Can men with elevated Follicle-Stimulating Hormone (FSH) levels still be fertile?

Men with High FSH and Fertility

Yes, many men with high FSH levels can still be fertile, though fertility potential is typically reduced as FSH elevation often indicates testicular dysfunction. 1, 2

Understanding High FSH in Men

FSH is a key hormone in male reproductive function that acts on Sertoli cells to support spermatogenesis. When FSH is elevated, it typically indicates:

• Primary testicular dysfunction (the testes are not responding adequately to hormonal signals)
• The pituitary is increasing FSH production to compensate for reduced spermatogenesis
• A feedback mechanism indicating impaired sperm production

Why Men with High FSH May Remain Fertile

Despite elevated FSH levels, fertility can be maintained for several reasons:

• Partial testicular function: Even with some testicular dysfunction, sufficient sperm production may continue 2
• Heterogeneous testicular damage: Some areas of the testes may remain functional while others are damaged
• Compensatory mechanisms: The elevated FSH itself may be stimulating remaining functional testicular tissue

Clinical Significance of FSH Levels

Recent evidence shows that FSH levels correlate with fertility status but with important nuances:

• FSH values between 2.9-9.3 IU/L have poor predictive value for fertility status (PPV 0.49-0.59) 2
• Only very high FSH levels (above the 95th percentile, >12.1 IU/L) have clinically useful predictive value for subfertility 2
• FSH should not be used as a standalone test for fertility assessment 2

Fertility Treatment Options for Men with High FSH

For men with high FSH who are experiencing fertility issues:

1. Medical therapy options:

   • SERMs (clomiphene citrate) may improve semen parameters in some men, though benefits are modest 3, 1
   • Exogenous FSH may have limited benefits in men with idiopathic infertility and high-normal FSH 3
   • Avoid testosterone monotherapy as it suppresses spermatogenesis 1

2. Assisted reproductive techniques:

   • Intrauterine insemination (IUI) if total motile sperm count >5 million 3, 1
   • IVF with ICSI for severe oligozoospermia 1

Important Clinical Considerations

• FSH normal range may need reconsideration: Some research suggests that FSH levels >4.5 IU/L may already be associated with abnormal semen parameters 4
• Testosterone/FSH ratio: A lower ratio may indicate higher risk of abnormal semen parameters 4
• Variability in response: Men with similar FSH levels may have very different fertility outcomes 2

Pitfalls to Avoid

• Don't rely solely on FSH: Complete semen analysis remains the cornerstone of male fertility evaluation 1
• Don't assume infertility with moderately elevated FSH: Many men with FSH levels up to 12 IU/L can still be fertile 2
• Avoid delayed referral: Men with significantly abnormal semen parameters should be promptly referred to reproductive specialists regardless of FSH levels 1
• Don't miss hypogonadotropic hypogonadism: Low testosterone with normal/low FSH requires further evaluation 1

In summary, while elevated FSH often indicates some degree of testicular dysfunction, many men with high FSH can still achieve pregnancy either naturally or with appropriate fertility treatments. The relationship between FSH levels and fertility is complex, and comprehensive evaluation is essential.