Relationship between testosterone and sexual
function in infertile men
It is well known that testosterone (T) acts on both central and
peripheral systems to help regulate libido and erectile function
. Centrally, T acts in the hypothalamus and amygdala to
modulate libido. Clearly, T therapy improves libido and sexual
. Peripherally, T targets the endothelial cells of
the trabecular arteries, increases nitric oxide synthase activity
in the trabecular arteries leading to increased nitric oxide
levels, smooth muscle relaxation, and increased penile blood
ow. Despite the elucidation of the action of T, the relationship
between serum T and sexual function remains complex
In this issue of
Fertility and Sterility
, Satkunasivam et al.
have evaluated symptoms of hypogonadism and erectile
dysfunction in a large case series of men evaluated for infer-
tility. They demonstrated that hormone abnormalities, most
notably T, are not directly associated with erectile dysfunc-
tion or decreased libido in this cohort. Interestingly, up to
one-third of men with infertility can have either low libido
or erectile dysfunction, and up to one-
fth of the men can
have both conditions. Unfortunately, Satkunasivam et al.
did not evaluate whether increasing T levels in these
men could have improved their libido and sexual function.
Medications, such as clomiphene citrate (CC) and hCG, can in-
crease serum T without affecting sperm production and there-
fore can be safely used in men with infertility. But exogenous
T, a medication known for its contraceptive potential, should
not be used for male infertility treatment
We agree with Satkunasivam et al.
that the primary
etiology of erectile dysfunction and low libido in most men
with infertility could be attributed to psychological reasons
and therefore unrelated to the serum T level. Until we can
identify the select a group of men with infertility in whom
stimulating intratesticular T production can improve semen
parameters, evaluating serum T and treating symptoms of hy-
pogonadism in men presenting with infertility is appropriate.
Ranjith Ramasamy, M.D.
Larry I. Lipshultz, M.D.
Baylor College of Medicine, Houston, Texas
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