Low Testosterone in Younger Men: Causes, Fertility Cautions and Alternatives to Testosterone Therapy

More men in their twenties and thirties are asking about testosterone. They’re tired, their drive is down, the gym isn’t paying off, and an online ad promises a fix. Sometimes low testosterone really is the problem. Often something else is driving the symptoms — and treatment choices made at 28 can have consequences at 35, especially for men who want children.

Here is how I evaluate younger men with suspected low testosterone, the fertility issue every man should understand, and the alternatives worth considering.

Confirm the diagnosis first

Testosterone levels vary through the day and are highest in the morning. A single afternoon test can be misleading. Major guidelines from the American Urological Association and the Endocrine Society recommend:

• At least two early-morning blood tests on separate days showing low total testosterone.
• Symptoms consistent with testosterone deficiency, such as low libido, erectile problems, fatigue, reduced muscle mass or low mood.
• Follow-up testing of LH and FSH to tell whether the problem starts in the testes or the pituitary, plus other lab work as indicated, such as prolactin, blood count and thyroid function.

Common causes in younger men

In younger men, low testosterone often has an identifiable and sometimes reversible cause:

• Excess weight and insulin resistance. Weight loss frequently raises testosterone.
• Sleep problems, including untreated sleep apnea and chronic short sleep.
• Medications and substances, especially opioids, heavy alcohol use and past anabolic steroid use. My addiction medicine training makes me especially alert to these.
• Pituitary conditions, including prolactin-secreting tumors.
• Genetic conditions such as Klinefelter syndrome, or prior testicular injury, infection or chemotherapy.
• Chronic illness and high stress, including overtraining with inadequate calories.

The fertility caution

This is the point I most want younger men to understand: taking testosterone suppresses your own sperm production. External testosterone signals the brain to stop sending the hormones (LH and FSH) that drive the testes. Sperm counts can fall dramatically, sometimes to zero. Recovery after stopping is common but can take months and isn’t guaranteed.

Both major guidelines advise against testosterone therapy for men who are trying to conceive in the near future. If you might want biological children, that conversation must happen before any prescription — and a referral to a urologist or reproductive specialist may be appropriate.

Alternatives worth considering

1. Treat the root cause. Weight loss, sleep apnea treatment, reducing alcohol and reviewing medications can meaningfully raise levels. For men with obesity, a medically supervised weight loss program is sometimes the most effective hormone therapy.
2. Medications that stimulate your own production. Options such as clomiphene or hCG, used off-label and prescribed by specialists, can raise testosterone while preserving sperm production in appropriate candidates.
3. Lifestyle foundations. Strength training, adequate protein and managing stress support healthy hormone levels.

When testosterone therapy is appropriate

For men with confirmed deficiency, meaningful symptoms and no near-term fertility plans, testosterone therapy can improve libido, energy, mood and body composition. The TRAVERSE trial, published in 2023, found that testosterone therapy did not increase major cardiovascular events compared with placebo in middle-aged and older men with hypogonadism and heart risk, which was reassuring. Therapy still requires monitoring of blood counts, PSA when age-appropriate, and symptoms.

Testosterone is generally not appropriate for men with untreated severe sleep apnea, a high red blood cell count, prostate or breast cancer, or uncontrolled heart failure.

Frequently asked questions

What testosterone level is considered low?

The American Urological Association uses a total testosterone below 300 ng/dL, confirmed on two morning tests, along with symptoms.

Will testosterone therapy make me infertile?

It can significantly reduce or stop sperm production. Recovery is common after stopping but can take months and isn't guaranteed.

Can weight loss raise testosterone?

Yes. In men with excess weight, losing weight often improves testosterone levels.

Are there options that preserve fertility?

Yes. Some medications stimulate the body's own testosterone production and may preserve sperm production. A specialist can advise.

Get evaluated the right way

Our hormone optimization program begins with thorough testing and a conversation about your goals, including family plans. At our Hudson location we also offer dedicated men’s health services. Start with a complimentary, no-commitment consultation.

• Hudson, OH: 50 W Streetsboro St, Suite 2 · (330) 460-5915
• Barboursville, WV: 1 Chateau Grove Ln · (304) 520-0461

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References: Mulhall JP, et al. Evaluation and management of testosterone deficiency: AUA guideline. Journal of Urology. 2018. · Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism. 2018. · Lincoff AM, et al. Cardiovascular safety of testosterone-replacement therapy. New England Journal of Medicine. 2023.

This article is for general information only and is not medical advice. Treatments are provided only after consultation and evaluation by a licensed provider. Individual results vary.