Human Chorionic Gonadotropin
Human chorionic gonadotropin (HCG) has essentially the same hormonal action as luteinizing hormone (LH), the signal from the pituitary gland to tell the testicles to make testosterone. Since HCG works by increasing LH activity, if the LH is already elevated—indicating Leydig cell dysfunction—then HCG will not be as effective. In men with a baseline LH over 20 IU/L, HCG is not likely to work very well.
HCG is the strongest medication available to increase endogenous production of testosterone. It is also the most expensive choice and needs to be given by injection, which is why it is typically used only when clomiphene and anastrazole have not been effective. Like clomiphene, HCG can increase estradiol to abnormally high levels in some men.
A common question is whether HCG is more effective than clomiphene or anastrazole. Remember that these medications do not directly improve sperm quality, but rather exert their effect by increasing testosterone production (and, in the case of clomiphene and anastrazole, possibly FSH levels if these are low). Therefore, a man whose testosterone is pushed back up into the normal range by either clomiphene, anastrazole, or HCG should have the same potential clinical benefit to sperm quality. However, HCG is a more powerful medication in the sense of driving increased testosterone production, and therefore it may be effective in men whose testosterone levels have not risen sufficiently with clomiphene or anastrazole. Another difference is that, unlike clomiphene and anastrazole, HCG does not increase FSH production, although this should not matter clinically in men whose FSH is already elevated.
Commercial availability of HCG
Commercially, HCG comes in several different formulations. In men, generic HCG, Pregnyl, and Novarel are most commonly used. The three are essentially equivalent in terms of dosing and potency. All three of these medications use HCG extracted from the urine of pregnant women. Other forms of HCG that are less commonly used in men include Ovidrel, Follutein, Profasi, Choragon, and Choropex. Note that blood LH levels often do not increase in men taking HCG, as the exogenous hormone does not display much cross-reactivity with most commercial laboratory assays.
HCG is not available at most local pharmacies due to a nationwide shortage, and typically needs to be ordered through specialty pharmacies. The shortage is attributed to the popularity of a HCG as a weight-loss supplement, despite controlled studies failing to show any evidence that HCG use actually enhances weight loss. Currently, the FDA deems as fraudulent the marketing of HCG as a weight loss enhancement. The popularity of HCG has also risen through its use by “rejuvenation” clinics for men seeking an improved quality of life and/or sexual function, as well as body builders, who often use HCG between cycles of anabolic steroid use to maintain testicular function.
HCG may be covered by your insurance company, but if you do not have insurance coverage for your medications, the pricing of HCG from some regional and fertility-specific pharmacies is reviewed in the "Fertility Medications Cost" section of this website.
How HCG Is Used
HCG must be given by injection, either intramuscular (IM) or subcutaneous (SQ). Protocols for injection schedules differ, but most experts recommend three times per week. A typical starting dosage is 2,000 IU three times per week. As with clomiphene and anastrazole, I usually recommend follow-up testing two weeks after starting HCG, or two weeks after any change in dosage or medications. Dosages can then be adjusted depending on the findings of the follow-up blood hormone tests.
HCG dosages can vary widely, from 500 IU to 4,000 IU three times a week. Here is a sample range of dosages:
• 500 IU three times a week
• 1,000 IU three times a week
• 1,500 IU three times a week
• 2,000 IU three times a week (typical starting dosage)
• 2,500 IU three times a week
• 3,000 IU three times a week
• 3,500 IU three times a week
• 4,000 IU three times a week
Most men taking HCG do not have any adverse side effects and may even feel better at the higher testosterone levels. However, some uncommon adverse side effects can occur, including:
2) Gynecomastia (male breast enlargement; this is rare if estradiol levels are followed and kept in the normal range)
3) Weight gain
6) Acne (due to increased skin gland oil production; usually subsides after a few months of treatment)
8) Restlessness or insomnia
10) Mood changes (depression, irritability)
11) Pain at the injection site
If you experience significant negative side effects, it is best to stop the medication and contact your doctor for further guidance.