Clomid (clomiphene citrate) is a synthetic estrogen and anti-estrogen often used in females for ovulation. In men, it blocks the pituitary from its normal feedback, and causes a rise in FSH (follicle stimulating hormone) and LH (luteinizing hormone). This typically leads to an increase in testosterone, and hopefully an increase in sperm production. In series of patients without sperm in their ejaculates, 64% of these patients had sperm return to their ejaculate when treated with Clomid.

Based upon studies, we shoot for a testosterone in the range of 600 to 800 ng/dl. We start off with 25 mg, which is half a tablet. After two weeks, we redraw the FSH, LH, testosterone and estradiol levels, expecting them all to rise. If the testosterone is between 600 and 800 ng/dl, we continue at this dose, and repeat it again in a month or so. Spermatogenesis is a three month cycle, so we repeat the semen analysis at six weeks and three months. If the testosterone remains low, we increase to 50 mg daily, and repeat the labs in two weeks. If the testosterone is then between 600 and 800 ng/dl, we stop. If it is lower, we can increase the dose. If it is higher, we can give alternating doses of 25 and 50 mg daily.

In cases where Clomid does not work, the problem may lie in the pituitary. In cases of pituitary dysfunction, meaning a lack of FSH and LH production, we start off by giving hCG (it is an analog of LH; it looks like it and functions like it) to stimulate testosterone production. By stimulating the production of testosterone in the testes, sperm production often returns if absent, and increases when present without concomitant FSH supplementations. However, in the absence of FSH production, or in cases where we need to expedite the process, recombinant FSH supplementation can be given. The hCG and FSH are both given by self injection three times per week.