Part 2 of the TRT Fertility Playbook: The hMG Masterclass.
Everyone knows about hCG but very few know and even less care about hMG.
As well as your Leydig cells you have Germ cells and Sertoli cells.
Both of these cells live in the seminiferous tubules which make up over 3/4s of your testes. The Leydig cells live in the interstitial space which is the space between the tubules.
Because hCG only acts on the Leydig cells, your testes will never be the same volume as they were previously without hMG due to this anatomy.
Your Germ cells have no androgen receptors and are dependent on your Sertoli cells. When on hCG, just enough testosterone stay in the tubules for the Sertoli cells to maintain minimal fertility.
High ITT allows early spermatogensis to continue more or less normally. But the maturation stage where the problems occur.
Enter hMG.
hMG binds to the FSH receptors on Sertoli cells. Which makes them produce Androgen Binding Protein (ABP).
ABP does exactly what it says on the tin. It traps the testosterone in the tubules to make sure there’s high and stable levels of testosterone where the Germ cells need them - with hCG these levels are not stable or high.
Constant FSH stimulation keeps the structure of the tubules, preventing long term permanent fibrosis you get after years of no FSH activity.
Sperm cycles last 74 days. No matter what you do this cannot be changed.
Testosterone starts the engine. Waking up dormant cells to start sperm production. With hCG alone many of these will die. FSH activity from hMG allows the cells to support massive amounts of sperm maturation.
Sperm need a specialised “cap” to pierce the egg called an acrosome - hCG alone gives them rounder, smooth heads.
The nucleus inside the sperm head needs to be condensed and secure - hCG alone leaves this less secure.
They need long and strong tails to swim - hCG alone results in short/bent/coiled tails.
Sperm need to lose the cytoplasm from when they were round cells - hCG alone results in more of this hanging around making them more sluggish.
A sperm sample for someone on hCG alone can show normal volume and sperm concentration, but poor motility and morphology.
hCG + hMG will have the same results as someone who is natural. Maybe even better if you bump the dose up.
Unlike for hCG and ITT levels we dont have data to give equivalent to baseline information.
Standard fertility protocols prescribe 75-150iu of hMG 2-3 times a week. This is a brute force method.
Physiologically both FSH and LH are released in small, frequent pulses. Not massive doses. The terminal half life of hMG is ~50 hours so big doses create overlapping concentrations which results in receptor internalisation.
Just like hCG you want to do EOD or even daily dosing for optimal.
Something like 37.5 EOD would be more than adequate to get someone back to baseline fertility.
From there you could switch to 25iu daily or EOD as maintenance. You could even get away with 15iu daily - only a sperm sample after 3 months would tell you if it’s enough.
Actual hMG usually comes in 75iu or 150iu vials. Whatever strength you get, it provides a 1:1 ratio of FSH and LH activity. Meaning 75iu contains 75iu of FSH and 75iu of hCG etc.
hMG brands like Menopur also usually come with sterile water as the dose is normally used all at once. If you split doses you’ll need to use BAC to prevent contamination.
There is also recombinant FSH (rFSH). This is 100% FSH only. No LH activity or hCG. But it is very expensive and usually comes in pens.
So do you NEED hMG? No, not really.
Plenty of men are entirely fertile
with just hCG. But hMG is the missing piece of the puzzle for complete fertility.
hCG has clear secondary benefits for neurosteroids. FSH/hMG activity is very localised to your testes. But we have no idea what decades of zero FSH activity does (except fibrosis).
All in all, taking hCG will give you some juicy grapes. Adding in hMG will give you grapefruits.
Okay hCG masterclass for the people.
Exogenous androgens whether its just TRT or full on blasts will shut down your HPG axis we all know this. This means no signal to your testicles to keep making testosterone as there's plenty in the system.
Most people think hCG is only use to "keep your balls big" or just to "preserve fertility" and it's not quite that simple although both do occur.
hCG is made up of 2 parts, an alpha and beta subunits. The alpha subunit is exactly the same for hCG, FSH, LH and TSH. The beta subunit is what allows allows it to be specific for the LH receptors in the Leydig cells and prevents its breakdown.
Small caveat hCG can technically bind to the TSH receptor due to the same alpha receptor. However, the binding is incredibly weak - like 1/4000th of actual TSH. Unless you're taking doses of 5000iu+ in one go this isn't at all a problem.
Endogenous LH has zero cross reactivity with the TSH receptor and hCG has zero cross reactivity with FSH receptor.
Once hCG binds to the LH receptors in the Leydig cells it activates cAMP, PKA blah blah intracellular mechanisms. The aim of the game is to express the Steroidogenic Actue Regulatory (StAR) protein. This is what allows the cells to produce testosterone.
But that's not where it starts. The first step is to force cholesterol into the mitochondria and create pregnenolone - the mother hormone.
It is pregnenolone that then gets converted into progesterone or DHEA, the latter then eventually becomes your testosterone. The progesterone has a massive role in regulating your CNS.
The binding of hCG to the LH receptors is also what leads to synthesis of aromatase enzyme. It's famously known that AIs do not work to block the aromatase in your testes, but why?
The concentration of testosterone in your bloodstream is much much lower than the concentration in your testes. The AIs have no problem saturating aromatase in fat and muscle. But they are simply outcompeted when it comes to the testes. Especially when you consider how little of your oral dose will get to your testes in the first place.
Now onto the fertility side of things. Your intratesticular testosterone (ITT) levels need to be like 100x higher than that in your bloodstream for sperm production. hCG allows this to take place and your Leydig cells pump out testosterone into the interstitial space.
A hCG only protocol prioritises raw sperm yield over optimal quality because of the lack of FSH. ITT prevents the death of sperm getting them through the first couple of phases giving you a viable sperm count.
FSH is what allows phase 3 to take place which is essentially quality control - building the head and tails of the sperm properly. But hCG has no FSH activity and therefore no Sertoli cell activation so sperm counts are good but sperm quality isnt the best. But usually still enough for most men to be fertile (you can always do a sperm analysis to check if curious).
So if there's no FSH how do any sperm make it alive?
The testicles are separated into 2 main compartments. The interstitial space where your Leydig cells are, and the seminiferous tubules where the Sertoli cells and Germ cells are.
Normally FSH stimulates Sertoli cells which produce Androgen Binding Protein (ABP) which traps testosterone inside the tubules. Without endogenous FSH or exogenous hMG, ABP production is zero.
However, because ITT is so high, some of this testosterone will still make it through. And although its not bound in the tubules by ABP, enough diffuses through to bind to the androgen receptors on Sertoli cells and get the absolute bare minimum nursing required to keep some sperm alive.
The downside is that after a decade or more of zero FSH activity, your tubules will develop fibrosis and scarring which is permanent. hMG or coming off is the only way around this but most people dont actually care about that which is fine.
Another benefit of taking hCG is that whilst it has zero FSH activity, just the act having high ITT levels will protect the tubules for longer compared to having no LH and FSH.
Luckily, if you don't take hCG for years and years, theres no scarring or fibrosis that takes place. Your Leydig cells can stay dormant for a long long time waiting for the signal to turn back on. Because Leydig cells will still involute, the longer they are in this state the longer the revival takes.
It's not all sunshine and rainbows though. Over decades, a lack of hCG or LH will and subsequent lack of neurosteroids like pregnenolone and progesterone, your CNS will likely suffer due to the protective nature of these hormones. How much this translates in reality though we simply don't know. Might not be noticeable for some, might be quite bad for others.
Now onto dosing. Endogenous LH has a half life of 20-30m and is released every 60-90minutes. hCG has a half life of 24-36 hours.
Bolus dosing like 250-500iu three times a week is the standard, and its fine for almost everyone.
If you truly wanted to optimise though, you would go for daily dosing to try and mimic endogenous LH as much as possible.
125iu EOD produces ITT around 25% below baseline.
250iu EID produces ITT around 7% below baseline.
500iu EOD produces ITT around 25% above baseline. - this can drive massive aromatisation too.
100iu daily produces ITT around 12% below baseline.
150iu daily produces ITT around exactly baseline.
200iu daily produces ITT around 12% above baseline.
250iu daily prodcues ITTaround 25% above baseline.
Fertility protocols usually prescribe 1000-3000iu hCG 2-3 times a week to drive massive ITT concentrations and wake up the cells. Sperm life cycles are 74 days so usually a minimum of 3 months is required to get some functional sperm.
In actual fertility protocols you're also usually prescribed hMG for more viable sperm.
Onto Leydig cell desnesitisation. Massive doses of 1000iu+ push cells into overdrive. This not only results in massive aromatisation but produces reactive oxygen species (ROS) and subsequent internalisation of the LH receptors to protect itself.
To balance out the ROS you can take antioxidants like NAC. Injectable glutathione can also help (dont inject into your balls please).
Last but not least I'll talk about the 'shooting strings' phenomenon. Many people report that their ejaculate is more stringy and kinda dense. Now while this may seem cool, it doesn't mean you have super sperm.
Your seminal vesicles produce 3/4s of your ejaculate volume and contain semenogelin - the protein causing the gel-like structure. Your prostate produces the rest of the volume providing zinc and PSA which breaks down semenogelin to liquify it as much as possible.
If your hCG dose is a bit high, too much ITT can result in too much semenogelin and not enough PSA to match, resulting in ejaculate thats more stringy and less liquidy. This can trap sperm as its very thick.
Not saying your sperm won't get to where they need to go, because higher ITT also means more sperm overall. Adding in hMG ofc will also help the quality of the sperm and help the PSA production.
Bonus points if you actually read all of this. If there's any other topics you want me to break down like this mention it below and I'll consider it.