Male Hypogonadism

What is male hypogonadism?

Male hypogonadism is a condition in which the testes do not produce enough testosterone, sperm, or both. It can start in the testes themselves (primary hypogonadism) or result from a problem in the pituitary gland or hypothalamus in the brain, which control the testes through the hormones LH and FSH (secondary or hypogonadotropic hypogonadism). The type matters, because treatment options for fertility are different.

Symptoms and signs

• Low sex drive and erection problems
• Tiredness, low mood and poor concentration
• Reduced muscle mass and increased body fat
• Reduced facial and body hair
• Small or soft testes
• Breast enlargement (gynaecomastia)
• Low sperm count or no sperm, leading to difficulty conceiving
• Delayed or incomplete puberty, if it starts in adolescence

Causes and risk factors

Primary (testicular) causes

• Klinefelter syndrome (47,XXY)
• Undescended testes, testicular injury or torsion
• Mumps orchitis
• Chemotherapy or radiation

Secondary (pituitary or hypothalamic) causes

• Use of testosterone or anabolic steroids
• High prolactin or pituitary tumours
• Kallmann syndrome and other congenital conditions
• Obesity, type 2 diabetes and long-term opioid use
• Head injury or pituitary surgery

How it is diagnosed

• Morning total testosterone, measured on at least two occasions
• LH and FSH to tell primary from secondary hypogonadism
• Prolactin, thyroid tests and sometimes SHBG
• Semen analysis
• Karyotype for suspected Klinefelter syndrome
• Pituitary MRI if prolactin is high or a pituitary cause is suspected

Treatment options

Avoid testosterone when trying to conceive

Testosterone therapy improves symptoms, but it switches off the brain signals that drive sperm production and can reduce sperm counts to zero. Men who want to father a child should discuss fertility-safe options before starting or continuing testosterone.

Hormone treatment for secondary hypogonadism

Injections of hCG, often combined with FSH, can stimulate the testes to make testosterone and sperm. Sperm may take 6 months to 2 years to appear. Treating high prolactin or reducing weight can also help. In some men, specialists use medicines such as clomiphene or aromatase inhibitors off-label to raise the body's own testosterone.

Sperm retrieval and ICSI

In primary hypogonadism with no sperm in the semen, micro-TESE may find sperm in the testes, which are then used with ICSI during IVF.

Donor sperm

If sperm cannot be found, donor sperm is an option some couples consider after counselling.

Chances of fathering a child

Men with secondary hypogonadism often respond well to hormone treatment, and many go on to father children. In primary hypogonadism, chances depend on whether sperm can be retrieved. The female partner's age and ovarian reserve also strongly affect the outcome. Results vary, and no treatment can guarantee pregnancy.

When to see a fertility specialist

See a specialist if you have symptoms of low testosterone and plan to have children, if a semen analysis is abnormal, or if you are using or considering testosterone. Iswarya Fertility offers male fertility evaluation across its 91+ centres.