Elevated FSH and Sperm in Ejaculate
With an FSH level of 20, it is unlikely but still possible that you have sperm in your ejaculate. 1, 2
Understanding FSH and Sperm Production
- FSH levels are negatively correlated with sperm production, meaning higher FSH generally indicates decreased spermatogenesis 1, 3
- An FSH level of 20 IU/L is significantly elevated and typically associated with non-obstructive azoospermia (absence of sperm in ejaculate) 1, 4
- FSH levels greater than 7.6 IU/L strongly suggest testicular dysfunction, which often manifests as reduced or absent sperm production 1, 5
- FSH values above the 95th percentile (>12.1 IU/L) have strong predictive value for subfertility, with even higher predictive value at 20.8 IU/L (99th percentile) 4
Probability of Finding Sperm
- Despite elevated FSH, sperm retrieval has been reported in up to 50% of non-obstructive azoospermia patients 1
- A 2025 study found that among men previously diagnosed with azoospermia, 15.8% had sperm identified in subsequent semen analyses 2
- The same study identified FSH level as a significant predictive factor for finding sperm, with a cutoff value of 15.3 mIU/mL 2
- With an FSH of 20 IU/L (above this cutoff), the chances of finding sperm are reduced but not zero 2
Next Steps to Consider
- A complete semen analysis is essential to confirm the presence and quantity of sperm in your ejaculate 1, 3
- Multiple semen analyses are recommended, as a single test may miss sperm in cases of severe oligozoospermia or cryptozoospermia 2
- Additional hormonal evaluation including testosterone and LH would provide a more complete picture of your reproductive health 1, 3
- Physical examination focusing on testicular size and consistency would provide additional diagnostic information 5, 3
Important Caveats
- FSH levels alone cannot definitively predict fertility status or sperm retrieval success in all cases 1, 3
- Men with maturation arrest on testicular histology can have normal FSH despite severe spermatogenic dysfunction, and the opposite can also be true 1, 5
- Avoid testosterone supplements if fertility is desired, as they can further suppress sperm production 1, 3
- If confirmed azoospermia, genetic testing (karyotype and Y-chromosome microdeletion analysis) is recommended 1, 5
Treatment Options If Needed
- For men with idiopathic infertility and elevated FSH, microsurgical testicular sperm extraction offers the best chance of retrieving sperm for use with assisted reproductive technology 1
- Selective estrogen receptor modulators (SERMs) and aromatase inhibitors have been used off-label to try to improve spermatogenesis in men with elevated FSH, though benefits are limited 1, 5
- FSH analogues may be considered to improve sperm concentration in some cases 5, 6