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Suggest treatment for low testosterone levels

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Posted on Wed, 20 May 2015
Question: Hi Doctor,

I am Male 31yr, 6'1" & 90 Kg. I am suffering from problem of severely low testosterone since I used Anabolic Steroid Cycle during bodybuilding.

I was on Injectable/oral Steroids for the period of 6-7 Months on and off. Last Steroid taken around 8 months ago since then I have done many tests for total testosterone But, level is hovering around 100 & 200 ng/dl which is quiet less to sustain erection. Other tests I have undergoes are Semen analysis, TSH, LH, FSH, PROLECTIN, CORTISOL, HGH & FT4 (All listed test are NORMAL but at lower side)

What I have found that, My testicals are not able to produce sufficient hormone to work properly.
So, kindly suggest some medication that can secrete testosterone naturally instead of replacing them

Please look into the problem, Thanks doctor!

PS: I have No Cardic, Diabetes or High BP problem
Please find the attached reports.

Regards,
XXXXX
doctor
Answered by Dr. Ajish TP (44 minutes later)
Brief Answer:
See detailed answer

Detailed Answer:
Hi XXXXX,

Welcome to HCM. I have gone through the question and understand your concerns. Your hormonal work up is normal other than for low testosterone.

I need to know few additional things before starting treatment.

1. Was these hormone tests done in morning at around 8 m? If not repeat testosterone and free testosterone in the morning 8 a.m. This is because the hormone levels drop as day progress.

2. How is the size of the testes? Is it small when compared to the size 18-20 years?

3. Is your semen analysis show normal sperm count - if so your testes is producing enough testosterone?

Testosterone replacement will not improve the sperm count, it in fact decreases it. So if you are in need of increase testosterone production in testes, the option is HCG therapy or LH/FSH therapy - both are available as injections.

If you have any further questions, I will be happy to help

Regards
Dr Ajish TP
Consultant Endocrinologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ajish TP (1 hour later)
Hi Doctor,
Big thanks to conquer my problem in single attempt!

Here are my responses on each point:
1.     I was gone under Total T test twice in span of 2 days, first analysis done at 10:30 AM resulted as 104.5 ng/dl, on second day test done at 9:30 with 166.5 ng/dl.
2.     I think testes size is comparative smaller, however It is tough to judge. But, seems smaller to me.
3.     Please find the new attachment contain Semen analysis, with 18 million counts ,45% mortality and 40% Normal morphology (Please analyze attachment with password = XXXXX in capital letters)

2 Months ago, I went under TRT by injecting Sustenon-250 injection 1 ml/ week and tested Total Testosterone as 791 ng/dl with no libido. But, after completion of 8 week cycle Testosterone level become worse and you are right doctor TRT decreases my sperm counts

I have done a mistake is past for not opting Post Cycle Therapy with (Clomid, Nolvadax & HCG) after Steroid Cycle.

I got married 4 months ago, due to poor erection I have used sildenafil/tadalafil tablets once in week sometimes twice also. But, suddenly as my testosterone level falls consequently these medicines stop working.

Few more things I would like to add into my problem,
I have a question, should I start with HCG if yes, then in combination with which other medicine (if required) and how much dose should I start with. As HCG only mimic LH not FSH. So, would it be good to stick with HCG only.

[I would like to add one more detail, as one doctor has asked me to go for Pituitary MRI, that resulted Pituitary Microadenoma, then, I went to a neurologist he told me that there is no problem with pituitary as doctor observed and said that you are healthy without baldness/good hair growth/no vision problem, Also, my pituitary size is very small as mentioned in attached report. But, as my attached report says very less HGH. for proper confirmation I have not gone under INSULIN TOLERANCE TEST to check the function of Pituitary, should I go for It or first try HCG?]

Kindly provide best possible guidance from here.
Best Regards!
XXXXX
doctor
Answered by Dr. Ajish TP (3 hours later)
Brief Answer:
See detailed answer

Detailed Answer:
Hi Mr XXXXX,

Welcome back. Sorry for the delay in replay - had a busy OPD.

I understand your concerns. I've gone through the reports.

My commends:

1. The testicular size is key in assessing which treatment you need. A testes size if more than 10 ml ( more than 4 cm in length), HCG alone is needed. This is because HCG acts as LH and it increase testosterone levels in testes. Increased testosterone production in testes results in sperm production.

If testes size is less you need LH and FSH therapy. LH/FSH therapy is more expensive than HCG therapy.

Mean while you can try Clomid, which is an off label drug to increase testosterone production from testes.

2. For erection- I suggest you to use tadalafil 10 mg or 20 mg alternate days.

3. You need to repeat a free testosterone in morning 8 am.

4. The pituitary adenoma could be an incidental finding - seen in up to 10% of normal persons. Since your cortisol, thyroid functions and prolactin are normal, we need not pay much attention to that now. Random growth hormone is not useful test as GH is released in pulses and some times values can be low in normal persons.

5. Store your semen in sperm back - do it immediately. Since you are at risk of low speed count in future the best thing to do now is to store sperm in sperm bank. So even if you develop some infertility issues in future you can use it for in vitro fertilisation. If fertility is not an issue treatment of low testosterone levels is simple with TRT.

Hope this will clear your doubts

Regards

Dr Ajish TP
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ajish TP (16 hours later)
Good Morning Dr, Ajish

Have a great day!

Many thanks to look into my concerns and now doubts are pretty clear.

1.     Testicular size seems around 4 cm in length and semen volume was 2.5 ml as per semen report
2.     Doctor tadalafil/sildenfil is not working may be because testosterone level is too low or my system created tolerance for those medicine.
I have another question regarding this, should these drugs (sildenafil/tadalafil) damage veins and arteries of Penis and in long term create permanent dysfunction.

3.     I will sure go for another free testosterone test in morning at 8 AM and will upload report for your review.

4.     Regarding pituitary, I wanted to convey all prior diagnosis and actions like a good patient, Will keep this is out of Interest

5.     Doctor, it’s scary! To think that I may develop Infertility in future. But, I will keep this precious suggestion of storing semen in bank and will do this activity very shortly.

I and wife has plan for baby in next 5-6 months. I have regrets and I am feel bad for going on Anabolic Steroid in past and Doctor, I can’t repeat mistake of future by going again for TRT.

Is that possible after HCG or Clomid or any other treatment that natural secretion of Testosterone remains continue as I am doing good physical workout from last 1 month?

Kindly assist me on HCG therapy, how much dose, course duration and frequency of Injection is required. Or for few weeks I should go for Clomid then with HCG or Vice-versa.

Always be thankful!
Greeting’s!
XXXXX
doctor
Answered by Dr. Ajish TP (55 minutes later)
Brief Answer:
See detailed answer

Detailed Answer:
Hi Mr XXXXX,

Good day.

1. Sorry if I scared you on infertility. Many patients with previous normal sperm count come to me later with azoospermia and sometimes sperm donors are the only options for them. So any one with pituitary disease or any problems with testes or erectile dysfunction not responding to tadalafil, I suggest them to preserve there sperm in an infertility center as a precaution till they complete their family naturally.

2. HCG tHerapy is usually started as injections 1000 iu 3 times a week , the dose can be titrated to 2000 iu 2-3 times a week.

3. Clomid is an off label medication in male, 50-150 mg daily is the dose. So there are no protocols for this treatment - less expensive and less side effects.

4. If free testosterone is low, you should try with HCG injections for erectile dysfunction. If it is not working, a single dose of testosterone will confirm whether it is due to low testosterone or not. If you cant produce good erection after testosterone shots, you should consult an XXXXXXX (urologist specialized in erectile problems).

5. Tadalafil is a relatively safe drugs, it can cause prolonged erection and problems related to priapism in them. If you are not getting a good erection on tadalafil,no need to get concerned on vascular side effect. I suggest you to take Tadalafil 20 mg alternate days x 6 doses. If there is no erection - stop the medications - it is not working. If you are getting erections, decrease dose to 10 mg alternate days.

6. Since your testes size more than 4 cm - no need for LH/FSH therapy now, HCG alone can improve testosterone levels.

Hope this information was useful

Regards
Dr Ajish TP
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ajish TP (2 days later)
Hi Doctor,

Thanks for your thoughout help since start.

I will do whatever you have said in above discussion.

Today, I will start with HCG 1000 IU with Clomid or Nolvadex. I wanted to know that for how many months should I continue this treatment.

Please convey any other suggestion if you have for me.

Many thanks to you, You are the Best Doc!! :)

Kind Regards,
XXXXX
doctor
Answered by Dr. Ajish TP (7 minutes later)
Brief Answer:
Continue it till testosterone levels are normal

Detailed Answer:
Hi Mr XXXXX,

Welcome back.

Do a free testosterone levels before injections. The way to go about this treatment is to start on HCG 1000 iu 3 days a week till free testosterone levels are normal. When testosterone levels are above mid normal values, you can start decreasing the dose of HCG.

The treatment duration depends on the response. Most Endocrinologist continue treatment till completion of family and change to testosterone injections if levels drop after that.

Wishing you all the best

Regards
Dr Ajish TP
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Ajish TP

Endocrinologist

Practicing since :2002

Answered : 819 Questions

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Suggest treatment for low testosterone levels

Brief Answer: See detailed answer Detailed Answer: Hi XXXXX, Welcome to HCM. I have gone through the question and understand your concerns. Your hormonal work up is normal other than for low testosterone. I need to know few additional things before starting treatment. 1. Was these hormone tests done in morning at around 8 m? If not repeat testosterone and free testosterone in the morning 8 a.m. This is because the hormone levels drop as day progress. 2. How is the size of the testes? Is it small when compared to the size 18-20 years? 3. Is your semen analysis show normal sperm count - if so your testes is producing enough testosterone? Testosterone replacement will not improve the sperm count, it in fact decreases it. So if you are in need of increase testosterone production in testes, the option is HCG therapy or LH/FSH therapy - both are available as injections. If you have any further questions, I will be happy to help Regards Dr Ajish TP Consultant Endocrinologist