lip and another where I was thrust into the airbag. I might have been dazed after each but didn't have any severe concussion symptoms afterward. I also competed a few years as an amatuer boxer in my 20's and may have taken some hard shots doing that but nothing severe that I am aware of. And drgs? The only thing relevant would be the use of opiates (percocet) semi regularly for a period of 4 about months (back issue) that ended a year before the test results I posted above. I hope this would not be a convoluting factor...

I've left a message for my endocrinologist this afternoon to ask if he could call me back about writing a lab order for a complete thyroid analysis. It's my understanding that TSH, Free T3, Free T4, Reverse T3 and Thyroid anti bodies should be on this order. Is there anything else?

No further tests come to mind at the moment. That price out of pocket sucks.
I asked as TBI (traumatic brain injury) can cause these issues. Same as testicular trauma can.
The below read is real long but worth it for you:

Acute Serum Hormone Levels: Characterization and Prognosis after Severe Traumatic Brain Injury

Opiates can also effect the HPTA and directly effect LH function.
The thyroid tests you mentioned are sufficient.

A caveat to what I said in my last post about clomid. I'm not a fan of it personally, I just feel in your shoes it's a viable first step.

Your head injuries could very likely be the cause of your issues. The pituitary sits behind the bridge of your nose and if you've taken a blow to the front of your head you could have damaged it. It doesn't seem to be working very well looking at your blood work.

I empathize with you as that is the reason I am on HRT, started at age 30.

Ballsak, sorry to hear that you had to go through with this as well. It seems like a big deal to me at such a young age. How has it been working out for you?

Kel or any of the other guys, in you opinion, is the levels I've posted above definitely something that treatment should be pursued for in your opinions? I guess I'm just looking to reaffirm what I feel because I'm second guessing and asking myself if I'm being hasty in looking down this route. But I'm thining that the numbers speak for them self. Do you guys agree?

You might consider attempting an HPTA restart before getting on TRT. Odds might be low, but I think it's worth a shot for those on the younger side who have tried AAS.

Other than that, you present with low Testosterone symptoms and blood work agree. Get that additional blood work.

Make sure you include hCG in your TRT protocol. Read the hCG and Pregnenolone sticky for more information.

Libido is complicated. Sometimes just getting on TRT will improve things, sometimes it takes a while, and sometimes Testosterone and hCG alone is not the answer. Did you get DHT tested? E2 is also important.

Yes, your levels suck and would definitely cause you to feel the way you do. Google and take the "Adam Questionnaire" and see how you do. Post up your MRI results when they are complete and if clear a consideration could be another attempt at pct as long as all else is ruled out.

Good timing OB!

Hey Kel, I received my thyroid and MRI results. Both came back negative. The thyroid results are as follows:

TSH 1.16 on scale of .4 to 4.5 mIU/L
T3 Free 3.0 on scale of 2.3 to 4.2 PG/ML
T4 Free 1.5 on scale of .8 to 1.8 NG/DL
Thyroid Peroxidase AB <1 with range up to <9 iu/ml
Thyroid Antibodies <1

I talked to my endocrinologist on the phone and his recommendation is 200mg/dl testosterone cyponate weekly. I inquired about hcg for maintaining testicle size and fertility and he said that I wouldn't take the hcg until I was interested in having kids. At that time, I would discontinue the testosterone and use hcg or other fertility methods. He also indicated that I could try hcg mono-therapy. I asked him about combining both testosterone and hcg and it didn't seem like that was a treatment plan that he was interested in. He also mentioned that insurance wouldn't cover both. In a way, he almost seemed opposed but I didn't press it and figured that I would post here first to get input.

Is hcg mono therapy something worth considering? If not, and the testosterone route is the best option, should I be more adamant about combining with hcg?

* I don't know why I added the "dl" after the mg in the statement about my dr recommending 200 mg....just ignore that.

200 mg seems high to start but I would definitely want the hCG . When I first started trt I was only doing testosterone , after a few months my testicles started hurting and were shrinking . It was about that time I found another Dr and this site. Once I got the hCG in the protocol I felt better, the boys dropped and stop hurting . Many Dr's that prescribe testosterone are not completely up to date with everything . Mine prescribes hcg but only shoots for mid level numbers and is reluctant to prescribe more than 100 mg per week . You got to work at this till you find the Dr and protocol .

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Originally Posted by strife2981

Hey Kel, I received my thyroid and MRI results. Both came back negative. The thyroid results are as follows:

TSH 1.16 on scale of .4 to 4.5 mIU/L
T3 Free 3.0 on scale of 2.3 to 4.2 PG/ML
T4 Free 1.5 on scale of .8 to 1.8 NG/DL
Thyroid Peroxidase AB <1 with range up to <9 iu/ml
Thyroid Antibodies <1

I talked to my endocrinologist on the phone and his recommendation is 200mg/dl testosterone cyponate weekly. I inquired about hcg for maintaining testicle size and fertility and he said that I wouldn't take the hcg until I was interested in having kids. At that time, I would discontinue the testosterone and use hcg or other fertility methods. He also indicated that I could try hcg mono-therapy. I asked him about combining both testosterone and hcg and it didn't seem like that was a treatment plan that he was interested in. He also mentioned that insurance wouldn't cover both. In a way, he almost seemed opposed but I didn't press it and figured that I would post here first to get input.

Is hcg mono therapy something worth considering? If not, and the testosterone route is the best option, should I be more adamant about combining with hcg?

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Good numbers. HCG is also used to maintain testicular function which is way more than just cosmetic. Google Dr. Crislers paper on HCG and present it to your doc. He needs to study up a bit. I'm not a fan of HCG mono and many of the respected docs in this field simply state that the benefits are not the same as exogenous testosterone.

I also agree with Beethoven that 200 mgs is starting at the high end. I never understand why doc's do this with testosterone when they don't do it with other meds. Why increase the risk for sides exponentially when you can start lower and titrate up based on BW. If you do start at that dose you're about guaranteed to need an anti-estrogen. Did he discuss this with you? If not, this shows a severe lack of knowledge on his part. Small, incremental changes in doses always work best.

Very good advice here op.

Sounds to me like your dr is old school, not up to date on current treatments.

Thanks for the input Kel, Beethoven and hakk14dl.

To answer your question above Kel, no, he did not discuss AI's or anti-estrogens over the phone but did talk about them with me today in person. I went there today to talk about the options of Test Cyp, HCG Mono, Test Cyp + HCG, Clomiphene Citrate or do nothing. I did have a copy of Dr Crislers papers but chose not to use it as I will explain further in this post.

- I definitely did not want to do nothing.

- Clomid would be my first choice considering my desire to preserve fertility but I've read so many accounts of the emotional issues that can accompany its use that I elected not to go that route. I am already prone to depression and suffer pretty bad with it so didn't feel exacerbating that problem was a good choice for me.

- I was not interested in Testosterone alone because of the testicular atrophy and I also did not want to roll those dice and come to a day where I would like to have children and be completely or partially impaired because of it - or - need a long recovery period with HCG to get to a point where I was again fertile.

- Testosterone + HCG would have been my second choice but was something that my endo did not seem completely open to and he did not seem to think insurance would cover both substances. I believe he could be persuaded into it but I decided not to press the issue at this time using the logic I am about to describe. Please tell me if this is faulty logic...

I chose to go with HCG Mono for a three month period to evaluate its efficacy. As already stated, my first choice of clomid is not a good fit for my particular situation. It is my understanding that a 3x weekly dose of 500iu's or 350iu's every other day has been shown to have a positive impact on testosterone and spermatogenesis and that such a dose does not put me at high risk for desensitization. I am aware the HCG mono protocol may not provide all the other positive benefits of TRT + HCG. However, the advantage for me would be the possibility that it may provide at least SOME, although not guaranteed, therapeutic benefit. Additionally, it is my assumption that over the next three months, my fertility would increase thus providing me with an option that may or may not exist today... which is to bank sperm. At that point, I would at least have that in my back pocket if everything else failed and I had to go with testosterone replacement. Perhaps it would bring peace of mind knowing that I did everything that I could that was available to me. Once that is accomplished, and if HCG is not providing the therapeutic benefits, I feel that I would be in a good position with my doctor to lobby for adding testosterone to my protocol.

What do you guys think? Thanks in advance for taking your time to read this or provide you valuable insight...

HCG does little to produce sperm. HMG does that.

HMG can be purchased that includes hCG, but I prefer to get mine without so I can have greater control of dosing.

If it were me, I would have pushed for Testosterone and hCG to address low Testosterone. And hMG to boost spermatogenesis.

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Originally Posted by oingoboingo

hcg does little to produce sperm. Hmg does that.

Hmg can be purchased that includes hcg, but i prefer to get mine without so i can have greater control of dosing.

If it were me, i would have pushed for testosterone and hcg to address low testosterone. And hmg to boost spermatogenesis.

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x2...

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Originally Posted by kelkel

x2...

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OB and Kel,

I wish that I had a doctor that would allow me to do both Test + HCG. At the moment, I don't have that luxury. I've also called another 10-12 offices in my area and have been told that they will prescribe Testosterone only - or - not received a call back after inquiring with the staff and asking them to find out if the doctor is open to a Test + HCG protocol. I will continue to search, and will travel if necessary, to find a doctor that will provide me with the best treatment.

In the interim, I am going to attempt the HCG mono. I know this is regarded as vastly inferior and that an AI will likely be needed but I'm putting my hopes into it until I can find a better option. That said, I'm very concerned about the desensitization rumors. Is this a valid concern? Is it proven? At what dose should I be concerned? I planned to attempt 300iu's every other day to start and adjust from there. At what dose would I be stepping into the danger zone, if such a zone exists?

As always, your input is very much appreciated. Thank you.

HCG and desensitization of leydig cells is more bro-science at the doses we use it for, imho. Highly unlikely you can find a study confirming desensitization.
Do not worry.

Hope you checked out the hCG and Pregnenolone sticky. Might be a good idea to give your doctor a copy so he can read it too. Or ask if he's willing to consult with Dr. Crisler. Might cost a few hundred dollars, but IMO it would be worth it to have an enlightened doctor.

Have to agree with kelkel that I haven't seen a study confirming desensitization. And your dose of 300IU EOD is far below Dr. Crisler's warning about 500IU daily for long periods.

Op

Check out lowtestosterone Dot Com . They're a site sponsor and have links everywhere on this site.

See if they have any doctors in your area. They used to (may still, but I'm not sure) have a travel program if they didn't have a dr in your area.

Their doctors are up to date on the latest protocols. I'm with them (only 29 years old here) and it's hassle free. the dr believes all the same things that are preached here.