HCG (human chorionic gonadotropin) is the most common adjunct to TRT — used to maintain testicular size, preserve fertility potential, and support intratesticular testosterone production that exogenous TRT suppresses. Its role is well-established. Its supply, since the 2020 FDA reclassification, is more complicated.
Why HCG on TRT
Exogenous testosterone suppresses LH production, which causes the Leydig cells to stop producing testosterone locally. The consequences: testicular atrophy (30–50% volume reduction is typical after 6–12 months), impaired spermatogenesis, and loss of intratesticular testosterone needed for sperm maturation. HCG mimics LH, directly stimulating the testes to continue functioning despite pituitary suppression.
Current Dosing Protocols
| Goal | Dose | Frequency |
|---|---|---|
| Testicular maintenance | 250–500 IU | 2–3x per week |
| Fertility preservation | 500–1500 IU | 2–3x per week |
| Post-TRT recovery support | 1000–2000 IU | 3x per week (limited duration) |
The Supply Problem
In 2020, the FDA reclassified HCG as a biologic under the Biologics Price Competition and Innovation Act (BPCIA). This means HCG now requires a Biologics License Application (BLA) for commercial production — a far more expensive and complex regulatory pathway than the previous drug approval process. Many compounding pharmacies that previously produced HCG can no longer do so without BLA approval.
The result: reduced supply, higher prices, and periodic availability gaps. Commercial pharmaceutical HCG (Pregnyl, Novarel) remains available but at higher cost ($200–$400/month vs. former compounding prices of $50–$100/month). Some compounding pharmacies continue producing HCG under specific regulatory exceptions, but availability varies by state and pharmacy.
Alternatives When HCG Is Unavailable
HCG Alternatives
- Enclomiphene: Blocks estrogen feedback to increase endogenous LH, supporting testicular function. Available through compounding pharmacies.
- Gonadorelin: Synthetic GnRH analog that stimulates pituitary LH release. Shorter half-life means less sustained testicular stimulation than HCG.
- Kisspeptin: Upstream stimulator of GnRH. Early evidence for testicular maintenance; very limited clinical availability.
The Bottom Line
Important Adjunct, Complicated Supply
HCG remains the gold-standard adjunct for maintaining testicular function on TRT. The supply landscape has tightened since the 2020 reclassification, increasing costs and requiring patients to work with pharmacies that maintain HCG access. For men who prioritize fertility or testicular preservation, securing a reliable HCG source — or establishing an alternative like enclomiphene — should be part of the TRT planning conversation before starting.