|Are today's "muscle men" not going to be able to procreate?|
Against that background it may sound funny that researchers from the New Castle Fertility Center devoted a complete study to the analysis of drugs and protocols highlighted by the online community of users for prevention and/or mitigation of adverse effects of steroid use. If you think about it, however, it's only logical that doctors will be better able to help their patients if they understand what brought them in a situation in which they have to see a doctor at a fertility clinic.
With the ever-increasing lifetime prevalence of AAS use in men being currently estimated to be between 3 0 and 4 2% (de Souza. 2011), it is after all not unlikely that many of the future patients of fertility clinics all over the world may suffer from the long-term consequences of AAS abuse - regardless of whether they belong to those 50% of AAS userswho tell their doctor about their stroid history or not (cf. Pope. 2004). This mistrust does not exist by chance, though. As Karavalos et al. (2015) point out in the paper at hand,
"[...] mainstream academic endocrinology rather lost credibility with the ‘performance-enhancement community’ in the 1980s and 1990s, by persisting overlong in (a) doubting whether further enhancement of athletic performance could be achieved through raising serum T levels above the physiological reference range and (b) questioning whether any therapeutic separation of androgenic and anabolic actions was achievable, due to the single androgen receptor (cf. Pope. 2004)" (Karavalos. 2014).And let's be honest. Someone who actually believes that superphysiological doses of AAS were not performance enhancing might actually learn something something from the broscientific expertise of his clients... well, as long as he is willing to listen to what they have to say.
|Figure 1: Illustration summarizing the keywords (left) the scientists used to select the top 20 websites, blogs and forums (right) they researched for information on the use of AAS and means to prevent side-effects (Karavalos. 2015).|
- the methods and substances advised to counteract the side effect of hypogonadism and
- the quality of medical information and advice provided online
As I already hinted at in the introduction the information on forums consisted of anecdotal reports and advice from unverifiable sources (some claiming to be medically qualified). These sources referenced mainstream scientific papers and abstracts on the issues discussed.
"We found that online discussions and advertisements concerning agents that can be used to combat the side effect of hypogonadism are very common. There was a mixture of information available from online communities (forums), AAS user blogs and from websites attempting to sell products such as anabolic steroids and substances directly related to hypogonadal recovery. Roughly one-third of the Internet sites we reviewed also offered to sell these drugs without prescription. Information was also available from official public health websites, such as the Welsh government funded and image-enhancing drugs website (SIED Sinfo.co.uk). The later provided risk reduction advice by provid ing information on safe injection practices" (Karavolos. 2014)
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"However, there were clear flaws to this superficially ‘evidence-based approach’. The papers quoted were of only limited generalizability to AAS users, ASIH, or to the argument proposed by the ‘expert’. Equally most users were unable or unwilling to progress beyond subscription paywalls, leaving them to draw conclusions from the abstracts or the ‘expert opinion’ alone" (Karavolos. 2014).The most commonly named drugs and supplements to bring back normal endocrine and liver function were clomid or nolva, toremifene, and raloxifene, various AIs (anastrozole, letrozole and exemestane) as well as stacks consisting of milk thistle blended with a multitude of ingredients, such as vitamins (notably vitamin D), minerals (most often zinc), amino acids, herbal extracts and compounds such as L-carnitine. While the effects on the HPTA were discussed in detail, potential long-term effects on spermatogenesis were largely ignored. In fact,
The problem with this assumption is that normal spermatogenesis is associated with intratesticular T levels some 30-fold higher than serum T levels. Exogenous administration cannot deliver anything remotely approaching this requisite T concentration within the seminiferous tubules; indeed, it will tend to markedly reduce it by suppressing endogenous LH-mediated T secretion.
"[...] discussions often lead to misunderstanding the pathophysiology of spermatogenesis and its impairment, leaving users to believe that return to normal serum testosterone levels translated to normal spermatogenesis.
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In most discussions, men seemed to equate regaining endogenous steroid production to normal fertility, ignoring long-term effects on quality of sperm, such as poor morphology and motility, which might potentially be irreversible." (Karavolos. 2014).
It is hard to predict how long the natural T production will be suppressed: Aside from the drugs that were used and the duration, age appears to be an important factor, with younger users recovering significantly faster than older ones (Moretti. 2007).Of the treatments mentioned on the boards, only two have some degree of scientific backup, albeit not exactly in form of reliable long(er)-term studies on former steroid users:
- SERMs such as clomiphene, tamoxifen and raloxifene which have long been used off-label for the treatment of male gynaecomastia and infertility, for which studies show highly variable success rates ad most promising data for clomiphene or tamoxifen in the treatment of idiopathic male infertility (Chua. 2013). How many of the subjects in the studies were infertile due to AAS (ab-)use is unknown, but in view of the low number of AAS users who speak openly about their steroid history, the rate could be high.
- Chua, M. E., et al. "Revisiting oestrogen antagonists (clomiphene or tamoxifen) as medical empiric therapy for idiopathic male infertility: a meta‐analysis." Andrology 1.5 (2013): 749-757.
- de Souza, Guilherme Leme, and Jorge Hallak. "Anabolic steroids and male infertility: a comprehensive review." BJU international 108.11 (2011): 1860-1865.
- Karavolos, Stamatios, et al. "Male central hypogonadism secondary to exogenous androgens: a review of the drugs and protocols highlighted by the online community of users for prevention and/or mitigation of adverse effects." Clinical endocrinology (2014).
- Liu, Peter Y., et al. "Predicting pregnancy and spermatogenesis by survival analysis during gonadotrophin treatment of gonadotrophin-deficient infertile men." Human Reproduction 17.3 (2002): 625-633.
- Moretti, E., et al. "Structural sperm and aneuploidies studies in a case of spermatogenesis recovery after the use of androgenic anabolic steroids." Journal of assisted reproduction and genetics 24.5 (2007): 195-198.
- Pope, Harrison G., et al. "Anabolic steroid users’ attitudes towards physicians." Addiction 99.9 (2004): 1189-1194.