Treatment Options for Elevated FSH and Low Sperm Count
For men with elevated FSH and low sperm count, FSH analogues are the most effective treatment option to improve sperm concentration, pregnancy rates, and live birth rates. 1
Diagnostic Evaluation
- Complete semen analysis is essential to confirm the diagnosis of oligospermia (low sperm count) versus azoospermia (no sperm) 1, 2
- Endocrine evaluation should include serum testosterone and FSH levels, especially if sperm concentration is less than 10 million/mL 1
- Physical examination should focus on testicular size, consistency, and presence of varicocele 1
- FSH levels are negatively correlated with the number of spermatogonia, meaning higher FSH generally indicates decreased sperm production 3
- Men with elevated FSH and normal semen analysis (compensated hypospermatogenesis) are at risk for subsequent decline in semen parameters over time 4
Treatment Options
Pharmacological Interventions
- FSH analogues are recommended for men with idiopathic infertility to improve sperm concentration, pregnancy rate, and live birth rate 3, 1
- FSH treatment (75-150 IU injections 3 times weekly for at least 3 months) can improve sperm morphology and fertilization potential 5, 6
- Selective estrogen receptor modulators (SERMs) may be considered but have limited benefits compared to assisted reproductive technologies 3, 1
- Aromatase inhibitors (AIs) and human chorionic gonadotropin (hCG) may be used for infertile men with low serum testosterone 3
- Avoid testosterone monotherapy as it can further suppress spermatogenesis 3, 1
Assisted Reproductive Technologies (ART)
- For men with persistently low total motile sperm count (<5 million motile sperm after processing), intrauterine insemination (IUI) has limited success 3
- In vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) may be considered for severe oligospermia 3
- For men with non-obstructive azoospermia, testicular sperm extraction (TESE) may be required to obtain sperm for ICSI 3
Special Considerations
- For patients with hypogonadotropic hypogonadism (low FSH and LH), treatment with exogenous gonadotropins or pulsatile GnRH can initiate spermatogenesis 3
- For men with hyperprolactinemia, evaluation for etiology and appropriate treatment is recommended 3
- Supplements and antioxidants have questionable clinical utility in treating male infertility 3, 1
Important Caveats
- FSH levels alone cannot definitively predict sperm retrieval success in all cases 3, 1
- Men with maturation arrest on testicular histology can have normal FSH despite severe spermatogenic dysfunction 3, 1
- For men with non-obstructive azoospermia, inform them about the limited data supporting pharmacologic manipulation with SERMs, AIs, and gonadotropins prior to surgical intervention 3, 1
- FSH is crucial for determining Sertoli cell number and for induction and maintenance of normal sperm production; both FSH and testosterone are required for optimal spermatogenesis 7