Why Men’s Fertility Is Declining: The Truth About Testosterone

Lipshultz argues that many young men with low T also have poor sperm production because the testicle isn't functioning well. Knowing the baseline count allows him to set a reasonable goal — if they were 10 million/mL to start, he won't chase 30 million/mL later. He also sends blood for whole genome sequencing in azoospermic or severely oligospermic men, looking for infertility genes and actionable health risks like cancer predispositions. This practice turns a fertility encounter into a broader health screening.

He notes that hCG's effect lasts about 48 hours, but a single weekly pulse still prevents atrophy. He offers this to every man when starting T because many dislike the shrinkage. It is distinct from his fertility protocol, where he uses hCG more frequently plus FSH. Patient acceptance is high because it's only once a week.

He describes the evolution from stopping T (which was miserable) to adding hCG with Clomid, and now to hCG + FSH. His insight was that if TRT turns off FSH and LH, you can simply replace those hormones. He has shown that men can stay on T while regaining fertility. He emphasizes that this approach gets couples pregnant faster and avoids the symptomatic crash. He now uses this as his standard for all men on TRT who want children.

He observes that patients using daily or frequent subq dosing have less hematocrit elevation and less adverse lipid changes compared to large weekly IM doses. He thinks the pharmacokinetic peak encourages these side effects. He allows patients to choose their frequency (3, 5, or 7 days) and uses them as a salvage strategy when side effects emerge on standard dosing.

Lipshultz explains that excess oxidants can break sperm DNA, impairing the ability to fertilize and increasing miscarriage rates. Studies support antioxidants for improving semen quality, so he offers a proprietary blend made by a specific pharmacy. He takes a pragmatic approach: if it's safe and might help, why not use it? He acknowledges the lack of FDA evaluation but relies on the biological rationale.

Lipshultz finds that men over 50 struggle to build muscle despite intense effort. He first demands they work with a trainer and dial in nutrition. Only if they still can't gain does he add nandrolone. He uses half the T dose to avoid ED issues that some attribute to DHT interference. He says he's never seen ED in his patients on this regimen. He monitors them every 3-4 months and sends those with any risk to a cardiologist for clearance. He prefers this over oxandrolone because of liver concerns with orals.

Lipshultz became aware that many men with normal testosterone but severe hypogonadal complaints actually have obstructive sleep apnea. He describes a case where a man might have normal T and free T but still feel terrible. Before considering CAG repeats or assuming androgen resistance, he insists on a sleep study. He says they pick up a lot of apnea this way, and treatment can turnaround the symptoms without ever needing higher T doses. This practice reflects his philosophy of looking beyond the hormone number.