HCG treatment can help or worsen sexual function and erectile dysfunction. 

HCG (human chorionic gonadotrophin) is similar to luteinizing hormone (LH) which is released from the pituitary gland and stimulates testosterone production in the Leydig cells of the testes. 

The American Urological Association (AUA) recommends using HCG for men with testosterone deficiency and infertility. Adding HCG to TRT (testosterone replacement therapy) is one of the best ways to prevent testicular atrophy (shrinkage) and maintain fertility (sperm production and sperm count). 

HCG has a half-life of 36 hours, compared to only 30 minutes for LH. This makes it a great substitute for LH and can be used every other day, instead of daily.

Since HCG is much harder to get now, doctors are prescribing gonadorelin more frequently, but it also has a short half-life and needs to be injected daily.

Testosterone and erectile dysfunction

HCG can effectively increase testosterone and testosterone can help with erections.

Testosterone helps with erections by:

1. Increasing nitric oxide production. Nitric oxide is a molecule that helps to relax the smooth muscles in the blood vessels, thereby increasing blood flow to the penis.
2. Enhancing penile sensitivity, which makes it easier to achieve and maintain an erection.
3. Stimulating libido. Having high libido helps to boost erections.
4. Increasing muscle mass, which can help support the pelvic floor that is responsible for maintaining an erection.
5. Improving mood. Testosterone helps to regulate mood, reducing anxiety, depression, and stress that can contribute to erectile dysfunction.
6. Converting stem cells to smooth muscle cells, ensures optimal penile integrity.
7. Allowing for proper relaxation of smooth muscle cells so that blood can flow into the penis.
8. etc.

Men with low testosterone levels are more likely to complain of ED and loss of spontaneous erections. However, this is only weakly associated (R).

Viagra plus TRT on erections

Meaning, when men with low T and ED go on TRT, they only notice a marginal improvement in erectile function.

In fact, the improvement in IIEF-EFD score is only 2.49 [1.61–3.36] points when men with low T go on TRT (R). 

The IIEF-5 scores range from 5 to 25, and ED was classified into five categories based on the scores: severe (5-7), moderate (8-11), mild to moderate (12-16), mild (17-21), and no ED (22-25).

So if you get a 2.49 point increase on a scale of 5 to 25, it’s something, but not that much.

PDE5i (PDE5 inhibitors like Viagra or Cialis) users usually see a 6-7 point improvement (R). Almost 3x as good as TRT.

The modest increase in IIEF-EFD score induced by TRT should be considered clinically meaningful only in patients with milder forms of ED.

However, some people are PDE5i non-responders and about 50% of them can become responders when they go on TRT (or do shockwave therapy) (R, R).

In summary, although testosterone is important for erections, it’s not the most important. Fixing testosterone naturally will boost erections to a much great extent than just injecting it.

HCG and testosterone

HCG can help to increase testosterone and maintain fertility when on TRT.

Let’s see how effective HCG is at boosting testosterone:

• 120IU was unable to increase serum testosterone in men with normal testosterone (461ng/dl) (R).
• 2,000 IU of HCG per week increased testosterone from 362ng/dL to 519.8 ng/dL (a 49.9% increase) (R).
• 1,500-2,000IU 2-3 times weekly increased testosterone into the normal range in hypogonadal men (R).
• 3,000-10,000IU of HCG every 3rd day with 25mg clomiphene citrate daily increased testosterone from 22ng/dl to 520ng/dl and 565ng/dl after 6 and 12 months respectively (R).
• 2,000IU of HCG 2-3 times per week increased testosterone from 307.36 to 422.11ng/dL.
• 1,500 to 2,000 IU 3 times weekly increased testosterone levels from 26 to 161ng/dl (R).

In summary, regular doses of 250-500IU every other day are unlikely to increase testosterone to any significant extent. However, low-dose HCG injections are effective at increasing intra-testicular testosterone, which is needed for sperm production.

Doses of 2000IU every other day are needed to increase testosterone into the mid-range (500-600ng/dl) and 4000IU daily is needed to increase testosterone into the upper range (1000ng/dl).

Such large doses are most commonly used for fertility treatment.

HCG improves erectile function

What effect does HCG have on erectile quality?

There are 4 studies that looked at that.

#1 The 1st study found that 5000IU HCG twice a week in hypogonadal men improved erections and sexual frequency (R).

HCG gave better results than placebo (47% vs 12%) and improved a higher number of sexual parameters (6/7) than placebo (2/7). Interestingly, HCG’s effect on sexual behavior did not correlate with the increase in plasma testosterone levels. 

#2 The 2nd study found that in patients who were previously on TRT, HCG monotherapy was shown to improve erections and libido without a change in testosterone levels (R). When evaluated for improvement of erectile dysfunction, low libido, and low energy, 57%, 63%, and 66% of patients reported improvement of each symptom, respectively (R).

#3 The 3rd study found that 1000-3000 of HCG (depending on how much the patient needed) twice a week increased erections and libido in 86% and 80% of patients (with testosterone >300ng/dl) respectively. No change was observed in the FSH, LH, estradiol, hematocrit, hemoglobin A1c, and PSA (R).

#4 In the 4th study, 2000IU of HCG per week increased testosterone 362 ng/dL (SD 158) to 519.8 and increase libido, energy and erectile quality in 50% of the patients after 8 months (R).

In summary, HCG is able to improve erectile quality and libido independent of testosterone.

How is HCG able to improve erections without increasing testosterone?

HCG might be able to improve erections by:

• Lowering serotonin (R). Serotonin is vasoconstrictive, so lowering it can help with vasorelaxation and vasodilation.
• Promoting thyroid function (R). Men with low thyroid function (low T3) are more likely to have ED and a lack of sexual desire (R).
• Acting on the β-adrenoceptors (R). β-adrenergic receptors mediate the relaxation of the corpus cavernosum, thus allowing for proper blood flow into the penis.
• Promoting NO release (R).
• Stimulating 5-alpha reductase and DHT production (R, R). DHT helps improve erectile dysfunction (R).
• Increasing testicular blood flow (R) and likely penile blood flow as well.

HCG might cause ED

On one side HCG might help improve erections, but on the other side, it might worsen ED. It can worsen ED by increasing prolactin (R) and estradiol.

Estradiol and ED

The testosterone-to-estradiol ratio is very important when it comes to erections.

A high estradiol-to-testosterone (E2/T) ratio is more likely to contribute to ED. The E2/T ratio had a more significant negative effect on the base of the penis compared with the tip of the penis. Moreover, if the erection time was more than 10 min, the negative effect of E2/T on penile root erection became more obvious (R, R).

This negative effect is evident even with a small 6-point difference. Men with an estradiol level of 31 were more likely to have ED than men with an estradiol level of 25pg/mL even though they had the same amount of testosterone (R).

Additionally, estradiol is an independent risk factor for ED in young eugonadal men and may be involved in the pathogenesis of organic erectile dysfunction (R).

This study found that the threshold level of serum estradiol where 32 pg/mL and above that, erectile function is negatively affected (R).

Interestingly, one of the ways Cialis improve erectile function is by lowering the estradiol-to-testosterone ratio.

10-20mg of Cialis on demand has been shown to significantly lower estradiol in men with ED (from 19.9 to 16.6ng/dL) with a parallel increase in the testosterone to estradiol ratio (26.3 to 32.6). Total or free testosterone did not change much (411.4 to 434.2ng/dL and 47.7 to 49.9pmol/L).

Erectile quality, based on the IIEF-5 score, increased from 13.7 to  25.7 (dramatic improvement) with on demand Cialis and as the T to E2 ratio improved.

This reduction in estradiol and increase in the testosterone to estradiol ratio was only seen in lean, but not obese men (BMI over 27.5kg/m2).

Why Cialis actually works

HCG on estradiol

Now that we know that estradiol can contribute to ED, let’s look at how HCG affects estrogen.

HCG has been shown to stimulate aromatase and increase total estradiol (R).

4 injections of 4000IU increased testosterone from 492 to 971ng/dl and estradiol from 33.4 to 73.4pg/ml😱 (R). They didn’t look at erectile function, unfortunately.

A client’s ED experience with HCG

I was working with a client who had PFS. We have dramatically improved his erections and penile sensitivity. He then decided he wanted to experiment with HCG to see if that would take him to the next level.

In the first week, he had great results. Felt great, had great erections, everything.

However, after that, everything went south quickly. His erectile quality declined rapidly and he lost a lot of sensitivity in his penis. He said that his penis felt like rubber. Like when the dentist numbs your gums, you can still feel, but there’s no pain. That’s how he felt.

After he quit, the feeling remained, and now we’re working on regaining what he’s lost and returning him to baseline before finasteride.

Summary

HCG can help with low sex drive and erections in a testosterone-independent manner. HCG therapy at doses of 250-500IU every other day is enough to maintain testicular size, improve/maintain testicular function and prevent male infertility. It’s also low enough not to increase testosterone or estradiol.

Doses of 2000IU every other day are needed to increase testosterone into the mid-range and 4000IU daily is needed to increase testosterone into the upper range.

But testosterone doesn’t need to be the focus here.

HCG has a >50% chance of improving sexual dysfunction and erectile dysfunction and has been used for a long time in combination therapy with testosterone in many clinics worldwide.

However, 1 of its adverse effects is that it might increase estradiol and contribute to ED, depending on someone’s predisposition.

Complementary articles:

• How to fix ED part 1, part 2, part 3, part 4 and part 5
• How to maximize your testosterone
• How to maximize your DHT
• Gonadorelin vs HCG: which is best for TRT

Check out this vid to learn more about the other potential downsides of HCG