Latest / UF Health MedEd Cast / The Role Testosterone Plays in Male Fertility?

Transcript

The Role Testosterone Plays in Male Fertility? · UF Health MedEd Cast

• 0:26
  Melanie (Host): Welcome to UF Health Med EdCast with UF Health Shan's Hospital.
• 0:30
  I'm Melanie Cole, and today we're talking about testosterone and fertility.
• 0:35
  Joining me is Dr.
• 0:36
  Kevin Campbell.
• 0:37
  He's an assistant clinical professor and an associate Medical Director
• 0:41
  in the Department of Urology at the University of Florida College of Medicine.
• 0:45
  Dr.
• 0:46
  Campbell, it's such a pleasure to have you join us today.
• 0:48
  Let's just start with kind of how common in the prevalence is testosterone
• 0:53
  deficiency and disorders in men?
• 0:56
  Kevin Campbell, MD: Absolutely.
• 0:57
  And Melanie, thanks for having me.
• 0:59
  It's a pleasure to be here today.
• 1:01
  So testosterone and, the implications of having high and low testosterone,
• 1:06
  are really, really, uh, at the forefront of, what I practice on
• 1:09
  a day-to-day in clinical medicine.
• 1:11
  And it's a topic that's, near to my clinical interests and heart.
• 1:13
  So if we're looking at.
• 1:15
  The number of people who have testosterone deficiency or, low testosterone,
• 1:21
  depending on what clinical picture you look at, you're gonna be seeing somewhere
• 1:24
  from like 5% all the way up to 20%.
• 1:28
  So it's not without, a big presence in the general community.
• 1:31
  And you likely know somebody who either has low testosterone or
• 1:36
  testosterone deficiency or is being treated for testosterone
• 1:39
  deficiency and may not even know it.
• 1:41
  Melanie (Host): Well, since it's so common, speak a little bit about what
• 1:44
  would send a man to a physician, whether it's his primary care or urologist.
• 1:50
  Tell us some of the signs and symptoms that they might notice
• 1:53
  or that a partner might notice.
• 1:55
  I.
• 1:55
  Kevin Campbell, MD: Absolutely.
• 1:56
  there's really two main drivers of men to the physician, especially
• 2:01
  for younger, healthier men usually, and that's fertility or sterility.
• 2:05
  Men are either trying to, either get a, a vasectomy or, or worried about
• 2:09
  their reproductive healthcare or something's going wrong and they're
• 2:13
  worried about their testosterone.
• 2:14
  And a lot of the times the signs and symptoms may be difficulty with pregnancy.
• 2:19
  It may be increased fatigue, it may be low sex drive.
• 2:23
  Low muscle mass, decreased, ability to achieve an erection.
• 2:27
  Now they're starting to have all this adipose or fat tissue around
• 2:30
  their abdomen And also, uh, sometimes orgasmic or other sexual disorders.
• 2:35
  And the thing we worry about with these is we try to screen them early
• 2:38
  because sometimes they might be a sign or symptom of something greater like a.
• 2:42
  Pituitary pathology or an endocrine disorder, or testosterone deficiency.
• 2:48
  So we have to rule out some of the scary things, to get down to it.
• 2:51
  And so we're really trying to listen to what the patient's are
• 2:54
  saying when they're coming to us.
• 2:56
  Melanie (Host): And then how is diagnosis made?
• 2:59
  Kevin Campbell, MD: So diagnosis is made with signs and
• 3:01
  symptoms of low testosterone.
• 3:03
  A lot of those symptoms we talk about like fatigue, decreased energy,
• 3:07
  decreased muscle mass, poor bone health, sometimes easy fractures.
• 3:11
  so Those are the, subjective, aspects.
• 3:14
  And then they have to have a low.
• 3:15
  Morning testosterone value.
• 3:17
  So testosterone, it's highest in the morning.
• 3:20
  It peaks with a pulse eye release of GNRH in your pituitary, and
• 3:24
  hypothalamus to then make LH and FSH and your LH goes to your testicles
• 3:29
  and tells 'em to make testosterone.
• 3:31
  And so that's signals highest in the morning And then starts
• 3:33
  to decrease throughout the day.
• 3:35
  So we do try to get a morning testosterone before 10:00 AM and depending on what
• 3:40
  reference range or what lab value you're using, you're gonna have some.
• 3:44
  Degree of, variation with that set number.
• 3:47
  So in many labs, and FDA will say that's around 300 nanograms per deciliter.
• 3:52
  And a testosterone below that, along with the signs and symptoms would,
• 3:56
  give you reason to say somebody has testosterone deficiency.
• 3:59
  Now if you look at, the Endocrine Society guidelines, they actually
• 4:03
  take their testosterone number and use it as a statistical.
• 4:07
  Reference and take two standard deviations beyond what's normal.
• 4:11
  And so their reference range is gonna be around like two 50 to to nine 50 or so.
• 4:15
  So you do see some change in the reference.
• 4:16
  And then even with the, the Androgen Society And the Society of the
• 4:20
  Aging male have used cutoffs as high as, three 50 in the past.
• 4:24
  And so a lot of This is really geared at signs and symptoms
• 4:27
  because not everybody has the same.
• 4:29
  Need for a certain level of testosterone.
• 4:32
  Not everyone has the same androgen receptors, so we have to look at the
• 4:36
  objective And the subjective together.
• 4:38
  Melanie (Host): Well, thank you for that.
• 4:39
  So, Dr.
• 4:40
  Campbell, as we look at a quick overview of the history of a UA
• 4:44
  guidelines on male infertility, speak a little bit about the priority topics
• 4:49
  addressed in the guidelines as they are today, and those statements.
• 4:54
  Kevin Campbell, MD: This is a really timely question.
• 4:55
  I'm glad you brought this up.
• 4:57
  The first guidelines came out in 2020, and prior to that we had a
• 5:00
  bunch of consensus statements and a lot of variations of different
• 5:04
  particular aspects of male infertility.
• 5:06
  But we didn't have any overarching or just, larger guidelines.
• 5:11
  That men could look at.
• 5:12
  And then those were updated in 2024 to continue to stay relevant with
• 5:16
  a, just a couple of major changes.
• 5:18
  But really the guidelines start And the work of starts with an evaluation,
• 5:22
  a history physical of both partners, both the male And the female partner.
• 5:26
  Because oftentimes, if we look at the breakdowns of what causes fertility,
• 5:30
  there's a 30% male factor alone, 20% combined factor, and a 50% female factor.
• 5:37
  So if you do some back of the envelope calculations and fudge the factors a
• 5:40
  little bit, you can say that the male aspect contributes to at least 50% of
• 5:45
  the infertility aspects for couples.
• 5:48
  And 15% of couples will have degree of infertility.
• 5:51
  And it might be something as, routine as a.
• 5:55
  Different type of lifestyle modification that a patient may employ that we find
• 5:59
  on the initial history and physical.
• 6:01
  There might be a medication that someone's taking, or it might be in the history that
• 6:05
  someone had some sort of chemotherapeutic or radiation that then may limit to what
• 6:10
  degree we can restore sperm production or lend us to recommend surgery over
• 6:16
  different stimulatory techniques.
• 6:17
  So the first and biggest part of the workup is going to be the history.
• 6:22
  And discussing with the patient And also finding their goals.
• 6:25
  We have some couples who come in who are very young and they're just
• 6:28
  starting to try their fertility journey and try to conceive, And so
• 6:32
  there's a little bit more leeway.
• 6:34
  We have some financial constraints as well sometimes, so we have
• 6:37
  to take that all into account.
• 6:38
  We.
• 6:39
  Whereas if we have a couple that might be a decade or two older than that,
• 6:42
  we're discussing potentially assisted reproductive therapies or ways to
• 6:46
  optimize the fertility outcomes when we don't have the same sort of flexibility
• 6:49
  that we may have with another couple.
• 6:51
  So a lot of the basic workup for fertility a.
• 6:54
  Goes into what I call the big three, and that's gonna be the
• 6:57
  history and physical blood work.
• 6:59
  So we can see how the hypothalamus And the testicles are talking
• 7:02
  to each other And the pituitary and and how they all feed back.
• 7:06
  And then also a semen analysis.
• 7:08
  And when we get those big three, we can make a recommendation
• 7:11
  of how to optimize fertility.
• 7:13
  No one test can really say someone is fertile or infertile, but we
• 7:17
  take all these things together to come up with our recommendations.
• 7:21
  Melanie (Host): That was very comprehensive.
• 7:22
  So first-line management of testosterone disorders.
• 7:27
  Tell us a little bit about some of the therapies that are available right now.
• 7:31
  Kevin Campbell, MD: Certainly, I think a lot of what goes into first-line
• 7:34
  therapy when people are thinking about testosterone deficiency is going
• 7:39
  to be giving somebody testosterone, and That is often the case.
• 7:43
  However, one of the first steps that we have to evaluate is why
• 7:46
  someone has low testosterone.
• 7:48
  Is it a issue with the testicles?
• 7:51
  Is it a issue with the pituitary?
• 7:53
  Is it an issue with the hypothalamus?
• 7:54
  Is it a, systematic or global insult to a patient's physiology?
• 7:59
  are they on some, chemotherapeutic or some medication that causes
• 8:03
  them to have blunting of this, HPG access or decreased testosterone?
• 8:08
  there's bounces down, even after starting some medications that men often will use.
• 8:13
  So it's important that we do, again, this history and physical and do this
• 8:17
  workup, the mainstay of treatment.
• 8:20
  It is often going to be replacement of testosterone or stimulatory therapy
• 8:24
  if someone's trying to conceive.
• 8:26
  We don't want to give that person testosterone right off the bat
• 8:29
  because that can shut down their natural production of intra testicular
• 8:33
  testosterone as well as sperm production.
• 8:35
  So.
• 8:36
  Many men who go on testosterone who are trying to conceive will
• 8:40
  drop their sperm counts to zero.
• 8:42
  Now we know that testosterone is not a contraceptive And that
• 8:45
  people will get pregnant on testosterone, but it doesn't optimize
• 8:49
  someone's ability to get pregnant.
• 8:50
  So we have to take that into account.
• 8:52
  And there are different, there's different therapies to, depending on
• 8:54
  what hormones, are elevated or normal.
• 8:58
  That we can employ.
• 8:58
  So if someone's F, s, H and LH are say in the normal range, we might
• 9:02
  try and stimulate that with say, a ER like Clomophine or in Clomophine
• 9:06
  or Tamoxifen, or even give someone FSH or HCG, which is an analog of lh.
• 9:12
  To try and stimulate testosterone production in the testicles.
• 9:16
  Now, if that's not an issue or we're looking at an androgen deficiency or
• 9:21
  a testosterone deficiency for, the aging male, we are gonna have a, more
• 9:26
  robust discussion about the different types of formulations of testosterone.
• 9:30
  There's almost a million formulations of testosterone out there, And that
• 9:33
  That is been a little bit facetious, but there are quite a few, many of
• 9:37
  which are all different types of, conjugated esters of testosterone.
• 9:41
  Different lengths which may last a little bit longer in the body.
• 9:44
  we will oftentimes use a injection either intramuscular, subcutaneous
• 9:48
  that may last for a week or, two weeks or, or even 48 hours in some
• 9:53
  of the shorter acting testosterones.
• 9:55
  And then there's gels or creams that men will put either on their, upper
• 9:59
  outer chest over the subclavians to absorb or the inner thigh or
• 10:03
  even on the forearms, to absorb.
• 10:05
  And that would be on a daily application.
• 10:07
  So a lot of what goes into our first-line therapy is tailoring it to the patient.
• 10:12
  I think it would be, inappropriate for us to give a, overall recommendation
• 10:17
  of what works for everybody.
• 10:18
  Because if we have the.
• 10:20
  Gardner who's going outside every morning and is going to be sweating and has
• 10:23
  to be up at, say, you know, 6:00 AM or when the sun's coming up, they're gonna
• 10:26
  sweat off a lot of this testosterone gel where we might have somebody who is,
• 10:31
  who has a fear of needles And so they don't, appreciate the idea of giving
• 10:34
  themselves injection or maybe a tremor.
• 10:36
  and once we've established a response to testosterone, we might move on
• 10:40
  to pellets or even an intranasal gel or many other, applications as well.
• 10:44
  So that's generally how we approach the first-line for testosterone management.
• 10:49
  Melanie (Host): Well, thank you for that Dr.
• 10:50
  Campbell.
• 10:51
  So speak a little bit with all of these available therapies and more
• 10:55
  tools in your toolbox all the time.
• 10:58
  What factors should.
• 11:00
  Other providers consider before recommending some of these therapies,
• 11:04
  speak a little bit about any side effects, complications you
• 11:07
  discuss with the patient's patient preference and lifestyle preference.
• 11:13
  Speak about to other providers about what they should consider when they're looking
• 11:17
  at all of these different therapies.
• 11:19
  Kevin Campbell, MD: Yeah.
• 11:20
  Thanks for bringing this up, Melanie.
• 11:21
  This is very important because I think.
• 11:24
  One testosterone application for one person is not the same for the next.
• 11:28
  And so when someone comes to see me, we're gonna talk about the risk
• 11:33
  and benefits of testosterone And then the modalities of treatment.
• 11:36
  So let's talk about the risks and benefits first.
• 11:39
  So.
• 11:40
  There's definitive evidence to say that testosterone, if it's low And we
• 11:43
  replace that, that can help with libido.
• 11:46
  It can help with sex drive, it can help with increasing muscle mass and
• 11:50
  decreasing visceral adipose tissue.
• 11:52
  It can help with bone density and prevent osteoporosis, and it can
• 11:56
  help with insulin sensitivity.
• 11:57
  There Sporadic reports of it, helping also with mental cognition and brain fog.
• 12:03
  Those are a little bit less reported in large studies and
• 12:07
  having definitive evidence.
• 12:09
  But we do have a lot of anecdotal evidence there and there are also risks involved.
• 12:14
  Testosterone is a molecule that's seen by the body, so it's, we
• 12:18
  call bioidentical, so it's not.
• 12:20
  As high-risk as other synthetic molecules, but it does have an
• 12:23
  effect on a body's physiology.
• 12:25
  It can go to your bone marrow and tell it to make more red blood cells.
• 12:28
  So if someone is undergoing testosterone therapy and not undergoing monitoring,
• 12:33
  they can get polycythemia, they can have increased hematocrit,
• 12:37
  they can put themselves at-risk for blood clots, for their legs, for
• 12:40
  their hearts, and brains as well.
• 12:41
  So there's a Non insignificant risk for heart attack, stroke, DBTs.
• 12:46
  if someone has, polycythemia that's unchecked.
• 12:49
  Now, testosterone has been proven to cause these, but secondarily, if
• 12:52
  it's raising the hematocrit And that goes unchecked, it can lead to it.
• 12:55
  So that's very important as a risk.
• 12:57
  Another risk that.
• 12:59
  It's very popular as prostate health.
• 13:01
  So there is a misconception that testosterone causes prostate cancer.
• 13:06
  Testosterone has never been known to cause prostate cancer since it's
• 13:10
  been first synthesized in 1935.
• 13:13
  So what we worry about though is that if someone has prostate cancer
• 13:17
  and it goes to other parts of the body metastasizes, well then one of
• 13:20
  the ways we know we can actually.
• 13:22
  stop that spread or help kill the cancer is to starve it of testosterone.
• 13:26
  So we do think of testosterone, in that regards as being a.
• 13:30
  Lack of testosterone is a treatment for some prostate cancers and it can
• 13:34
  So, it can help grow prostate cells.
• 13:36
  So if someone's hypogonadal, they have low testosterone and they have potentially
• 13:40
  a smaller prostate or a prostate that's not fully saturated by their androgens
• 13:44
  'cause their testosterone's low.
• 13:45
  And now you give someone testosterone, that prostate can respond in a
• 13:49
  more robust way than it has been.
• 13:51
  And so some people will see urinary tract symptoms like, like an increased
• 13:55
  prostate size that can cause, what we call lutz, or increased urinary F frequency
• 13:58
  hesitancy and growth of the prostate.
• 14:01
  And with that comes an elevation of PSA, because if you have more
• 14:04
  prostate tissue, you make more PSA.
• 14:07
  Now it does not, again cause prostate cancer, but it is something we screen
• 14:11
  for in this population because we're already seeing them And we wanna make sure
• 14:15
  that if we're growing the prostate, if there's any already present, significant
• 14:19
  prostate cancer, that we can catch it early and treat it appropriately.
• 14:23
  Some of the other effects that we see or side effects with testosterone therapy
• 14:27
  is how your body recycles testosterone.
• 14:29
  There's enzymes in your, your natural adipose tissue and fat,
• 14:33
  and your liver and brain, called aromatase, which will take your
• 14:37
  testosterone and turn it into estrogen.
• 14:39
  And so if that estrogen gets very high, that can also put
• 14:42
  you at-risk for blood clots.
• 14:43
  And it can decrease sex drive, it can decrease, erectile quality.
• 14:48
  And so we have to take that into account and, monitor estrogen and
• 14:52
  even put someone on an estrogen blocker if it gets too high.
• 14:55
  But we also don't want to go too low because then that can put
• 14:57
  someone at-risk for osteoporosis.
• 15:00
  Some other issues we see with testosterone management are increased acne because
• 15:05
  there's increased oil production by the skin think of someone when they're
• 15:07
  going through puberty and, and they're getting these testosterone surges.
• 15:10
  The, the skin produces more oil and sebum And that can cause
• 15:13
  blockages of all the hair follicles.
• 15:16
  Then, it's other times we can even see some hair thinning.
• 15:18
  So if someone is prone to male pattern baldness.
• 15:22
  Testosterone if, given in a, higher state, it can lead
• 15:26
  to advanced in hair loss.
• 15:28
  So all these are things we're taking into effect.
• 15:30
  Now, when someone goes on testosterone, they may have a job that may not
• 15:36
  allow them to have a daily application.
• 15:39
  Like, let's say someone's traveling a lot and it's harder to travel with
• 15:41
  hypodermic syringes or needles, then we may say, okay, a, daily application with
• 15:46
  a gel or a cream will be best for you.
• 15:48
  Versus if someone has a, maybe a deployment job or maybe a, job
• 15:53
  that would say, let's go ahead and use a weekly syringe or even a
• 15:57
  biweekly injection of testosterone, then certainly they can use that.
• 16:01
  some providers, will also favor putting in pellets, for patient's.
• 16:05
  And these last for about three months before they dissolve.
• 16:08
  And so some patient's like the kind of the set it and forget it.
• 16:12
  So all these are things that we, consider Some of the newer testosterones are
• 16:15
  the oral formulations And the 1980s oral formulations were, were very
• 16:19
  popular too, but they were alkylated.
• 16:21
  And so every time somebody would take testosterone, it was putting a
• 16:24
  little bit of pressure on the liver.
• 16:25
  And so we.
• 16:26
  Quickly, moved and pivoted from that application.
• 16:30
  But now there are newer formulations.
• 16:31
  There's three of 'em that are out now.
• 16:33
  These types of testosterone, ECNO eight that get absorbed
• 16:36
  with the lymphatics in the gut.
• 16:38
  So you take them, once or twice a day and it brings your testosterone up.
• 16:42
  So if someone doesn't wanna do a gel or a cream or an injection,
• 16:45
  we have different options now.
• 16:47
  So the future is bright for testosterone management.
• 16:50
  Melanie (Host): Wow.
• 16:51
  It's such an exciting time in your field, Dr.
• 16:54
  Campbell, and you are such a wealth of knowledge.
• 16:56
  As we wrap up, I'd like you to speak a little bit about lifestyle factors,
• 17:00
  relationships between infertility and general health, and how you, as you
• 17:06
  summarize, with shared decision-making.
• 17:09
  Form your patient's of all of these different therapies And what goes
• 17:13
  into the treatment options available.
• 17:17
  Kevin Campbell, MD: Yes, This is really important because when
• 17:19
  someone's coming in to be evaluated for either testosterone deficiency
• 17:24
  or fertility, it's not always the.
• 17:28
  Spend all, be all of that particular person.
• 17:31
  This is oftentimes the peak of an iceberg where there's something underlying that
• 17:35
  we really need to evaluate and treat.
• 17:37
  We know that men who have increased fertility issues have an
• 17:41
  increased morbidity and mortality.
• 17:43
  There's a increase by one to 3%, higher mortality rate in
• 17:47
  the infertility population.
• 17:49
  And that might be because there's some overlying condition that we identify.
• 17:53
  Sometimes There's no overlying condition that's identifiable.
• 17:56
  But we do know that.
• 17:58
  And treatment does have a burden as well.
• 18:00
  So we have to keep all those things in mind.
• 18:02
  When, evaluating for patient's for fertility.
• 18:05
  Now sometimes people will come in and they understand their fertility
• 18:08
  burden, but don't necessarily want treatment and just want answers.
• 18:12
  And so really the workup is going to be dependent on the back and
• 18:15
  forth with patient and provider.
• 18:17
  So.
• 18:18
  I would really harp on, this patient and physician model where we really
• 18:22
  try to hear what the patient's saying and, and meet them where they're at.
• 18:25
  Because if we're telling somebody that has low libido and decreased erectile quality
• 18:31
  and decreased adipose, or increased adipose tissue, decreased muscle mass
• 18:36
  that they need to go on testosterone.
• 18:38
  But then they say, Hey, but I'm trying to also start a family, or I
• 18:41
  wanna get pregnant in a couple years.
• 18:43
  Well, now we've just added a degree of complexity that we can't overlook.
• 18:46
  So we have to keep all these things in mind when going
• 18:49
  forward with our patient care.
• 18:50
  I.
• 18:51
  Melanie (Host): Great information.
• 18:52
  Dr.
• 18:52
  Campbell.
• 18:53
  Thank you again for joining us and sharing your incredible expertise
• 18:58
  with other providers today.
• 18:59
  And to learn more, you can visit uf health.org/specialties/urology,
• 19:06
  or to learn more about this and other healthcare topics at UF Health
• 19:10
  Shands Hospital, you can always visit innovation dot uf health.org.
• 19:15
  That concludes today's episode of UF Health Med EdCast
• 19:19
  with UF Health Han Hospital.
• 19:21
  I'm Melanie Cole.