A male contraceptive
The seemingly obvious solution to persistently low testosterone after prior anabolic steroid abuse would be to raise the man’s testosterone levels by administering more testosterone. This treatment actually will have the opposite effect. “Putting an infertility patient on testosterone is the wrong thing,” Dr. Honig said, noting that exogenous testosterone potentially can be a male contraceptive.
Dr. Jaffe echoes that message. “When a young man, interested in achieving a pregnancy with his partner, has a borderline-low testosterone level, the worst thing to do is give him testosterone because it will shut down sperm production,” Dr. Jaffe says. “The more testosterone is raised, the lower the sperm count will go, so it’s almost like using steroids again.”
This piece of information is as important as it is counterintuitive to some practitioners, as illustrated by a case described by male-factor infertility specialist Daniel H. Williams IV, MD, assistant professor of urology at the University of Wisconsin School of Medicine and Public Health in Madison.
“I have a patient who was using a testosterone gel for just three or four months. His primary care doctor found him to be hypogonadal but put him on testosterone to try to boost his sperm count,” Dr. Williams recounts. “His sperm count went from low to zero. And it has taken me almost a year and a half of using different medical treatments to reverse that effect.”
Because non-specialists may not be keeping up with the literature on this subject, it is up to the urologist to adjust the treatment regimen. This usually means using medications to “jump start” the pituitary gland’s production of LH.
This, in turn, will stimulate the production of testosterone in the testicles. Commonly used agents are clomiphene citrate (Clomid) and LH analogs such as human chorionic gonadotropin (HCG), sometimes with synthetic FSH treatment. Aro-matase inhibitors also may be enlisted to combat low testosterone levels in infertile males. All these medications require careful monitoring by the urologist.
In some cases, the wait-and-see approach is more practical than medical management, at least initially. “I’m in a region with a lot of blue-collar people whose insurance does not cover testosterone-boosting drugs like Clomid or HCG,” Dr. Jaffe explains. “So, if the patient hasn’t been a very heavy user of anabolic steroids, I just give his levels time to come back up. Most of the guys I’ve seen with this problem are in their mid-20s, so they’ve got time to have children; there’s not a big rush.”
Dr. Jaffe monitors the testosterone levels and sperm counts of these patients every three months. “In my particular patient population, you start seeing slow but steady improvements in sperm production. Again, these are men who probably haven’t done more than one or two anabolic steroid cycles in general. Most guys I’ve taken care of have rebounded within three to six months; the longest took a year.”
Yet there’s little rhyme or reason as to who will suffer stubborn or even permanent effects of anabolic steroid use. “For a lot of these guys, it’s just one cycle of steroids and they might never have their sperm production return to normal levels,” Dr. Jaffe says. “Then there are guys who have done numerous cycles and they’re okay.”
Some males who have used anabolic steroids indeed fit the stereotype of the overly muscled physique. “Typically, they are obviously big, bodybuilder-looking types,” Dr. Honig observes.
Such physical effects are not always obvious, however. “In terms of my patients, if they hadn’t told you they used steroids you never would have known,” Dr. Jaffe states.
Verbal clues may be as unreliable as visual ones. Consider Dr. Honig’s usual experience with patients who have used performance-enhancing anabolic steroids: “They are often in complete denial. It usually takes three or four times of asking before they’ll admit that they’ve used anabolic steroids.”
Some patients are more forthcoming. “Most of the guys I’ve treated have come out and said, ‘I’ve used steroids; is that why I’m having a problem?’” Dr. Jaffe says. “Sometimes they feel guilty about having used the drugs.”
Blood tests can shed light on the matter. “If you suspect anabolic steroid use, you can draw testosterone levels,” Dr. Honig said. “If the normal range is typically 200 to 800 mg/dL, active users might have 1,500 to 2,000 mg/dL.” Dr. Jaffe adds that LH levels are also a good indicator of steroid use. “If they’re taking testosterone, then their luteinizing hormone levels should probably be pretty low—maybe almost undetectable.”
Distinguishing between natural and synthetic testosterone is a more difficult task. Some professionals believe that high levels of the testosterone derivative epitestosterone can help differentiate, but Dr. Williams is doubtful. “Even though most men have a general testosterone-to-epitestosterone ratio of about 1-to-1, some men have natural ratios that are higher. So, that test is an unreliable marker for exogenous testosterone use.”
Oral testosterone is no longer prescribed in North America because it can cause liver damage, but two currently popular forms of treatment for men with low testosterone are the topical gels, such as AndroGel and Testim, and the injectable formulations. “Both treatments are safe to prescribe if they’re being administered by an experienced medical professional who understands the risks and benefits of testosterone replacement therapy and who knows how to monitor the levels and make the necessary adjustments,” Dr. Williams says.
Men who have engaged in the cycling of anabolic steroids long enough to deplete their endogenous testosterone production now are grappling with erectile dysfunction. They may be able to achieve erections again after a period of testosterone supplementation alone, but this quality-of-life issue often re-quires a quicker resolution with a multimodal approach. “Treat these patients with testosterone supplementation plus an agent such as Viagra, Levitra, or Cialis,” Dr. Jaffe advises.