Helen L. Bernie, DO, MPH, outlines clinical management of hypogonadism in fertility-desiring men

In a talk at the 2025 Sexual Medicine Society of North America meeting in Grapevine, Texas, titled “Testosterone and Fertility – Novel Techniques in Monitoring and Treating Hypogonadal Fertile Men,” Helen L. Bernie, DO, MPH, director of sexual and reproductive medicine at Indiana University and an assistant professor of urology at Indiana University in Indianapolis, emphasized 2 central messages that remain underrecognized in clinical practice.

First, exogenous testosterone therapy and fertility are fundamentally incompatible. Any form of externally administered testosterone—whether injections, gels, or pellets—suppresses the hypothalamic-pituitary-gonadal axis, rapidly lowering intratesticular testosterone levels and often leading to oligospermia or azoospermia within months. Bernie stressed that many men are unaware of this risk due to inadequate counseling, particularly those receiving testosterone from direct-to-consumer platforms.

Second, she highlighted that effective, fertility-preserving alternatives exist for symptomatic hypogonadal men. These include selective estrogen receptor modulators such as clomiphene and enclomiphene, human chorionic gonadotropin (hCG) with or without recombinant FSH, and aromatase inhibitors. When appropriately used, these therapies can raise testosterone levels while preserving or even enhancing spermatogenesis. Bernie underscored the importance of proactive counseling and sperm banking prior to initiating testosterone therapy, along with discussion of updated FDA safety data and current guidelines, including revised cardiovascular warnings and the need for blood pressure monitoring.

When evaluating hypogonadal men who wish to maintain fertility, Bernie takes a structured approach that differs significantly from fertility-unconcerned patients. This includes documenting fertility goals, obtaining baseline semen analyses, performing detailed genitourinary exams, confirming biochemical hypogonadism with repeated morning testosterone testing, and assessing gonadotropins and other relevant labs. Risk–benefit counseling and shared decision-making are central, with ongoing laboratory surveillance tailored to individual risk profiles.

Finally, Bernie noted unresolved controversies in the field, including the optimal duration of fertility-preserving therapies, long-term outcomes of hybrid regimens combining testosterone with hCG, and best practices for sperm recovery after prolonged testosterone exposure. She emphasized the urgent need for larger, prospective, fertility-focused studies to guide future care.