What is the likelihood of sperm in my ejaculate with elevated Follicle-Stimulating Hormone (FSH) and low Total Testosterone levels?

Likelihood of Sperm in Ejaculate with Your Hormone Profile

With an FSH of 10.9 IU/L, LH of 7.7 IU/L, and testosterone of 40 ng/dL (extremely low), there is a moderate-to-high likelihood that sperm are present in your ejaculate, though likely at reduced concentrations, and the extremely low testosterone raises concern for progressive testicular dysfunction that warrants urgent evaluation. 1, 2

Understanding Your Hormone Results

Your FSH level of 10.9 IU/L is moderately elevated and indicates some degree of testicular dysfunction, but this level does not predict complete absence of sperm. 1, 2

• FSH levels greater than 7.6 IU/L suggest impaired spermatogenesis, but FSH alone cannot definitively predict whether sperm are present or absent 1
• Men with FSH levels in the 10-12 IU/L range frequently still produce sperm, though typically at reduced concentrations compared to men with normal FSH 2, 3
• Critical finding: Your testosterone of 40 ng/dL is severely low (normal range typically 264-916 ng/dL), which combined with elevated FSH and LH suggests primary testicular failure 1, 4

The combination of elevated FSH (10.9), elevated LH (7.7), and very low testosterone (40 ng/dL) indicates primary testicular dysfunction where your testes are not responding adequately to hormonal signals. 1

What the Physical Findings Mean

Your slightly smaller left testicle combined with the hormone pattern supports testicular dysfunction, but does not confirm azoospermia (complete absence of sperm). 1

• Testicular atrophy is characteristic of non-obstructive azoospermia, but even men with reduced testicular volume can have retrievable sperm 1
• Up to 50% of men with non-obstructive azoospermia and elevated FSH have sperm that can be retrieved, either in ejaculate or through testicular extraction 1, 2

Essential Next Steps

You must obtain a semen analysis immediately - this is the only way to definitively determine if sperm are present in your ejaculate. 2, 5

• Request analysis after 2-5 days of abstinence, with centrifugation to detect even low sperm counts 1
• If the first analysis shows very low or no sperm, repeat testing is essential as sperm counts can fluctuate 1

Complete your hormonal workup to understand the cause of your extremely low testosterone:

• Repeat testosterone measurement (morning sample) to confirm the severely low level 1, 5
• Check prolactin levels to exclude hyperprolactinemia as a reversible cause 1
• Obtain thyroid function tests (TSH, free T4) as thyroid disorders commonly affect reproductive hormones 1

Genetic testing should be considered if sperm concentration is found to be less than 5 million/mL:

• Karyotype analysis to detect chromosomal abnormalities like Klinefelter syndrome 1, 5
• Y-chromosome microdeletion testing, as complete AZFa or AZFb deletions predict near-zero sperm retrieval success 1

Critical Warning About Testosterone Treatment

Never use exogenous testosterone therapy if you desire fertility now or in the future. 6, 2

• Testosterone supplementation suppresses FSH and LH through negative feedback, which will further impair or completely shut down sperm production 6
• Recovery after stopping testosterone can take months to years, and some men never fully recover spermatogenesis 6

Treatment Considerations Based on Semen Analysis Results

If oligospermia (low sperm count) is found:

• Human chorionic gonadotropin (hCG) injections (500-2500 IU, 2-3 times weekly) can stimulate testosterone production and improve spermatogenesis, with response correlating to baseline testicular size 6
• FSH injections may be added after testosterone normalizes on hCG if sperm counts remain low 6
• Assisted reproductive technology (IVF/ICSI) offers the highest pregnancy rates and should be discussed early given your female partner's age considerations 6

If azoospermia (no sperm) is confirmed:

• Selective estrogen receptor modulators (SERMs) or aromatase inhibitors have limited evidence but may be tried before surgical intervention 6, 5
• Microsurgical testicular sperm extraction (micro-TESE) offers up to 50% success in retrieving sperm for IVF/ICSI even with elevated FSH 1

Prognosis and Timeline Considerations

Men with your hormone profile are at risk for progressive decline in testicular function over time. 7, 8

• Research shows that men with elevated FSH and initially normal semen parameters experience further deterioration in sperm counts over subsequent years 7
• Consider sperm cryopreservation if any sperm are found, as counts may decline further 8
• Do not delay fertility treatment if parenthood is desired, as testicular function may worsen 8

Most Likely Scenario

Based on your specific values (FSH 10.9, LH 7.7, testosterone 40 ng/dL), the most probable scenario is oligospermia (reduced but present sperm) rather than complete azoospermia, though the extremely low testosterone is concerning for significant testicular impairment. 1, 2, 3 Only semen analysis can provide a definitive answer.