HMG

What is HMG?

Human menopausal gonadotropin (HMG), also called menotropins, is a fertility medicine made from the urine of women after menopause. After menopause the pituitary gland releases large amounts of two reproductive hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and much of that passes into urine. HMG is a purified extract of those hormones. It is a glycoprotein preparation rather than a short peptide.

Urinary gonadotropins have been used in fertility treatment since the 1960s. The main product in the US today is Menopur, a highly purified HMG with both FSH and LH activity.⁵ It is used mostly in IVF and other assisted reproduction. In men, HMG is used by fertility specialists to start or restore sperm production when hCG alone is not enough.

How HMG works

Reproduction depends on two signals from the pituitary. LH tells the testes to make testosterone and, in women, helps trigger ovulation. FSH tells the ovaries to grow egg-containing follicles and tells the testes to support sperm production. HMG supplies both signals at once.

In men, this is why HMG is paired with hCG. hCG mimics LH and raises testosterone inside the testes. But sperm production also needs FSH acting on Sertoli cells, the support cells that nurse developing sperm. When hCG alone does not restore sperm counts, adding HMG provides the missing FSH signal.

In more precise terms, FSH binds the FSH receptor on Sertoli cells in the testis and granulosa cells in the ovary, while the LH activity acts through the shared LH/hCG receptor on Leydig and theca cells. Older HMG products held roughly equal amounts of FSH and LH activity. In highly purified products, much of the LH-type activity comes from hCG. Compared with recombinant FSH, Menopur produces a different hormonal profile during stimulation, including differences in androgen and estradiol levels.⁵

What the research shows on HMG

HMG has a large evidence base in women undergoing fertility treatment. Its role in men is older and better described in clinical reviews than in modern trials.

The best single trial compared highly purified HMG with recombinant FSH in 620 women predicted to respond strongly to stimulation. Ongoing pregnancy rates after fresh transfer were 35.5% with HMG and 30.7% with recombinant FSH, which met the test for noninferiority. HMG also led to less ovarian hyperstimulation syndrome (9.7% vs 21.4%), and cumulative live birth rates were similar at about 51%.⁴ A 2025 Cochrane network meta-analysis, which covered more than 59,000 women, rated this finding of lower hyperstimulation risk with HMG in high responders as low-certainty evidence, since it rests on one study.²

Across IVF more broadly, Menopur gave pregnancy rates as good as recombinant FSH despite collecting fewer eggs.⁵ In women with polycystic ovary syndrome who did not ovulate on clomiphene or letrozole, a 2025 Cochrane review found too little evidence to say whether HMG beats urinary FSH.³ A meta-analysis comparing recombinant FSH plus recombinant LH with HMG suggested the recombinant combination may work better, but the authors called the evidence not definitive.⁸

For men, a long-standing clinical approach is to start with hCG alone. Men whose hormone deficiency began after puberty often respond to hCG by itself. Most men whose deficiency began before puberty need hCG plus HMG to start sperm production.⁶ Results in men can take many months to appear, and studies are generally small and uncontrolled.

Studied for: Assisted reproduction (IVF), Male fertility restoration (off-label in the US).

HMG reference data

HMG dosage in published research

How HMG is used in practice

Most HMG is prescribed by reproductive endocrinologists for IVF and related treatments. It is injected under the skin daily during a stimulation cycle, with ultrasound and blood tests to track follicle growth.

In men, urologists and endocrinologists who specialize in fertility use it alongside hCG, typically injected two or three times a week. It comes up most often in men with hypogonadotropic hypogonadism, and in men whose sperm counts do not recover on hCG after testosterone or anabolic steroid use. Studies have used a range of doses, shown in the dosing table on this page.

HMG is rarely offered by general telehealth TRT services. It is expensive, needs specialist monitoring, and is regulated as a biological product, so it is not compounded. Grey-market HMG exists in bodybuilding circles, but buyers cannot verify its potency or sterility. HMG is prohibited in male athletes under anti-doping rules.

HMG risks and side effects

Common side effects include injection-site reactions, headache and abdominal discomfort. Men may develop breast tenderness or gynecomastia as testosterone and estradiol rise.

In women, the main serious risks are ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. OHSS can cause fluid shifts, abdominal swelling and, in severe cases, blood clots or kidney problems. Careful dosing and monitoring reduce but do not remove these risks. Higher letrozole doses combined with HMG may also raise the risk of OHSS and multiple pregnancy.⁷

HMG should not be used in pregnancy, with hormone-sensitive cancers, or in primary gonadal failure. In that last case the testes or ovaries themselves do not respond, so adding more FSH and LH cannot help. Because HMG is extracted from urine, it varies more between batches than recombinant products, although modern purification has narrowed that gap.

Reported side effects

Alternatives to HMG

Recombinant FSH (follitropin alfa or beta) is the main alternative. It is more potent and better tolerated at the injection site than older urinary products.¹ It can be combined with recombinant LH when LH support is wanted.

For ovulation induction in women with polycystic ovary syndrome, oral letrozole or clomiphene comes first, and gonadotropins are second-line.³ In men, hCG alone may be enough, especially when the deficiency started after puberty. Pulsatile GnRH therapy is an option for men whose problem lies in the hypothalamus.⁶ For men on TRT who want children, stopping testosterone under medical supervision is often part of the plan.

Questions for a clinician

• What evidence applies to my situation, and at what level?
• What established alternatives should I consider first?
• What monitoring would be necessary, and how often?