Am I likely to have sperm in my ejaculate with hypogonadism and elevated FSH?

Likelihood of Sperm in Ejaculate with Your Hormone Profile

Yes, you are likely to have sperm in your ejaculate, though possibly at reduced concentrations. Your FSH of 10.9 IU/L is moderately elevated but does not predict complete absence of sperm, and your normal LH (7.7) with adequate total testosterone (40 nmol/L ≈ 1154 ng/dL) indicates preserved testicular function despite some degree of spermatogenic stress. 1, 2

Understanding Your Hormone Results

Your hormone profile suggests compensated testicular function rather than primary testicular failure:

• FSH 10.9 IU/L is elevated above the typical reference range but falls in a gray zone where sperm production is often maintained, though potentially reduced. 1, 2
• Men with FSH levels even as high as 54.6 mIU/ml have been documented to have sperm in their ejaculate, demonstrating that FSH alone cannot definitively predict azoospermia. 3
• Your normal LH (7.7) and robust testosterone (40 nmol/L) indicate your testes are responding appropriately to pituitary stimulation, which is a favorable sign for ongoing spermatogenesis. 4, 1
• The elevated FSH likely reflects your pituitary compensating for some degree of impaired spermatogenesis, but this compensation appears successful given your normal testosterone. 3

Critical Context About FSH and Sperm Production

FSH levels correlate negatively with sperm production but the relationship is not absolute:

• FSH >7.6 IU/L is associated with non-obstructive azoospermia and testicular dysfunction, but this is a statistical association, not a definitive threshold. 1, 2
• Research shows men with FSH >4.5 IU/L have increased risk of abnormal sperm concentration and morphology, with a dose-response relationship as FSH increases. 5
• However, up to 50% of men with non-obstructive azoospermia (who typically have much higher FSH than yours) still have retrievable sperm at testicular extraction. 4
• Men can maintain normal fertility despite FSH levels in the 10-12 IU/L range, representing biological variation. 1, 2

Essential Next Steps

You must obtain a comprehensive semen analysis to determine your actual sperm production:

• Collect at least two samples, 2-3 months apart, after 2-7 days of abstinence to assess sperm concentration, total count, motility, and morphology. 4, 2
• Normal parameters are: concentration >16 million/mL, total count >39 million per ejaculate, with adequate motility and morphology. 6
• Your extremely elevated SHBG (90 nmol/L) may affect your free testosterone availability, which could impact fertility despite normal total testosterone. 4

Additional evaluation should include:

• Physical examination focusing on testicular volume and consistency—normal-sized testes with your FSH level suggest better prognosis than atrophic testes. 1, 6
• If semen analysis shows severe oligospermia (<5 million/mL) or azoospermia, proceed with karyotype and Y-chromosome microdeletion testing. 1, 2

Critical Warnings About Treatment

Never use testosterone therapy if you desire fertility now or in the future:

• Exogenous testosterone will suppress your FSH and LH through negative feedback, causing further reduction or complete cessation of spermatogenesis. 4
• Recovery after stopping testosterone can take months to years, and some men never fully recover. 4

If semen analysis shows reduced sperm parameters, treatment options include:

• FSH analogue treatment may improve sperm concentration, pregnancy rates, and live birth rates in men with idiopathic infertility and FSH <8 IU/L (though your FSH is slightly higher). 4, 1
• Selective estrogen receptor modulators (SERMs) or aromatase inhibitors can be considered for optimizing hormones, though benefits are limited compared to assisted reproductive technology. 4, 1
• Address any metabolic factors—obesity, poor diet, smoking—as these can temporarily worsen FSH levels and sperm parameters. 1

Most Likely Scenario

Given your hormone profile, you most likely have oligospermia (reduced sperm count) rather than azoospermia (complete absence). Your preserved testosterone production and normal LH suggest ongoing testicular function, while the elevated FSH indicates your pituitary is working harder to maintain this output. 1, 3 The definitive answer requires semen analysis, which should be your immediate next step.