Pairing hCG With TRT to Preserve Fertility

You might think testosterone replacement therapy (TRT) would boost fertility. After all, testosterone is famous for revving up men’s sex drives, and low testosterone is associated with decreased fertility. In reality, TRT can actually reduce sperm production. That’s why some doctors pair TRT with human chorionic gonadotropin (hCG), a hormone that helps protect fertility.

Historically, men on TRT were past their reproductive years. But recent research shows a 58 percent increase in testosterone prescriptions for 35- to 44-year-old men and a 35 percent increase for those 45 to 54. ¹ One driver: Testosterone levels in younger men have dropped significantly. A 2021 study found a 25.5% decline in men ages 15–39 between 2000 and 2016. ²

HCG mimics luteinizing hormone (LH), which stimulates the testes to produce testosterone and sperm. “Over the last five to 10 years, evidence suggests that prescribing human chorionic gonadotropin (hCG) along with TRT can preserve sperm parameters in men on testosterone therapy,” says Amy Pearlman, M.D., a board-certified urologist. In fact, she offers hCG to all her patients on TRT who want to preserve fertility—a practice echoed by a 2018 clinical review. ³

Curious whether hCG should be part of your TRT protocol? Here’s what you need to know.

About the Experts

Amy Pearlman, M.D., a board-certified urologist specializing in male sexual and hormonal health.

Larry I. Lipshultz, M.D., professor of urology and chief of male reproductive medicine and surgery at Baylor College of Medicine in Houston

Joshua Calvert, M.D., a board-certified urologist specializing in men’s hormone health and fertility

Why Is hCG Prescribed With TRT?

HCG is prescribed with TRT to maintain sperm production, which can decline on testosterone therapy.

When you’re on TRT, your brain senses the additional testosterone and essentially tells your testicles, “We’re good on T—shut it down,” which reduces sperm production, explains Pearlman. TRT suppresses what’s known as the hypothalamic-pituitary-testicular axis, which is the communication system between your brain and testicles. When this system is suppressed, “your pituitary gland makes less luteinizing hormone and follicle-stimulating hormone, key hormones that drive production of sperm and testicular testosterone,” explains urologist Larry I. Lipshultz, M.D.

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The result? Lower sperm counts, fertility issues, and even testicular shrinkage. But hCG, used alongside TRT, can help mitigate these effects in the following ways:

hCG increases testosterone

TRT can suppress natural testosterone production in the testicles by up to 94 percent. ⁴ That’s because when you take TRT, your body stops producing luteinizing hormone (LH).

When hCG is added to TRT, it acts as a stand-in for LH. “Patients benefit from both their prescribed testosterone and their body’s own natural production stimulated by the hCG,” explains Lipshultz.

hCG improves sperm production

Testosterone inside the testicles—not just in your bloodstream—is what drives sperm production. hCG stimulates the Leydig cells in the testes to produce that internal testosterone, explains Pearlman.

This makes hCG a game-changer for men on TRT who want to preserve their fertility. Research shows that combining hCG and testosterone maintains testosterone levels in the testicles, which supports healthy sperm production, even after a year of treatment. ⁵

In more complex cases, doctors may prescribe hCG with follicle-stimulating hormone (FSH). A groundbreaking 2024 study revealed that 75 percent of men with low to no sperm counts saw significant increases in sperm production with FSH/hCG combination therapy. ⁶

hCG prevents testicular atrophy

Roughly 80 percent of testicular volume is sperm and developing sperm cells. “If there’s no signal to make sperm, your testicles shrink,” says Lipshultz. Taking hCG while you’re on TRT helps prevent testicular atrophy by keeping sperm production active. Even for men unconcerned about fertility, many experts recommend hCG with TRT simply to avoid testicular atrophy. ⁷

Additional benefits of hCG

Beyond fertility preservation, hCG offers other clinical upsides:

• Improved libido: About 80% of men reported a libido boost when using hCG, according to a 2022 study looking specifically at hCG alone. ⁸ Lipshultz reports that many of his own patients experience higher sex drive when using hCG, likely due to the increased testosterone production in the testicles.
• Smoother TRT transitions: hCG helps maintain hormone balance during planned breaks from testosterone therapy, which some men elect to do to help manage side effects like testicular atrophy. ⁹
• Better erectile function: Over 85 percent of men self-reported improvements in erectile dysfunction (ED) on hCG monotherapy, according to a small, retrospective study in the journal Cureus. ¹⁰

How Often Should I Take hCG on TRT?

While hCG dosing can vary depending on your goal, the most common protocol is 500 to 1,500 IU injected two to three times per week. “For maintenance, 250 IU every other day is a common option,” says board-certified urologist Joshua Calvert, M.D.

While your doctor will help tailor your hCG/TRT protocol to your specific needs, but here’s how it typically plays out:

• Timing: You can take hCG and testosterone on the same day, but some men opt to space out their injections. “This is more about convenience than necessity,” says Calvert.
• Injection site: hCG can be injected subcutaneously into belly fat or into your glutes or thigh muscles. “Most patients find subcutaneous injections easier and just as effective,” notes Calvert.
• Monitoring: Your care team will regularly test your blood, urine, and semen to monitor side effects and ensure your TRT/hCG therapy is working properly. The American Urological Association recommends evaluating red blood cell levels (hematocrit) and testosterone levels every six to 12 months after starting treatment. ¹¹ However, some physicians test more frequently, at least initially. “I typically check testosterone, hematocrit, and estradiol—a type of estrogen—levels one month after starting therapy, then again at three and six months,” Pearlman explains. “If anything about the therapy changes, I repeat the labs one to three months after the shift.”

Side Effects of Taking hCG with TRT

Both hCG and TRT can cause side effects. But most are mild and manageable, especially with regular check-ins, dosage tweaks, and simply paying attention to your body’s signals.

Common side effects:

• Headache
• Restlessness
• Tiredness
• Pain at injection site
• Acne or oily skin
• Water retention
• Testicular discomfort

Seek immediate medical attention if you experience:

• Swelling of your hands, ankles, and/or feet
• Mental or mood changes, such as feeling depressed or irritable
• Breast tissue pain or swelling (gynecomastia)
• Sudden vision changes
• Sudden severe headache
• Rash, itching, and/or swelling
• Trouble breathing ¹²

When to Skip TRT and hCG

Should I take hCG with TRT? It’s a smart question, and the answer depends on your health profile. Conditions like a history of blood clots can make TRT or hCG riskier. Testosterone can raise red blood cell counts, increasing clot risks for those prone to cardiovascular issues. That’s why it’s vital to discuss risks and benefits with your doctor, especially if any of the following apply to you:

• Untreated heart problems
• Atrial fibrillation or other heart rhythm issues
• Blood clots
• Sleep apnea
• Been treated for prostate cancer or breast cancer
• Experienced elevated red blood cell counts

Testosterone and/or hCG therapy can potentially worsen these conditions. Your doctor might need to carefully monitor you or recommend alternative treatments if these health concerns are present. ^{13 14}

Risk factors to consider:

• Age: Men over 50 face an elevated chance of blood thickening from TRT, which may contribute to blood clot risk. This is especially true for men with a history of clotting issues. However, therapeutic phlebotomy or donating blood can address the issue.
• Sleep Issues: “If you are already dealing with sleep apnea, TRT therapy can worsen your symptoms,” says Calvert.
• Hormone Levels: If you have high baseline estrogen (your physician should test this biomarker as part of your testosterone panel), you’re more prone to estrogen-related side effects, like gynecomastia, mood swings, and water retention.

Other Options for Preserving Fertility on TRT

If hCG isn’t your ideal match, there are other options that can help protect your fertility, either as part of your TRT plan or on their own.

Clomiphene citrate

Research suggests combining certain forms of TRT with clomiphene citrate (sold under the brand name Clomid) to help maintain fertility and testicular size. ¹⁵ That said, both Pearlman and Calvert strongly advise against combining clomiphene citrate with higher doses of conventional TRT, especially injections.

As Calvert explains, it’s “like stepping on the gas and the brakes at the same time.” While clomiphene tries to boost your natural hormone production, high doses of most forms of TRT shut it down completely. The same effect isn’t as pronounced with low-dose testosterone. Your best bet? Have a thorough chat with your healthcare provider about whether clomiphene citrate alone or another approach might be right for you.

Anastrozole

Since some testosterone is converted to estrogen in the body, some men on TRT experience elevated estrogen levels, which in turn tamps down the production of LH and FSH, both of which are critical for sperm production. Adding an aromatase inhibitor, like anastrozole (sold under the brand name Arimidex) can help bring estrogen down, says Calvert.

A 2021 report in the journal Sexual Medicine found that men receiving anastrozole significantly reduced their elevated estrogen levels without compromising their testosterone levels. ¹⁶ By keeping estrogen levels in check, anastrozole also helps protect fertility for men on TRT.

Sermorelin

Sermorelin, a growth hormone secretagogue, is often used by men on TRT for its powerful effects on human growth hormone (hGH) and insulin-like growth factor 1 (IGF-1) levels, which support fat loss and muscle growth. But one small study suggests it may also slightly boost LH and FSH, hormones that are typically suppressed on TRT. While more research is needed to confirm these effects, this hints at sermorelin potentially offering dual benefits for men on testosterone. ¹⁷