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These agents suppress the hypothalamic\u2013pituitary\u2013gonadal (HPG) axis, leading to reduced intratesticular testosterone levels and impaired spermatogenesis. This review examines the pathophysiological mechanisms underlying azoospermia and outlines therapeutic strategies for recovery. Azoospermia is categorized into pretesticular, testicular, and post-testicular types, with a focus on personalized treatment approaches based on the degree of HPG axis suppression and baseline testicular function. Key strategies include discontinuing ET and monitoring for spontaneous recovery, particularly in patients with shorter durations of ET use. For cases of persistent azoospermia, gonadotropins (human chorionic gonadotropin [hCG] and follicle-stimulating hormone [FSH]) and selective estrogen receptor modulators (SERMs), such as clomiphene citrate, are recommended, either alone or in combination. The global increase in exogenous testosterone use, including testosterone replacement therapy and AAS, underscores the need for improved management of associated azoospermia, which can be temporary or permanent depending on individual factors and the type of testosterone used. Additionally, the manuscript discusses preventive strategies, such as transitioning to short-acting testosterone formulations or incorporating low-dose hCG to preserve fertility during ET therapy. While guidelines for managing testosterone-related azoospermia remain limited, emerging research indicates the potential efficacy of hormonal stimulation therapies. However, there is a notable lack of well-structured, controlled, and long-term studies addressing the management of azoospermia related to exogenous testosterone use, highlighting the need for such studies to inform evidence-based recommendations.<\/jats:p>","DOI":"10.4103\/aja2024104","type":"journal-article","created":{"date-parts":[[2025,1,17]],"date-time":"2025-01-17T03:00:14Z","timestamp":1737082814000},"page":"330-341","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":6,"title":["Clinician\u2019s guide to the management of azoospermia induced by exogenous testosterone or anabolic\u2013androgenic steroids"],"prefix":"10.4103","volume":"27","author":[{"given":"Manaf Al","family":"Hashimi","sequence":"first","affiliation":[{"name":"Global Andrology Forum, 130 West Juniper Lane, Moreland Hills, OH 44022, USA"},{"name":"Department of Urology, Burjeel Hospital-Abu Dhabi, Abu Dhabi, United Arab Emirates"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Germar-Michael","family":"Pinggera","sequence":"additional","affiliation":[{"name":"Global Andrology Forum, 130 West Juniper Lane, Moreland Hills, OH 44022, USA"},{"name":"Department of Urology, Innsbruck Medical University, Innsbruck 6020, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rupin","family":"Shah","sequence":"additional","affiliation":[{"name":"Global Andrology Forum, 130 West Juniper Lane, Moreland Hills, OH 44022, USA"},{"name":"Division of Andrology, Department of Urology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra 400050, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashok","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Global Andrology Forum, 130 West Juniper Lane, Moreland Hills, OH 44022, USA"},{"name":"Cleveland Clinic, Cleveland, OH 44195, 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