Anabolic steroid misuse and male infertility: management and strategies to improve patient awareness

ABSTRACT

Introduction: Anabolic androgenic steroid use is an uncommon but important cause of male infertility. As paternal age and anabolic steroid use increases, providers are more likely than ever to encounter men with infertility and prior or concurrent anabolic steroid use. In this review, we outline the background, epidemiology and pathophysiology of anabolic steroid induced male infertility and provide recommendations regarding the diagnosis, management, and future prevention of this condition.

Areas covered: Male reproductive physiology is a tightly regulated process that can be influenced by exogenous sources such as anabolic steroids and selective androgen receptor modulators (SARMs). Data suggest that a combination of selective estrogen receptor modulators (SERMs), human chorionic gonadotropin (hCG), aromatase inhibitors (AIs), and recombinant follicle-stimulating hormone (rFSH) may lead to spermatogenesis recovery.

Expert opinion: Anabolic steroid and SARM users continue to exhibit lack of understanding regarding the potential side effects of their use on male fertility. Current literature suggests that spermatogenesis can be safely recovered using a combination of SERMs, hCG, AIs and rFSH although additional studies are necessary. While anabolic steroid prevention strategies have largely been focused on the individual level, further investigation is necessary and should be approached in a socioecological manner.

KEYWORDS:

• Anabolic androgenic steroids
• clomiphene citrate
• human chorionic gonadotropin
• hypogonadism
• male infertility
• selective androgen receptor modulators
• selective estrogen receptor modulators
• spermatogenesis
• testosterone
• testosterone replacement therapy

Article highlights

• Anabolic androgenic steroid use is an important cause of male infertility that physicians should be aware of.

• The hypothalamic pituitary gonadal axis is a finely tuned process that is easily influenced by exogenous anabolic steroid use which leads to impaired spermatogenesis and male infertility.

• The majority of anabolic steroid users are unaware of the fertility side effects associated with its use.

• Chronic anabolic steroid use has been linked with myocardial infarction, cardiomyopathy, accelerated atherosclerosis, stroke and premature death.

• Anabolic steroid users can be categorized into four separate groups: the YOLO (You Only Live Once) type, the Athlete type, the Well-Being type, and the Expert type.

• A growing preoccupation on male body image and increasing social media use among men may contribute to the rising prevalence of anabolic steroid use.

• Selective androgen receptor modulators are a new class of performance and image enhancing compounds being misused by men and can have similar side effects of hypogonadism and male infertility.

• While data regarding the management of anabolic steroid induced infertility is limited, studies suggest that the use of SERMs (clomiphene citrate), hCG, anastrozole, and rFSH may have success with spermatogenesis recovery although some patients may experience permanent dysfunction of the HPG axis following steroid use.

Although anabolic steroid prevention tactics have been enacted, the prevalence of steroid use appears to be on the rise. Future prevention efforts may be more successful if a socioecological approach is utilized, targeting not just individuals but multiple ecological levels including social network, institutional, community and societal.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.