Sperm and Testosterone: A Love-Hate Relationship

He stood there looking at me, as deflated as an old circus balloon. “Doc, I heard that testosterone is important for my fertility, so that’s why I started taking it. I had no idea my sperm count would drop!”

It’s Complicated

Sure, testosterone is good for you. It’s critical for good overall health and for normal fertility. But more isn’t necessarily better. You see your body has its own way of regulating hormones and does it quite precisely I might add. Probably better than most home thermostats. But if you perturb the system by taking hormones, it throws it out of balance.

Testicle as Orchid

Allow me an analogy here. Imagine that the testicle is a plant, say an orchid. Not a bad choice as the Greek word for testicle is actually orkhis. Anyway, think of the blooming orchid as a testicle that is making sperm. When conditions are right, the orchid blooms and the testicle makes mature sperm. When they are not right, the plant subsists but does not bloom and the testicle simply makes fewer or no sperm.
Now, let’s go a little further. To get an orchid to bloom, it needs the proper amount of water and sunlight (indirect of course). To get a testicle to make sperm, it needs the proper amount of testosterone (water) and follicle stimulating hormone (FSH, sunlight). You may be able to eke out a few sperm with only water or only sunlight, but not normal amounts and counts.

The Pituitary Gardener

Now the gardener tending this orchid is the pituitary gland. It controls how much water (testosterone) and sunlight (FSH) that the orchid (testicle) sees. The one fault of this gardener though is that he can only give the orchid water and sunlight together, and not separately, and he makes the decision to give both on how much water (testosterone) he senses is around.
You with me? Good, let’s keep going. One day the gardener notices that it has rained a lot recently; that is, that the man who owns the testicle has taking testosterone supplements. He looks at the plant and says: “Plenty of water here, no need for more water (or sunlight).” So, yes it’s true that the orchid has plenty of water (testosterone), but it still needs sunlight (FSH) to bloom, which is precisely what the gardener withholds. In this state, the orchid will subsist but will not bloom, just as the testicle will subsist but not make sperm. Until the balance of hormones returns after stopping the testosterone supplements, sperm counts will be low or even zero. And it may take 3-6 months to get the testicle to make sperm again, once the proper hormone balance returns.
The medical word for this balance is homeostasis. Get yourself some, by taking great care of yourself and treating your body like a temple. Then watch your orchid bloom!
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56 thoughts on “Sperm and Testosterone: A Love-Hate Relationship

  1. My husband was your client 3 years ago , I’m still hoping that you can do something for us !
    We have the same last name 🙂
    Thank you

    1. Dear Faten, thank you and of course I remember. I also hope that I can do more for you before my time is up on this good earth.

  2. Sir,I have normal FSH of 8.6 normal LH of 5.3 normal inhibin B of 239 and testosterone normal of 613 but no sperm could be retrieved in two TESE treatments and doc says sertioli cell only with masturbation arrest at primary stage. Also at places occurrence of leydig hyperplasia. What to do

    1. Dear Shanky, Thanks for the correction on the type of arrest! Hadn’t heard that one before…Your ability to have sperm depends on how hard someone looks. IF the TESE procedures used micro dissection, then that is good. If there were only a few biopsies, then sampling harder in more places could find sperm. Consider FNA Mapping at least 6 mos after your last TESE procedure.

  3. Hi Dr. Turek I have a question about my husband’s health and feel as though we need a second opinion from another urologist. We are trying to conceive and he did a semen analysis and it came back with zero sperm. The doctor ordered blood work to check hormones. They came back FSH normal, LH normal and low testosterone 231. Is this the cause of the zero sperm count? I find it odd that there is nothing to be found. I feel as though it is an obstruction and every time I say something it is ignored because my husband’s exam went fine will he was at the clinic. Isn’t there the possibility of not feeling an obstruction if it was higher up near the ampulla? I don’t know if that is common but he continues to order more blood work; now checking prolactin, TSH and free testosterone. My husband is very healthy, he exercises 4+ times a week, eats healthy, no family history of fertility problems and is 25. If his FSH and LH levels are okay, shouldn’t there be at least minimal sperm? With it being zero I feel it is an obstruction but the doctor is talking about clomid for him without even wanting to do an ultrasound or anything else! Please let me know what you think, thank you!

    1. Dear BSG, With a normal LH, the testosterone will probably be normal on a repeat, morning blood draw. Therefore it is NOT likely to be the cause of azoospermia. Having normal LH and FSH is typical of obstruction but may also indicate non obstructive azoospermia due to early maturation arrest (EMA) or Sertoli cell only syndrome. If testicular volume is normal, then it is typically EMA or a blockage. Ultrasounds typically do not have much value here; a good physical exam that palpates each vas deferens and the epididymides, can be very informative. Taking clomid will not likely lead to a normal sperm count, but it may result in small numbers of ejaculated sperm. Clomid is reasonable but should not be used for more than 4-6 mos before a biopsy is considered.

      1. Thanks so much for your reply to my question! He got his second round of blood work back and had normal TSH, prolactin and testosterone. Then a normal scrotum ultrasound and now will be doing a TRUS in the morning to check things out higher up. He did another semen analysis and a urine sample to rule out retrograde ejaculation also. Hopefully we find something out soon and hopefully there is a solution to fixing it all.

  4. I Used to wear a lot of equipment arunod my waist 2 cell phones, 1 pager and one Satellite cell phone for more than 5 yearsWhen I tried to have a baby i was diagnosed with haven law sperm count.

  5. Hoping you can share some quick advice. Bilateral varicoceles, low testosterone (150 ng/dL), low FSH (0.5 mIU/ml), borderline low LH (1.5 mIU/mL). Sperm count above 60 mil/ml, forward motility 55%, morph 2%
    Can the T, FSH or LH cause low morph, can vericoceles cause low T, FSH or LH?
    Doctor wants to just wait right now for 3 months. I feel that this is wasting time.
    Thank you!

    1. Dear Sammy, It is usually thought that a normal sperm count cannot be generated (like you have) in the setting of true clinical hypogonadism (low T). I would repeat the T levels to make sure it is low. No evidence that hormones affect anything other than sperm count or motility. No real evidence that the varicoceles are the culprit of anything here, besides maybe causes sperm function to be poor (are you infertile?).

      1. Thanks for the response. Interesting information. I am on fertilaid and l-carnitine for the last 3 months we have trying for an year but only using ovulation kits for 3 months.
        Another blood draw was done so I am waiting the test results. Hope they are ok.. I also do not really exhibit any low testosterone symptoms

  6. Yes, just curious on the chances of fixing the prolactin and conceiving quicker. My husband has low testosterone at 32 170. He doesn’t really have any of the commen symptoms from it but the dr said he prolactin is high, maybe caused by a benign tumor. ( freaked me out) she said if there isn’t a tumor then they would have to control the prolactin. I am just like some of the other ladies I feel like the drs don’t here me. Thank you

    1. Dear Jackie, most mild elevations of prolactin (normal range I think is 2-17) are due to a blood draw done too early after waking up in the morning (which just happens to be the best time to test for testosterone levels). Medications are another reason. Stressful blood draw is yet another. All mildly elevated prolactins should be repeated before treating. Significantly elevated prolactin levels usually lower LH and FSH and testosterone levels.

      1. Hi dr Turek, i would like to know is it possible for a male to have high Lh and FSH and then normal testosterone level…leading to no sperms. Previous sperm count were ok. What could be the causes? And is it reversible? Thanks

  7. Hi Dr.
    I’m a male-to-female transgender person, who already has one child with my wife, which we conceived before I started taking hormones. Due to bad planning on my part, I decided to start, and then stop, taking estradiol and spironolactone (total about 6 months) prior to us deciding we’d like to have a second child (long story…) I’m age 42 and she’s 36. She has put a hard stop to attempting pregnancy after the end of 2017. So I have basically just under 3 months to get her pregnant. I’ve been off the hormones now about 6 weeks, and some erectile functionality has returned, but my libido has not (was not strong to begin with), and overall ejaculate volume is low. My “total testosterone” before starting hormones last April was 360ng/dL from one lab, and 288ng/dL from another. I haven’t had a blood test recently, but I”m sure the T is still low. I’ve visited a reproductive urologist, but he told me to wait another couple of months, which I don’t have. My testicle size was normal. So the question is what medication is available to maximize my chance of getting wife pregnant before the end of 2017?

    1. Dear R.O.O.T; Great questions! I would stick with the advice of your reproductive urologist. Honestly, you can’t hurry sperm production along…it takes 3-6 months to get anything back. However, you could consider looking into the testicle for sperm and doing IVF-ICSI as sperm shows up there before it ends up in the ejaculate. She has you on a tough timeline!

  8. I am a 28 y/o. My wife and I have been trying to conceive for 1 year. I had a semen analysis done and it was less than 2 million. My PCP ordered blood tests.
    Testosterone Total (Serum): 378 (Range 264-916)
    Free %: 2.0
    Free Testosterone (Serum): 76 (Range 52-280)
    TSH: 1.880 (Range: 0.450-4.500)
    T4: 1.42 (Range: 0.82-1.77)
    FSH: 2.5 (Range 1.5-12.4)
    Prolactin: 13.1 (Range: 4.0-15.2)
    LH: 6.3 (Range: 1.7-8.6)
    Estradiol: 16 (Range: 8.0-35)
    I also have many symptoms of low testosterone levels (exhaustion, sleepiness, mood swings, loss of muscle mass, low strength). In addition, I have gynecomastia with no discharge. MRI with and without contrast also showed no signs of pituitary adenoma.
    Any suggestions or ideas on how to improve my testosterone levels, quality of life and sperm count? Has there been success with the improvement of testosterone levels/sperm count and have a child?
    Thank you in advance.

    1. Dear L.F.A., this is a complex question that really requires care and not on line advice. Your numbers appear within the normal range and your symptoms could be due to simply life stress and poor sleep habits. Know that you can certainly take testosterone and see how you feel but that your fertility may be impaired. There are ways to give testosterone and also protect your fertility but this really requires an office visit.

  9. doctor am 34 , we have been trying to conceive for 10 months now no issued I did blood work and sperm count to a specialize hospital here in Oklahoma , blood works drown at 2:45 pm T . testosterone 192, FSH 4.5 and for semen analysis 12 noon count 308 million ,motility quick progression 55.3 % total progressive 55.3%, liquefaction complete is yes , color normal, ph 7.6, viscosity ok ,kruger strick morphology (stain-diff quick) 5 % and volume 0.09 which is down. and the doctor says every thing is fine ,but I don’t understand because I used to have testicles pains ,I did ultrasound and ct can result normal in 3 and one show grade 1 varicocle and ct and other ultrasound show normal.
    and am really ejaculate little ,what is really causing our problem. thanks in advance what is your own suggestion

    1. Dear Tabidaniel, Although men can have normal sperm counts and motilities on semen evaluation, it is important that ejaculate volume be normal as well. After all, semen hits the female vaginal vaults with low PH and has to survive and insufficient semen volume means less protection for sperm. I always evaluation low ejaculate volumes as this finding is almost always explainable: retrograde ejaculation, ejaculatory duct obstruction, simple collection error, low testosterone or missing vas deferens.

  10. I have oligospermia with count 15 millions per ml.80% sperms are immotile.Sperm motility is not good.No rapid progression of sperms.FSH 22.88 mIU/ml and LH is 17.5 Testosterone is normal (Quite confusing).No erection.I used fluoxetine (prozac) for long time which considerably dried body secretions.I consulted endo and he prescribed (horny goat weed+maca) supplement.I am not satisfied and need your second opinion.

    1. Dear Sajjad, the combination of low sperm count and motility and elevated FSH suggests that there is a sperm production problem. Something is holding down production. Clearly its not the hormones which are trying to push it harder (high FSH and LH). You should consider a formal urologic evaluation for varicocele or other correctable causes and possibly an evaluation for genetic causes, which are typically not correctable.

  11. Can I ask for some advice from you?
    My husband was diagnose Azoo Oct last year. His Test is low and FSH is high(196/30). We did one TESE (Jan’18) and didn’t success. Doctor said his testis are arthopic. Do you think we still have HOPE to produce just enoung for ICSI without open up again?
    We are only 29 and 30, never expect that we can’t have own baby.

    1. Dear S. tee, This appears to be nonobstructive azoospermia. We can find sperm in 40+% of men who have failed TESE procedures and in 29% of men who have failed mTESE procedures by simply using nonsurgical FNA mapping. Whether or not he can avoid another surgical sperm retrieval once sperm are found is very difficult to say without seeing the FNA map.

      1. Hi Doctor,
        The best chance of us is to finding Urologist who willling to do FNA mapping, is that right?
        We live in Thailand, so we hardly to go to see you in the State.
        Another question, last hormones testing was collected his blood in the evening time, is it nescessary to repeat the test in the morning?
        and Do you think we should try Clomid or not?
        I’m really glad to hear from you.
        Thank you so much for you help.

    2. Hamza Idrees age 22 My T.test is 392 FSH is 1.95 lh is 3.7 I feel very weak after masturbation. I’m not married yet. The doctor says reports are normal but I feel very weak after masturbation.

      1. Dear hamza, Feeling “weak” after masterbation may or may not be significant. There are anhedonia syndromes that surround ejaculation, and there can be other measurable hormonal and metabolic issues that might cause this feeling. A thorough medical evaluation is encouraged.

  12. Hello Dr,
    My first semen analysis was done in Dec 2016 and I was diagnosed with azoospermia. Without taking any treatment, second semen analysis was done in March 2018 and it showed sperm count 4.6 million. Seeing this report, urologist advised me for a hormonal analysis – LH was 6.52, FSH was 2.6, serum prolactin was 7. 45 and total testosterone was 266. Seeing this, they advised me testosterone supplements. After taking supplements for approx 45 days, i went through semen analysis again and it came Zero. After this I came across many articles which said testosterone supplements can cause sperm count to drop. Scrotum sonography did not showed any abnormality. I am 33 years old. Doctor has suggested testicular biopsy and then IVF. My question is, can my sperm count become normal again so as my wife can conceive naturally?

    1. Dear Trent, It is not uncommon for men with normal sperm production to fall to zero on occasion. I see this happen about half a dozen times every flu season! It’s also true that taking testosterone supplements will drive sperm production down to 0 in at least 90% of men doing this. However, taking SERMs such as clomid or tamoxifen should encourage sperm production in this situation.

  13. Sir, iam a 30 yrs old male tried for baby by one year of my marriage with no any type of contraception. But every month result is negative.
    Now i was go for consult of a gyn who suggest a USG of my wife and semen analysis for me. My wife found a Cyst of 3.14 inch in left ovary. And the shock is that i have semen with 0 sperm and lots of (6-8) pus cells.
    I did tests and found FSH 9.14 and TSH 13.94. and a normal erection no PE and great sex life. And in past i conceive a girl before 4 years.But now its very unimaginable things happen.
    Our doc completely concluded i will never be a father at all.
    Please help what i do.???

    1. Dear Nick, I cannot make an accurate diagnosis of your condition over the intranet. However, These labs suggest that maybe you might be seriously hypothyroid, an unusual but real cause of male infertility. Get thee to a proper reproductive urologist!

  14. Dear Dr. Turek,
    I have a question about my husband’s health. He had an SA, and it came back with 0 sperm but with high volume. Unbeknownst to me, he had been taking OTC testosterone supplements, which our RE said to stop taking, which he did immediately. He went to get his labs done about 2 weeks later, and his numbers were as follows:
    TSH: 1.23
    FSH: 20.1
    LH: 4.3
    Testosterone Total: 282
    He has only had the one SA done, and I’ve scheduled him with an urologist. I am hoping it was just the testosterone supplements, and not something else that could be causing the 0 sperm and perhaps he could be given medication to aid sperm production. With the above-numbers, does that seem to the case? I would sincerely appreciate any insight you could give me. Thank you.

    1. Dear Estela, The “look” of the hormones with low normal T and high FSH is not at all typical for testosterone supplements. It is more typical for nonobstructive azoospermia than it is for secondary azoospermia due to testosterone (suggested by LOW FSH and low T). I agree with seeing a urologist. Sperm mapping might be considered after this evaluation.

  15. Hi Doc,
    I have been diagnosed with Azoospermia in semen analysis. But my FSH and LH is normal with Testosteron of 9.41 ng/ml. Do you think there is a chance of producing sperm in my testicle.

    1. Dear Zakir, YES there is definitely a chance that you are making sperm! Based on FNA mapping to locate testis sperm in men like you, I would estimate that chance to be 60%.

  16. I am 32 years old male my testosterone level is 682 my PSA is 0.49 in recent test showed that my testicles are also fine mostly my tests are cleared but still i find difficult in eraction is it possible that my sperm motality is weak???

    1. Dear Fistnow, Erectile dysfunction in young men (assumption here) is far more likely to be stress-related than “organic” (ie due to T issues). Not sure how the sperm motility fits in here.

  17. About 2 months i find difficulty in eraction my all tests are cleared my testosterone level is 682 PSA is 0.49 testicles are also in good shape no liver and kidney disease found during ultrasound is it possible with such high testosterone and possibility to have low sperm motality???

    1. Dear Sam, Issues of erections, testosterone and sperm motility may be related but it’s complex. So “yes” one can have all three conditions. Only rarely are erection issues related to low T and the relationship between low T and sperm motility is even less well understood.

  18. Hello, i did twice horomonal and spermogram tests. The firs hormonal test, testosteron lh fsh were low. The second one were normal.. But both spermogram test were normospermia. I steel feel low testosteron. My doc said to do the tests after 3 months

  19. Hello doc,
    I ve done twice hormonal and semen analysis, both of semen analysis ara normozoospernia but at one of the hormonal tests was below and the other one was ok. Is it imbalance?

    1. Dear Sinan, it is difficult for the body to generate a normal semen analysis in the presence of a clinically significant hormone problem.

      1. Actually the second tests i ve done for hormonsso the tst, fsh and lh values were normal. Does it correspond to the normozoospermia. That was also my doctor believed. Thank you doc so much for answer..

  20. My total testosterone is normal but free testosterone is slightly higher from border line . my Sperm count and mobility and morphology is perfect. but still my wife not conceiving. we are trying from last 1.5 year. her all test are also normal. what is problem? is my lover free testosterone is cult.

    1. Dear ravindra, typically a man cannot generate a normal sperm count in the setting of truly low testosterone levels. You have both. Look elsewhere! This is unexplained infertility and could be due to poorly functioning sperm or female issues. Give us a shout if you need help getting started.

  21. I am 58 years old and I had a vasectomy about 2 years ago. Ever since the vasectomy the intensity of my orgasms have dropped considerably. In addition I produce a very low amount of seaman and it is clear. Sex is marginal at best. I was hoping things would get better but it is not happening. I take clomiphene 25 mg per day and my testosterone level is 947. Is there anything you can do to help me?

    1. Dear Patrick M, I have had a handful of men who note altered ejaculation/orgasm after vasectomy. Typically semen volume is NOT altered by vasectomy, so other causes should be examined. Retrograde ejaculation due to prostate enlargement? Ejaculatory duct obstruction? It is most certainly NOT testosterone related with a T of 947ng/dL!!

      1. Thank you Dr. Turek, I may be in that handful of men you are referring to. Even my wife noticed the decrease in seaman after the vasectomy. I do have an enlarged prostate and take medication for it. I have a PSA of 3.64. I was taking Flomax and the doctor who performed the vasectomy indicated that may be the culprit. I switched medication to Alfuzosin 10mg.
        My frustration is that the intensity of my orgasms have decreased significantly and climax is over in 1 second. Very brief and almost non existent.
        Is there any hope?

        1. Dear Patrick, Ah! The alpha blockers for BPH (prostate issues) are a MUCH more common cause of low ejaculate volume than having a vasectomy. You might consider REZUM or UROLift or other “bladder neck sparing” surgical procedure instead of alpha blockers.

  22. Hello Doctor
    I’d like to share smth. i’d ask you that i had low T but normal spermagenesis. few days ago my wife get pregnant (normal ways) i am so so so happy. so, i remember your important words about this ”it is difficult for the body to generate a normal semen analysis in the presence of a clinically significant hormone problem” Dear Doctor, how should i analyse this situation/ and how to continue to my life with low T ?? because i am pretty sure that I feel low T maybe normal low T.

  23. Hi dr Turek, i would like to know is it possible to have high Lh and FSH and then normal testosterone level…leading to no sperms. Previous sperm count were ok. Thanks

    1. Dear Ritienne, yes this is possible. In the setting of having “ok” sperm counts in the past and now being 0, I think of exposures to medications, hot baths, social drugs and genetic issues. Given the high LH and FSH, I doubt that a physical blockage is present however.

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