What hormone tests are recommended for patients experiencing fertility issues?

Recommended Hormone Tests for Fertility Issues

For patients experiencing fertility issues, the basic hormonal workup should include serum total testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) measurements, with additional tests based on initial findings. 1

Basic Hormone Panel for Male Fertility Evaluation

• Total testosterone: Evaluates Leydig cell function and overall androgenic status
• Follicle-stimulating hormone (FSH): Correlates with spermatogenic function; elevated levels often indicate impaired spermatogenesis 1
• Luteinizing hormone (LH): Helps differentiate between primary testicular failure and hypothalamic-pituitary disorders 1

These tests should be performed when:

• Semen analysis shows abnormal results, particularly if sperm concentration is <10 million/mL 1
• Sexual function is impaired
• Clinical findings suggest a specific endocrinopathy 1

Extended Hormone Testing (Based on Initial Results)

For Low Testosterone Results:

• Free or bioavailable testosterone: More accurately reflects biologically active testosterone 2
• Prolactin: Required for men with low/low-normal LH and testosterone <150 ng/dL 1
  • Persistently elevated prolactin may indicate pituitary tumors (prolactinomas)
  • MRI recommended for persistently elevated levels 1

For Abnormal Semen Analysis:

• Estradiol: Should be measured in testosterone-deficient patients with breast symptoms or gynecomastia 1
• Anti-Müllerian hormone (AMH): May predict sperm retrieval outcomes in men undergoing microdissection testicular sperm extraction 1

Special Testing Considerations

For Azoospermia or Severe Oligospermia:

• Complete the basic hormone panel (testosterone, FSH, LH)
• Genetic testing: Karyotype and Y-chromosome microdeletion analysis for men with:
  • Nonobstructive azoospermia
  • Sperm concentration <5 million/mL 1

For Hypogonadotropic Hypogonadism:

• GnRH stimulation test: May help differentiate between hypothalamic and pituitary causes
• Referral to an endocrinologist or male reproductive specialist is recommended 1

Interpretation Guidelines

• High FSH + High LH + Low testosterone: Suggests primary testicular failure 2, 3
• Low/normal FSH + Low/normal LH + Low testosterone: Suggests hypogonadotropic hypogonadism 2
• Normal hormones with abnormal semen: Consider other causes (varicocele, infection, etc.) 4

Common Pitfalls to Avoid

1. Timing matters: Collect blood samples in the morning when testosterone levels are highest 5
2. Single measurements can be misleading: Consider repeat testing for borderline results
3. Don't overlook prolactin: Essential for evaluating low testosterone with low/normal LH 1
4. Fertility preservation discussion: Should occur before starting treatments that may affect fertility 1
5. Don't rely solely on FSH: While valuable, a complete hormone profile provides more comprehensive information 3

Follow-up Testing

• If initial testing suggests a specific endocrinopathy, additional specialized testing may be required
• For men with fertility concerns who are also considering testosterone therapy, be aware that exogenous testosterone suppresses spermatogenesis 5
• Consider alternative approaches such as human chorionic gonadotropin (hCG), selective estrogen receptor modulators, or aromatase inhibitors for men who wish to maintain fertility 5

Remember that hormone testing is just one component of a complete fertility evaluation, which should also include a thorough semen analysis and appropriate genetic testing when indicated.