Medications for the Infertile Male

How to cite: Köhler TS. “Medications for the Infertile Male.” Grand Rounds in Urology. November 13, 2025. Accessed Apr 2026. https://grandroundsinurology.com/medications-for-the-infertile-male/

Summary

Tobias S. Köhler, MD, MPH, FACS, Professor of Urology, Director of the Andrology Fellowship, Head of Men’s Health, Mayo Clinic, Rochester, Minnesota, reviews pharmacologic strategies for managing the infertile male, with emphasis on preserving spermatogenesis while addressing symptoms of low testosterone.

Dr. Köhler begins with foundational counseling on lifestyle modification, which he emphasizes as the most powerful intervention for male fertility. Regular exercise, dietary optimization, weight management, smoking cessation, moderation of alcohol intake, and adequate sleep are highlighted as having substantial effects on semen parameters and reproductive outcomes. A daily multivitamin is presented as a reasonable, low-cost adjunct.

Exogenous testosterone therapy is discussed as suppressive to luteinizing hormone and follicle-stimulating hormone, leading to azoospermia in most men within several months. Recovery of spermatogenesis after discontinuation is variable and not guaranteed, reinforcing the counseling point that testosterone therapy should never be used in men actively pursuing fertility.

Fertility-preserving pharmacologic options are reviewed in detail. Selective estrogen receptor modulators such as clomiphene citrate and enclomiphene increase endogenous testosterone production while maintaining spermatogenesis. Enclomiphene is highlighted for fewer estrogenic side effects and superior sperm parameter outcomes compared with traditional clomiphene. Aromatase inhibitors are discussed as cost-effective options for obese men or those with elevated estradiol, with attention to bone health monitoring. Gonadotropin therapy, including human chorionic gonadotropin and follicle-stimulating hormone, is presented as effective but costly and reserved for select clinical scenarios.

Dr. Köhler provides a practical, lab-driven treatment framework emphasizing individualized therapy based on fertility goals, hormone profiles, cost considerations, and tolerance of side effects.

About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.