What are the treatment options for azoospermia with normal Follicle-Stimulating Hormone (FSH) levels, normal Luteinizing Hormone (LH) levels, and normal testosterone levels?

Treatment Options for Azoospermia with Normal FSH, LH, and Testosterone

Your hormonal profile (FSH ~10 IU/L, LH 7.7 IU/L, testosterone 40 nmol/L) suggests either obstructive azoospermia or a very focal spermatogenic defect rather than primary testicular failure, and treatment should focus on identifying any obstruction first, followed by consideration of empiric hormonal optimization or surgical sperm retrieval. 1, 2

Understanding Your Hormonal Profile

Your hormone levels are actually reassuring and indicate preserved testicular function:

• FSH around 10 IU/L is only mildly elevated and sits just above the typical threshold of 7.6 IU/L that distinguishes obstructive from non-obstructive causes 1, 2
• Normal testosterone (40 nmol/L ≈ 1150 ng/dL) confirms your testes are producing hormones effectively 3
• Normal LH indicates intact pituitary-testicular communication 2

This pattern is distinctly different from classic non-obstructive azoospermia, where FSH is typically well above 15-20 IU/L with testicular atrophy 1. Your profile suggests either a partial obstruction, focal spermatogenic defect, or potentially reversible cause 2, 4.

Diagnostic Steps Before Treatment

Rule Out Obstruction First

• Check for physical signs of obstruction: absent or abnormal vas deferens, dilated/indurated epididymis, or low ejaculate volume (<1.5 mL) 2, 5
• Consider transrectal ultrasound (TRUS) if ejaculate volume is low to evaluate for ejaculatory duct obstruction, looking for dilated seminal vesicles (>15 mm), ejaculatory ducts (>2.3 mm), or prostatic cysts 3
• Post-ejaculatory urinalysis if volume <1 mL to rule out retrograde ejaculation 2

Genetic Testing

• Karyotype analysis and Y-chromosome microdeletion testing are mandatory for all azoospermic men, even with normal hormones, as genetic abnormalities can occur with this profile 3, 2, 4

Treatment Algorithm

If Obstruction is Identified

Microsurgical reconstruction (vasovasostomy or vasoepididymostomy) is preferred over sperm retrieval when the female partner has normal fertility, as it can restore natural fertility 3, 5

• For ejaculatory duct obstruction: transurethral resection of ejaculatory ducts (TURED) can restore sperm to ejaculate for natural conception 3
• Alternative: surgical sperm extraction with IVF/ICSI achieves 25-65% pregnancy rates 4, 5

If No Obstruction Found (Non-Obstructive with Normal Hormones)

This represents a focal spermatogenic defect with preserved hormonal function—a favorable scenario.

Medical Optimization (Off-Label, Limited Evidence)

The 2024 AUA/ASRM guidelines acknowledge that selective estrogen receptor modulators (SERMs), aromatase inhibitors, and gonadotropins may be tried prior to surgical intervention, though data supporting their use is limited 3:

• Clomiphene citrate (starting 25-50 mg daily, titrated based on response) can increase FSH and testosterone further 6
• Human chorionic gonadotropin (hCG) 1000-2500 IU 2-3 times weekly if testosterone optimization is needed 3
• Aromatase inhibitors may improve the testosterone-to-estrogen ratio 3, 7

One multicenter study showed that hormonal optimization with clomiphene citrate ± hCG ± human menopausal gonadotropin resulted in sperm appearing in the ejaculate in 10.9% of non-obstructive azoospermia cases, and improved surgical retrieval rates from 33.6% to 57% 6. However, the AUA/ASRM guidelines emphasize these benefits are limited compared to assisted reproductive technologies 3.

Surgical Sperm Retrieval

Microdissection testicular sperm extraction (micro-TESE) is the gold standard for non-obstructive azoospermia, retrieving sperm in 30-70% of cases even with elevated FSH 3, 4, 6:

• Micro-TESE is 1.5 times more successful than conventional TESE and causes less testosterone suppression 3
• With your near-normal FSH and preserved testosterone, your chances of successful retrieval are likely at the higher end of this range 1, 6
• Retrieved sperm can be used fresh or cryopreserved for IVF/ICSI with 20-50% pregnancy rates 4

Critical Pitfalls to Avoid

• Never use exogenous testosterone therapy—it will completely suppress spermatogenesis through negative feedback and can take months to years to recover 3
• FSH levels alone cannot predict sperm retrieval success; men with maturation arrest can have normal FSH despite severe dysfunction, and conversely, up to 50% with elevated FSH have retrievable sperm 1, 2, 7
• Supplements and antioxidants have questionable clinical utility and should not delay definitive treatment 3

Recommended Approach

1. Complete the diagnostic workup (physical exam for obstruction, TRUS if indicated, genetic testing) 2, 4
2. If obstructive: pursue surgical reconstruction or sperm retrieval based on female partner's age and fertility status 3, 5
3. If non-obstructive with your favorable hormone profile:
   • Consider a 3-6 month trial of clomiphene citrate ± hCG with monthly semen analyses 6
   • If sperm appear in ejaculate: proceed with IUI or IVF/ICSI 3
   • If azoospermia persists: proceed directly to micro-TESE, which offers the best chance of retrieving sperm given your preserved testicular function 3, 6

Your normal testosterone and only mildly elevated FSH suggest active spermatogenesis is occurring somewhere in your testes, making you a strong candidate for successful sperm retrieval 1, 2, 6.