T Nation

Help Hack My TRT


#1

OK, new guy trying to hack my current, just-begun TRT approach.

My Uro:
--has recommended TRT for a few yrs but have held off until now because of fertility issues.
--says indirect via clomid won't work b/c natural FSH already pegged high to no avail
--just wrote Rx for 100mg/wk cyp IM, targeting 700-800 total T.
--when asked about HCG/HMG to preserve testicular size & sperm count, said not good because requires EOD IM injections (=hassle) & insurance probably won't pay.
--soft-pedaled concerns about shrinking testes and ejac volume, saying he doesn't see it much in his pts & not big concern b/c not boosting above physio levels.
--says doesn't measure free T because calculation via Total T & SHBG levels give more accuracy than the typical direct assays
--doesn't want to do Arimidex unless/until E2 levels become concern...leery b/c of side fx, also says AI not a natural hormone like T, and therefore is more of an intervention than merely supplementing T.

We'll see how I do on the main TRT regimen... but what (if anything) is the best way to preserve the boys, ejac volume & swimmers--HCG? HMG? Clomid? nolvadex? Something else? Already saw from reading here that HCG could go subQ, which I'd be OK with doing EOD

If my doc isn't receptive to mods, is there a good SF/Oakland/norcal alternative who might take insurance?


Here are the vitals/history/labs as asked for in the noob sticky:

-age 41
-height 6'2"
-waist 40"
-weight 230

-describe body and facial hair: tall, overweight [but no longer obese], somewhere between meso and endo type. Full beard/mustache, fairly hirsute overall.

-describe where you carry fat and how changed: primarily abdominal, also back, face, upper thighs. I recently lost 115 lbs thru eating LCHF & walking, but am sorta stuck with another ~30 lb yet to go (stubborn beer gut)... which I hope TRT will help resolve.

-health conditions, symptoms [history]:
History of classic "diabesity"--ie., borderline T2D fasting BG, morbidly obese, high blood pressure, lower leg edema. Also severe obstructive sleep apnea, GERD, frequent URIs, migraines, fatigue, low libido & mild depression.

All of the above symptoms have largely disappeared with weight loss, except for the low libido, depressive outlook and motivational issues. Low T (in ~330 range) was confirmed 3 years ago and remains low; I now suspect it's been an issue for much longer. I apparently have one testicle w/ abnormally low volume--possibly related to varicocele and birth-related physical trauma.

-Rx and OTC drugs, any hair loss drugs or prostate drugs ever:
No to last 2 items. Prior to changing diet, I took many meds--ssri, ppi & bulk antacids, beta-blocker, nasal decongestant sprays--but weaned off all in 2011 as I lost weight and am drug free since start of 2012. I have zero history with any kind of AAS cycling but did once take Clomid for about 5 weeks (see below).

-lab results with ranges
December 2009 (NB: body weight 325lb)

E2 43 pg/mL [10-50]
FSH 9.2 mIU/mL [2-12]
LH 6.5 mIU/mL [<10]
TSH 2.28 uIU/mL [0.40-4.0]
Prolactin 7 ng/mL [2.6-13.1]
Total T 338 ng/dL [200-1200]
PSA 0.5 ng/mL [<4.00]
SHBG 20 nmol/L [10-60]


Feb 2010 (NB: body weight 330lb and after TAKING CLOMID 50mg EOD for 5 weeks)

E2 51 pg/mL [10-50]
FSH 14.0 mIU/mL [2-12]
Total T 701 ng/dL [200-1200]

Fasting BG: 105 mg/dL [70-100]
TChol 262 mg/dL [0-199]
Triglycerides 208 mg/dL [20-150]
LDL (direct measured) 205 mg/dL [<130]
HDL 33 mg/dL [>35]

I stopped clomid in Feb 2010 and haven't taken it since


June 2012--baseline before TRT (body wt 230lb):

E2 40 pg/mL [20-75]
FSH 14.7 mIU/mL [1.3-19.3]
LH 3.1 mIU/mL [1.2-8.6]
TSH 1.74 mIU/L [0.45-4.5]
Prolactin 2.0 ng/mL [2.6-13.1]
Total T 341 ng/dL [175-781]
PSA 0.36 ng/mL [0.00-4.00]
SHBG 38.70 nmol/L [13.3-89.5]
Free T (calc) 61.8 pg/mL

August 8: began T cyp IM 100mg/wk


Aug 31 2012--3 weeks into TRT 100mg/wk (body wt 230lb):

E2 not reported
FSH not reported
LH not reported
TSH 1.73 mIU/L [0.45-4.50]
T4, Free 0.98 ng/dL [0.60-1.20]
Prolactin not reported
Total T 764 ng/dL [175-781]
PSA not reported
SHBG not reported

Fasting BG: 94 mg/dL [70-100]
HbA1c 5.1% [4.6-6.2]
TChol 208 mg/dL [0-199]
Triglycerides 35 mg/dL [20-150]
LDL (Friedewald calc) 155 mg/dL [<130]
LDL (Iranian calc) 113
HDL 46 mg/dL [>35]

Sep 5 2012 - began 250IU hCG SQ EOD to combat receding & pain


Sep 12 2012--5 weeks into TRT 100mg/wk & 1wk of 250IU hGC EOD (body wt 230lb):
This is day 7 just before weekly T injection
E2 44 pg/mL [20-75]
FSH 0.4 mIU/mL [1.3-19.3]
LH <0.2 mIU/mL [1.2-8.6]
Total T 615 ng/dL [175-781]
SHBG 40.8 nmol/L [13.3-89.5]
Free T (calc) 118 pg/mL


Sep 13 2012--5 weeks into TRT 100mg/wk & 1wk of 250IU hGC EOD (body wt 230lb):
This is 1 day (24h) after weekly T injection
E2 48 pg/mL [20-75]
FSH 0.6 mIU/mL [1.3-19.3]
LH 0.2 mIU/mL [1.2-8.6]
Total T 776 ng/dL [175-781]
SHBG 41.6 nmol/L [13.3-89.5]
Free T (calc) 154 pg/mL

-describe diet:
from 2000-3500 total daily calories, 66% fat, 12-15% protein, total carbs capped at 50-100gr/day
whole meats, fish, nuts, eggs, low-starch vegetables, low-glycemic fruit, fermented full-fat dairy;
NO grains, bulk sugars, milk/soda/fruit juice, corn, legumes, soy, vegetable oils, or processed food.
I try for organic/pastured stuff, but am not fanatical about it. If it comes in a box or has more than 3-4 ingredients, I probably don't eat it. My natural tendency is to fast ~20 hours and consume bulk of calories in one evening "window".

-describe training:
I hike, a LOT. Started walking daily along with diet change and worked up to longer distances & hills. Currently I walk up a steep 4.5-mile trail and back down 3-5x per week (2500' gain with most of it in 1st & last miles) and do a flat 6-miler other nights with the wife. I just hit 1000 total miles for the year. I don't lift, but I know I should--legs look great; upper body, not so much. I don't run or do any "chronic" max-HR cardio, nor do I intend to. With weight plateauing, however, I do plan to start HIIT (sprinting or hill repeats) approx once/wk.

-testes ache, ever, with a fever?
EDIT 8/17: 2 weeks in, am experiencing aching and pullback...no fever though.
EDIT 9/21: hCG has helped some with these symptoms

-how have morning wood and nocturnal erections changed
reliable MW, dunno about nocturnal.

EDIT 9/6: update labs, add lipid panels.
EDIT 9/21: update labs.


#2

I agree with pretty much everything your doctor has stated. Good starting point, IMO. Know the symptoms of high E2 and need for HCG, and adjust as needed if the situation arises.


#3

Congratulations on your huge transformation, well done!
What is your fasting glucose like ?
Regarding ejac volume, I had a vasectomy a few years back and before TRT, Doc said sperm is actually
only 2-3% and you won’t see a real difference. Now, I was never Peter North, but I did see a reduction.

After a year of TRT, and no HCG I have not seen a further reduction.
Your E2 at 40 looks a bit on the high side, now that you are adding 100mg/wk of Test that # will most likely
rise. I would keep an eye on it, and look up the symptoms of high E2.
Keep up the great work!


#4

^ Peter North reference…awesome


#5

[quote]PKNY wrote:
Congratulations on your huge transformation, well done!
What is your fasting glucose like ?
Regarding ejac volume, I had a vasectomy a few years back and before TRT, Doc said sperm is actually
only 2-3% and you won’t see a real difference. Now, I was never Peter North, but I did see a reduction.

After a year of TRT, and no HCG I have not seen a further reduction.
Your E2 at 40 looks a bit on the high side, now that you are adding 100mg/wk of Test that # will most likely
rise. I would keep an eye on it, and look up the symptoms of high E2.
Keep up the great work![/quote]

Thanks for the responses… I do feel far healthier & younger down 115lbs, and the only real disappointment was that my T numbers didn’t improve with the rest. But I guess you can’t fix everything with diet, and it seems my low T has a concrete physical cause (varicocele, birth injury, hypotrophy).

I’m now on 2nd week of 100mg/wk test cyp IM…so far clinic nurse has injected for me using 3mL/21g. I found that the quad site was very sore for 4-5 days, but dorsogluteal is feeling much better 2 days in, if harder to do solo. Still curious about SC injection route–and smaller needles regardless.

I hear you on the ejac volume issue, thx for confirming…and will be checking blood levels in a few wks and presumably responding to E2 if it starts spiking up.

My biggest concern right now is TRT-induced testicular shutdown. I’m already feeling some aching and scrotal “drawback”, and I feel strongly that I’d like some add-on therapy to preserve native HPTA/endocrine function and some degree of fertility.

HMG seems ideal, but expensive as hell…HCG, more do-able. I’m going to approach my doc about that once I get my thinking organized. Is clomid/nolvadex/etc a third option here, or have I got their functions wrong? Still trying to assimilate a complex topic…


#6

21g needles are completely unnecessary! I use 25g for IM, and the guys who do SQ use 29g . I cycle through my delts and quads so I don’t over-do any one injection site. I’d do glutes but don’t, like you, feel comfortable doing it solo. You’re going to want hCG over a SERM as it will preserve testicular function better. Clomid does mimic LH, but no to the degree that hCG does and clomid won’t help with atrophy. As was said above, you are also going to want to keep tabs on your E2 and get an AI like anastrozole (Arimidex) if necessary.


#7

[quote]ctastrophe wrote:
Clomid does mimic LH, but no to the degree that hCG does and clomid won’t help with atrophy. [/quote]

Not really correct here…Clomid actually mimics estrogen at certain receptor sites, and the pituitary in turn cranks out more LH/FSH naturally…so it is not a mimic, it is the real deal.

Also clomid won’t help when you are on TRT because the doses you are taking suppress the pitutiary function to the point where Clomid and other SERM’s are not able to be taken in high enough doses to overcompensate for the exogenous T.


#8

Yeah, sorry, I messed that one up. Thanks for the correction.


#9

Thanks guys…looks like Clomid etc is out of the running.

You mention hCG in the context of its LH mimicry. The [prohibitively expensive] hMG appears to contain both LH & FSH, but I’m still not sure of their relative importance when it comes to preserving function. A hypothetical question, then: suppose a TRT patient happened to have a modest supply of injectable rFSH on hand. Any relevant practical uses for this (& citable precedent for same), or is controlling LH the main goal?


#10

According to the wikipedia page on hCG, it mimics both LH and FSH (and also according to its wikipedia article, TSH which I didn’t know), but I haven’t seen anything to back-up the claim that hCG also mimics FSH. And, this info is from a wiki page, so take that for what it’s worth!

Here is an article I found about a fertility study in which the men who had low LH were given hCG and the men with low LH AND low FSH were given both hCG and recombinant FSH (which I’m guessing is the rFSH you mentioned?).

http://www.nationalmedicalclinic.com/html/HCGTherapyToIncreaseFertility.html

According to this article, it looks like LH and FSH both need to be present in order to create sperm. So if hCG doesn’t mimic FSH then you will lose your sperm count after a while. I don’t know about any of this for sure as staying fertile hasn’t been a concern of mine, so I just haven’t put in the time to learn about it.

HCG is enough to keep the testicles producing hormones (testosterone, pregnenolone) and prevent them from aching and receding. I had both, and let me tell you: Receding ball pain is awful! I have never had a sperm-count taken, so I don’t even have anecdotal evidence that hCG will preserve sperm production.

“Suppose a TRT patient happened to have a modest supply of injectable rFSH on hand. Any relevant practical uses for this?”

Based on what I’ve read so far, it looks like recombinant FSH will keep you producing sperm which may or may not be important for you. Again, I have no idea if hCG alone will keep your sperm numbers rolling, but since FSH is the hormone that specifically triggers spermatogenesis, it would seem that, hypothetically speaking, taking rFSH would ramp up sperm production for someone who has insufficient amounts of FSH.

So I think that taking FSH will only serve to preserve sperm production. I can’t find anything that shows any use for FSH outside of fertility that hCG doesn’t cover already. I wish I knew more, but I’ll keep you posted if I find anything worthwhile.


#11

Just a point of clarification on LH/FSH regulation and production. I believe the hypothalamus can not measure testosterone levels directly and can only measure testosterone through measuring E2 levels- in men the product of aromatized testosterone - it assumes E2 follows T just like we do. SERMs bind the estrogen receptors in the brain and inactivate them making the hypothalamus think there is no E2 and therefore there is no testosterone. To compensate the hypothalamus produces more GnRH causing the pituitary to produce LH and FSH. AI’s work to achieve a similar outcome by simply keeping E2 levels low this limiting the feed back inhibition on the hypothalamus .

Correct me if I’m wrong…it’s been years since I took an endocrinology class.


#12

Your baseline labs show that you are very estrogen dominant. You needed anastrozole then and with lower E2, your T numbers would increase.

TSH=1.75: please read new guys sticky re iodine, thyroid and body temperatures

Your high FSH is a concern. When you do your first labs while injecting, test LH/FSH again. If FSH remains elevated, that is a symptom of an FSH producing testicular cancer. TRT should take LH and FSH to zero.

Yes AI’s reduce T–>E2 aromatization and that would affect the HPTA. But the main advantage is a more favorable FT:E2 ratio. And lower E2 leads to more FT as there will be less SHBG and less T bound to SHBG.

Read the protocol for injections sticky and start self injections with #29 0.5ml [“50iu”] insulin needles. Inject SC and avoid a lifetime off accumulated muscle damage.


#13

Wow…thanks for all the in-depth replies! You guys are giving me a lot to think about.

–I know my E2 is high. Doc didn’t rule out AI, but wants to check E2 after stabilizing on TRT.

–I’ve put in a request advising of side FX and requesting an hCG Rx

–SC vs IM: I’d prefer SC, but do you know how big a fluctuation in T levels results from changing admin route? I have it in mind to stick with IM (via the glutes using 27G x 1") to stay consistent until next blood work at the 2-month mark.

–I did wonder about my iodine, and I’ve asked doc for a full thyroid panel. I realized a while ago that I’ve been using non-iodized kosher salt and only rarely use the Morton’s. I eat a lot of canned tuna, and used to supplement with kelp pills but ran out of a while back. I’m going to grab some KI tonight to supplement.

–I edited my OP with some more labs. Not sure what to make of the implied trends (LH, prolactin, SHBG), but the '09 and '12 E2 and T baselines are pretty consistent despite my being 100 lbs lighter…TSH did fall a bit.

–I was on clomid for about 5 weeks in early 2010 and doubled my T (Feb '10 lab). However, note my FSH was lower before starting the SERM (9.2 in Dec '09). This time, I was told clomid wouldn’t work to raise T, because my 2012 pre-TRT FSH was already pegged at 14.7, just as high as it was after 5 wks clomid.

–sure hope I don’t have cancer…I thought having one undersized nad and a varicocele was enough. If runaway FSH is diagnostic, then I guess I won’t explore the idea of supplementing recombinant FSH until I have a clearer picture of what’s going on.


#14

The Thread for Iodine/Thyroid is here:

Just thought I’d link it for you since it can be difficult to find. I don’t think this thread is actually a Sticky, but it should be. The only thing mentioned about Iodine in the “Prototype” Sticky is in regards to how many Iodine Ions are in T3 and T4, which I’m guessing won’t help you out a ton.


#15

Thanks for posting that link… I did find that page, eventually, but even then I wasn’t sure it was what KSMan was referring to. I started taking KI last night.

I’m in a real state of confusion about which way to go here. It’s time for my Week #3 cyp shot, haven’t heard back from doc re: hCG yet…meanwhile my balls ache and I can barely see my ankles for the @#%$ edema (a symptom last seen 100+ lbs ago).

Inertia & some common sense says go forward with current TX until can evaluate its effects w/ actual numbers.

But reading the responses again, and having spent time digging up case studies on AI treatment of obese/oligozoospermic/low-T & low-T:E2 men (see below), I’m really beginning to wonder if AI monotherapy along with continued weight loss, a more anti-estrogenic diet and a keener focus on thyroid health might help me just as much as TRT with less disruption to HPTA.

I’m also wondering why AI was never mentioned during many months of ART despite my clear male-factor infertility and my then-morbid obesity (only clomid was suggested & tried).


Citations, with my severely edited summaries:

1: Gregoriou O, Bakas P, Grigoriadis C, Creatsa M, Hassiakos D, Creatsas G. Changes in hormonal profile and seminal parameters with use of aromatase inhibitors in management of infertile men with low testosterone to estradiol ratios. Fertil Steril. 2012 Jul;98(1):48-51.

OBJECTIVE: try 2.5 mg letrozole vs 1 mg anastrazole daily in infertile men with low T/E(2) ratios.
RESULT(S): Both drugs improved hormonal and semen parameters.
CONCLUSION(S): Men with severe oligospermia, low T, and normal gonadotropins may have a treatable endocrinopathy.


2: Patry G, Jarvi K, Grober ED, Lo KC. Use of the aromatase inhibitor letrozole to treat male infertility. Fertil Steril. 2009 Aug;92(2):829.e1-2.

RESULT(S): Testis biopsy showed normal spermatogenesis following 4 months of
letrozole therapy.


3: Roth MY, Amory JK, Page ST. Treatment of male infertility secondary to morbid obesity. Nat Clin Pract Endocrinol Metab. 2008 Jul;4(7):415-9. Epub 2008 Jun 3.

BACKGROUND: 29-yo fat guy w/ infertility & hypogonadism; had taken TRT for 4 mos, after which sperm count = 0, elevated E2:T ratio.
RESULT: Stopping TRT for 2mo & then taking anastrozole led to normalization of T, LH & FSH, suppression of E2, and to normalization of spermatogenesis and fertility


4: de Boer H, Verschoor L, Ruinemans-Koerts J, Jansen M. Letrozole normalizes serum testosterone in severely obese men with hypogonadotropic hypogonadism. Diabetes Obes Metab. 2005 May;7(3):211-5. PubMed PMID: 15811136.

BACKGROUND: Being really fat promotes T->E2. Higher E2 can knock down LH and lead to hypogonadotropic hypogonadism (HH). Can AI normalize T in fat guys with HH?
PATIENTS AND METHODS: 10 middle-aged fat guys got Letrozole 7.5-17.5 mg/wk for 6 wks.
RESULTS: E2 dropped (from 120 +/- 20 to 70 +/- 9 pmol/l) but never lower than 40. LH increased from 4.5 (+/-0.8) to 14.8 (+/-2.3) U/l. Total T rose from 7.5 (+/-1.0) to 23.8 (+/-3.0) nmol/l without a concomitant change in SHBG. Letrozole @17.5 mg/wk spiked LH too high.
CONCLUSION: Short-term Letrozole --> “normal” T in all obese men. Needs long-term study.


5: Leder BZ, Rohrer JL, Rubin SD, Gallo J, Longcope C. Effects of aromatase inhibition in elderly men with low or borderline-low serum testosterone levels. J Clin Endocrinol Metab. 2004 Mar;89(3):1174-80. PubMed PMID: 15001605.

Some older guys with borderline T (<350 ng/dl) got Adex at either 1mg/d or 2mg/wk. On average, free & total T nearly doubled while E2 dropped by more than 50% in both groups.
Conclusion: AI “increases [free & total T] to the youthful normal range in older men with mild hypogonadism […] [E2] levels decrease modestly but remain within the normal male range.”


6: Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002 Feb;167(2 Pt 1):624-9. PubMed PMID: 11792932.

Gist: Infertile men w/ low T:E2 can take AI (1mg/d) to improve T:E2 & sperm count/motility. Adex just as effective as testolactone (a far less convenient AI) unless you have Klinefelter syndrome.


7: Pavlovich CP, King P, Goldstein M, Schlegel PN. Evidence of a treatable endocrinopathy in infertile men. J Urol. 2001 Mar;165(3):837-41.
(roughly same as #6 above)


#16

OK, think I killed my thread with that last post…

Saw doc again for continued retraction/pain issue and for 4-week lab result. The latter was a major disappointment as the lab did not do many requested items incl. E2, FSH, LH, and SHBG! Somebody just dropped the ball, probably related to labor day vacations & floater techs.

–I did get my total T up to the 760’s (2 days after inject), and got some other interesting metabolic data…will update the OP.

–Cholesterol breakdown much improved despite my 65%-fat diet that conventional wisdom swears will clog my arteries and kill me ;-D

–After the comments on thyroid upthread, I began taking iodine (as KI). Wondering what would be an ideal TSH & T4?


Doc appt was mixed. I ran into some flak for taking forum/google advice…I say accepting drug-induced failure of the entire HPTA is a prime example of scientific arrogance. doc says to remember I’m not an expert, and there’s really nothing wrong with shutting down testes as they only make sperm and T. Hmm.

He doesn’t see much retraction pain with his other patients on TRT, apparently, because he was a bit skeptical of my reported symptoms (which I am definitely not making up). He eventually agreed to write me for 500IU hCG EOD. But he claimed it must be done IM, and that I’d never stay compliant because that’s such a big hassle. Yarite…I started with half that dose yesterday, SQ with 31g slin pins, which I literally cannot feel. How long should it take to restart native testicular function with hCG?

One other cool thing he ultimately did was write me a standing lab order for the basic hormonal panel so I can get a dynamic profile of my intradose levels. I will use this to get the baseline E2 the lab failed to do and also investigate weekly vs semiweekly cyp and possibly SQ vs IM.

Only piece left (I hope) is arimidex to dial in E2…which I can get online if no rx forthcoming. I’m going to stay the course until I see if I can get the TRT optimized, but I am still pretty interested in adex monotherapy. Doc didn’t have any more to say regarding my sheaf of pubmed abstracts (above) than readers here did…Anyone have direct experience with this treatment?


#17

A number of guys here have tried AI monotherapy and despite an increase in TT and Free T, and a lowering of E2, they did not respond well symptom wise. I have no clue why this is, but I can think of at least 5 guys in the same boat.

I do not recall a single success story.

It sounds like your doctor is willing to help you out with things though. Get the bloodwork done before deciding whether or not you need to worry about an AI.


#18

There was a study in 2005 where men were shutdown with 200mg/ T cyp per week, then given different doses of hCG. They measured serum T and also measured intratesticular testosterone levels [ITT] by fine needle aspiration. They determines that 250iu SC EOD roughly was a replacement dose for LH, to restore ITT levels.

SC was clinically proven. Suggest that you do 250iu EOD, NOT 500. Some men make huge amounts of E2 in their testes with higher doses and anastrozole cannot control T–>E2 inside the testes.

Yes, inject SC. The drug literature is based on women injecting 3000 or 5000iu at once to trigger ovulation for IVF egg harvesting or artificial insemination. The slower delivery of SC is preferable for men. hCG is a peptide hormone. GH and insulin peptide hormones are injected SC, not IM.

Muscles should not be subjected to decades of needle damage.


#19

Thank you both!

Kind of surprised by the negative anecdotal reports on AI monotherapy–by “symptom-wise,” I assume you mean libido/ED/energy/mood? I wonder what’s going on there, if all the numbers are improved but the subjects don’t feel any better.

Wife did IVF with many Novarel injections, so I knew SC was fine; I just decided not to argue the point with the doc after the rocky beginning of our session. I did start off with 250IU EOD, not the 500 prescribed, and it’s going into the belly area with the smallest insulin needle I can find…piece of cake, really.

I appreciate the pointer on the 2005 hCG study, which I see is available in full text online at
http://jcem.endojournals.org/content/90/5/2595.full – very informative!

I’m still doing test cyp IM (dorso glute via 1" 25G–also painless) just for the sake of consistency during initial labs. But I’d like to move to SC there too. With my standing lab order I hope to be able to compare the peak level and time profile of IM vs SC at equivalent dose…unless there’s an applicable pharmacokinetic study out there already?


#20

Another update: Have been on 250IU EOD hCG 2 weeks now and it’s helped quite a bit with the pullback and pain, but they aren’t completely gone. I was prescribed 500IU so have flexibility to bump up the dose…would it help to go up to 500IU EOD, or perhaps just do 250IU daily?

It’s been hard to get to lab as often as I’d like, but I managed to grab a day 7 and day 1 (full data added to OP). Total T at 615 after 7 days, rising to 776 24h after injection. I’m surprised the implied profile is so flat; I assumed I’d be very low on day 7 and perhaps higher right after injecting. (These labs were done in early afternoon, which is also when I inject.)

E2 is hovering mid-to high 40s…but it may go up as hCG effect reaches steady state, especially if I up the dose. I might have trouble getting an AI Rx unless my E2 goes above lab ranges, which sux as I’d like to get it around 20 and see what that does for me subjectively.

What is an ideal Total T level for TRT, anyway? Should I be happy with an afternoon peak level of 776, or shoot for ~1000? I know 100mg/wk is where most ppl start off, but how much flexibility is there in the ultimate dosages? For example, would 200mg/wk be considered reasonable, if that’s what it took to get ideal numbers, or would few doctors push it that high?