Anabolic steroid-induced hypogonadism and fertility

The testes work under instruction from two pituitary hormones, luteinising hormone and follicle-stimulating hormone. The pituitary adjusts its output according to the testosterone level it detects in the blood. When anabolic steroids raise the level artificially, the pituitary reads this as an excess and quietens down. Without LH and FSH, the testes shrink, natural testosterone falls and sperm production drops, sometimes to zero.

This is a form of secondary hypogonadism, meaning the testes are capable but are not being told to work. Paradoxically, a man can have high levels of androgens in his blood and still have symptoms of low testosterone as soon as the supply stops, because his own production has been shut down.

The NHS describes reduced sperm production and infertility, testicular shrinkage, erectile dysfunction, hair loss and breast development as consequences in men. It also warns of risks to the heart and circulation, including heart attack and stroke, liver and kidney problems, high blood pressure and high cholesterol, along with mood effects such as aggression, paranoia and manic episodes.

After stopping, the abrupt loss of androgen effect can cause low mood, tiredness, loss of drive and reduced libido. The NHS notes that these substances can be addictive and that withdrawal can bring depression, anxiety, insomnia and fatigue. Low mood after stopping should be taken seriously and discussed with a clinician.

A doctor will ask without judgement about what was taken, for how long and when it stopped, because these details determine how suppressed the system is likely to be. Examination looks at testicular size and signs of androgen effects.

• Semen analysis, repeated, to see whether sperm are present.

• Morning blood tests for testosterone, LH, FSH and often prolactin.

• Blood count (haematocrit), liver, kidney and lipid profile.

• Blood pressure and sometimes cardiac assessment, depending on history.

• Screening for low mood and anxiety.

The NHS recommends speaking to a GP if you suspect addiction, and says treatment involves referral to a specially trained drugs counsellor who can help plan safe cessation. Stopping suddenly after long use can be hard physically and psychologically, so support is advised rather than going it alone.

In many men natural testosterone and sperm production return gradually over months once the drugs are stopped, though some take a year or longer and a minority do not recover fully. Recovery tends to be slower after prolonged or high-intensity use. Repeat blood tests and semen analyses track progress.

Where fertility is the priority, endocrinologists and fertility specialists may use medicines that stimulate the testes directly, such as gonadotrophin-type treatment, which are prescribed and monitored in hospital. This is different from taking more testosterone, which would suppress sperm further. The NHS notes that testosterone replacement used in hypogonadism does not reverse infertility, which is why it is avoided in men who wish to father children soon.

If sperm remain absent despite recovery attempts, surgical retrieval and ICSI may be discussed, as for other forms of azoospermia. Sperm freezing before or after restarting medicines may also be considered.

Women who use these substances may find periods become irregular or stop and may experience facial hair, deeper voice and clitoral enlargement. Some of these effects, especially voice change, can be permanent. A pregnancy should not be attempted while taking them, and anyone who finds out they are pregnant should tell a midwife or doctor quickly.

Chest pain, breathlessness, one-sided leg swelling, yellowing of the skin, severe headaches or thoughts of self-harm need urgent attention through 999, A&E or NHS 111. A GP appointment is appropriate for fertility concerns, low mood or any worry about stopping.