HCG on TRT: Preserving Fertility While on Testosterone

Here's the conversation most TRT clinics skip: testosterone replacement therapy will shut down your sperm production. For men who already have children and don't want more, this may not matter. For men in their 20s and 30s who might want a family someday, it's potentially the most important thing to know.

HCG (human chorionic gonadotropin) is the primary tool for preserving fertility while on TRT. This guide covers how it works, how to use it, what it costs in Malaysia, and what alternatives exist.

Why TRT Kills Sperm Production

To understand HCG, you need to understand the HPG (hypothalamic-pituitary-gonadal) axis:

1. Hypothalamus releases GnRH (gonadotropin-releasing hormone)
2. Pituitary gland responds by releasing LH (luteinizing hormone) and FSH (follicle-stimulating hormone)
3. LH tells the Leydig cells in the testes to produce testosterone
4. FSH drives sperm production (spermatogenesis) in the Sertoli cells

When you inject exogenous testosterone, the hypothalamus detects high T levels and shuts down the entire cascade. No GnRH → no LH → no FSH → no sperm production → no intratesticular testosterone.

The result:

• Sperm count drops to near-zero within 2–3 months (sometimes faster)
• Testes shrink by 20–40% due to lack of LH stimulation
• Intratesticular testosterone (50–100x higher than serum) collapses — this is needed for sperm development

Studies show that 90% of men on TRT alone become azoospermic (zero sperm) or severely oligospermic within 6 months.

How HCG Works

HCG is structurally similar to LH. When injected, it mimics LH signaling to the testes, telling them to:

• Continue producing intratesticular testosterone
• Maintain Leydig cell function and testicular volume
• Support (partially) spermatogenesis via intratesticular T levels

HCG doesn't replace FSH, so sperm production on TRT + HCG is typically reduced but not zero. Most men maintain enough sperm production to remain fertile, though counts are lower than natural baseline.

HCG Dosing Protocol

Parameter	Standard Protocol	Notes
Dose	250–500 IU per injection	Lower doses (250 IU) are increasingly preferred to minimize estrogen conversion
Frequency	2–3 times per week	EOD (every other day) for more stable levels; M/W/F is common
Weekly total	500–1,500 IU/week	Higher doses (1,000–1,500 IU) for fertility; lower (500–750 IU) for testicular maintenance
Injection method	Subcutaneous (belly fat or thigh)	Insulin syringe, 29–31 gauge. Painless
Timing	Same days as testosterone injection or alternating days	No strong evidence for one timing over another
Storage	Refrigerate after reconstitution	Good for 30–60 days once mixed. Keep cold in Malaysia's climate

When to Start HCG

• Best: Start HCG at the same time as TRT. Prevention is easier than recovery
• Late start: Can be added after already being on TRT, but testicular recovery takes longer (4–8 weeks to see effect)
• Before TRT: Some clinics use HCG monotherapy as a first-line treatment for secondary hypogonadism (low T with low LH)

Cost of HCG in Malaysia

Item	Cost (RM)	Notes
HCG 5,000 IU vial	RM80–200	Brands: Pregnyl, Ovidac, Choriomon. Lasts 2–4 weeks depending on dose
Monthly cost	RM150–400	Depending on dose and brand
Insulin syringes	RM15–30 (box of 100)	Available at any pharmacy
Bacteriostatic water	RM20–50	For reconstitution. Available from compounding pharmacies or online

Total add-on cost to TRT: approximately RM200–450/month. This brings the total TRT cost to RM600–1,500/month when including HCG.

HCG Side Effects

• Estrogen increase: HCG stimulates intratesticular testosterone, which aromatizes to estradiol. May need estrogen management (see TRT side effects guide)
• Water retention: Mild, related to estrogen increase
• Injection site reactions: Rare with subcutaneous injection
• Desensitization: Theoretical concern with very high doses (>2,000 IU/injection). Not an issue at standard TRT-adjunct doses
• Mood fluctuations: Some men report feeling "more emotional" on HCG days — likely related to estrogen fluctuation

Alternatives to HCG

1. Enclomiphene

Enclomiphene is a selective estrogen receptor modulator (SERM) that blocks estrogen feedback at the pituitary, causing increased LH and FSH release.

• Dose: 12.5–25 mg/day
• Advantage: Oral (no injections), stimulates both LH and FSH
• Disadvantage: If used alongside TRT, the exogenous testosterone still suppresses GnRH — enclomiphene may not fully overcome this
• Best use: As a standalone TRT alternative OR during PCT (post-cycle therapy) to restart natural production
• Availability: Available at Malaysian compounding pharmacies and some men's health clinics

2. Gonadorelin

Gonadorelin is synthetic GnRH that directly stimulates the pituitary to release LH and FSH.

• Dose: 100–200 mcg subcutaneous, 2x/day
• Advantage: Mimics the body's natural signaling pathway
• Disadvantage: Requires twice-daily injections (short half-life), more expensive than HCG
• Availability: Limited in Malaysia; primarily through specialty clinics

3. FSH (Recombinant)

For men where HCG alone doesn't restore sperm production, adding recombinant FSH (e.g., Gonal-F) directly stimulates spermatogenesis.

• Cost: Expensive (RM500–1,500/month)
• Used primarily in fertility clinics for men actively trying to conceive
• Available at fertility centers in KL (e.g., Sunfert, TMC Fertility)

Coming Off TRT for Conception

If you're on TRT and want to conceive, here's the typical approach:

Option A: TRT + HCG + FSH (Stay on TRT)

• Add HCG 1,000–1,500 IU 3x/week + optional FSH
• Check semen analysis at 3-month intervals
• Some men achieve adequate sperm counts while staying on TRT

Option B: Stop TRT + Recovery Protocol

1. Stop TRT
2. Start HCG 1,000–1,500 IU 3x/week for 4–8 weeks
3. Add enclomiphene or clomiphene 25–50 mg/day to restart pituitary signaling
4. Wait: Sperm production takes 72 days per cycle. Expect 3–6 months minimum for recovery
5. Semen analysis at 3 and 6 months post-TRT

Recovery Timeline

Timeframe	Expected Recovery
1–2 months post-TRT	LH and FSH begin to recover; testosterone may be low (the "crash" period)
3–4 months	Sperm start appearing in semen analysis; counts still low
6–12 months	Most men recover adequate sperm counts for conception
12+ months	Some men need longer; 1–5% may not fully recover (especially after years of TRT)

Sperm Banking: The Insurance Policy

If you're starting TRT and there's any chance you may want children in the future, bank sperm before starting. This is cheap insurance against worst-case scenarios.

• Cost in Malaysia: RM500–1,500 for collection and initial cryopreservation
• Annual storage: RM300–800/year
• Where: Sunfert Fertility Centre, TMC Fertility, Alpha Fertility, KPJ Fertility (all in KL/Selangor)
• Process: Simple — provide a semen sample, they freeze and store it
• Viability: Frozen sperm can remain viable for decades

Availability in Malaysian Clinics

Not all TRT clinics in Malaysia routinely offer HCG as part of their protocol. When choosing a clinic, ask:

• "Do you prescribe HCG alongside TRT?" — If they say no or look confused, find another clinic
• "What's your fertility preservation protocol?" — A good clinic will have a clear answer
• "Can you order semen analysis?" — Monitoring fertility markers should be standard

Clinics that specialize in men's health and hormone optimization (rather than general GPs prescribing testosterone) are more likely to offer comprehensive protocols including HCG.

The Bottom Line

TRT without fertility consideration is reckless medicine, especially for younger men. HCG is a simple, relatively affordable addition to any TRT protocol that preserves testicular function and maintains sperm production. If your clinic doesn't discuss fertility preservation before starting you on testosterone, that's a red flag.

For men who want to optimize testosterone without any fertility risk, consider enclomiphene or natural optimization first. And regardless of your approach, get your baseline hormone panel and semen analysis before making any decisions.