Testicular failure

Definition

Testicular failure occurs when the testicles cannot produce sperm or male hormones, such as testosterone.

Alternative Names

Primary hypogonadism - male

Causes

Testicular failure is uncommon. Causes include:

Certain medicines, including glucocorticoids, ketoconazole, chemotherapy, and opioid pain medicines
Diseases that affect the testicle, including hemochromatosis, mumps, orchitis, testicular cancer, testicular torsion, and varicocele
Injury or trauma to the testicles
Obesity
Genetic diseases, such as Klinefelter syndrome or Prader-Willi syndrome
Other diseases, such as cystic fibrosis

The following can increase the risk of testicular failure:

Activities that cause constant, low-level injury to the scrotum, such as riding a motorcycle or bicycle
Frequent or heavy use of marijuana
Undescended testicles at birth

Symptoms

Symptoms depend on the age when testicular failure develops, either before or after puberty.

Symptoms may include:

Decrease in height
Enlarged breasts (gynecomastia)
Infertility
Loss of muscle mass
Lack of sex drive (libido)
Loss of armpit and pubic hair
Slow development or lack of secondary male sex characteristics (hair growth, scrotum enlargement, penis enlargement, voice changes)

Men may also notice they do not need to shave as often.

Exams and Tests

A physical exam may show:

Genitals that do not clearly look either male or female (usually found during infancy)
Abnormally small, firm testicles
Tumor or an abnormal mass in the testicle or the scrotum

Other tests may show low bone mineral density and fractures. Blood tests may show a low level of testosterone and high levels of prolactin, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). These hormone levels determine if testicular failure primary or secondary (due to a pituitary gland problem).

If your concern is fertility, your health care provider may also order a semen analysis to examine the number of healthy sperm you are producing.

Sometimes, an ultrasound of the testes will be ordered.

Testicular failure and low testosterone level may be hard to diagnose in older men because testosterone level normally decreases slowly with age.

Testicular failure and low testosterone level also may be hard to diagnose in obese men. This is because obesity lowers a carrier molecule for testosterone called sex hormone binding globulin (SHBG). The free testosterone level in the blood is usually normal in obese men who do not have testicular failure.

Treatment

Male hormone supplements may treat some forms of testicular failure. This treatment is called testosterone replacement therapy (TRT). TRT can be given as a gel, patch, injection, or implant.

Avoiding the medicine or activity that is causing the problem may bring testicle function back to normal.

Outlook (Prognosis)

Many forms of testicular failure cannot be reversed. TRT can help reverse symptoms, although it may not restore fertility.

Men who are having chemotherapy that can cause testicular failure should discuss freezing sperm samples before starting treatment.

Possible Complications

Testicular failure that begins before puberty will stop normal body growth. It can prevent adult male characteristics (such as deep voice and beard) from developing. This can be treated with TRT.

Men who take TRT need to be carefully monitored by their provider. TRT may cause the following:

Enlarged prostate, leading to difficulty urinating
Blood clots
Changes in sleep and mood
Changes in good cholesterol (HDL)
Blood becomes too thick (polycythemia)

When to Contact a Medical Professional

Contact your provider for an appointment if you have symptoms of testicular failure.

Also, contact your provider if you're on TRT and you think you're having side effects from the treatment.

Prevention

Avoid higher-risk activities if possible.

Remain active and prevent weight gain as you get older.

References

Morgentaler A, Zitzmann M, Traish AM, et al. Fundamental concepts regarding testosterone deficiency and treatment: international expert consensus resolutions. Mayo Clin Proc. 2016;91(7):881-896. PMID: 27313122 pubmed.ncbi.nlm.nih.gov/27313122/.

Schlegel PN. Clinical management of male infertility. In: Robertson RP, ed. DeGroot's Endocrinology. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 113.

Swerdloff RS, Wang C. The testis and male hypogonadism, infertility, and sexual dysfunction. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 221.

US Food and Drug Administration website. FDA drug safety communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use. www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-cautions-about-using-testosterone-products-low-testosterone-due. Updated February 26, 2018. Accessed May 29, 2023.