What is the likelihood of azoospermia given my symptoms and hormone levels?

Likelihood of Azoospermia Assessment

Based on your hormone profile (FSH 10.5 IU/L, normal testosterone 40 nmol/L, elevated SHBG 90), combined with low semen volume and sexual dysfunction symptoms, you have an intermediate-to-high probability of having either severe oligospermia or non-obstructive azoospermia—but definitive diagnosis absolutely requires semen analysis, which is the only way to confirm whether sperm are present. 1

Your Hormone Profile Interpretation

Your FSH of 10.5 IU/L is elevated above the 7.6 IU/L threshold that indicates testicular dysfunction and is strongly associated with impaired spermatogenesis. 1 This level suggests your pituitary is working harder to stimulate sperm production because your testes are not responding optimally. 1, 2

Critical context: FSH levels are negatively correlated with spermatogonia numbers—higher FSH reflects compensatory pituitary response to reduced testicular function. 1, 2 However, FSH alone cannot definitively predict whether you have complete azoospermia versus severe oligospermia. 1, 2

Why You're Not Necessarily Azoospermic

• Up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm, meaning your FSH level doesn't guarantee complete absence of sperm production. 1
• Your total testosterone of 40 nmol/L (~1154 ng/dL) is actually normal-to-high, which indicates your Leydig cells (testosterone-producing cells) are functioning well—this typically correlates with at least some preserved spermatogenesis. 3
• Men can maintain fertility despite FSH levels in the 10-12 IU/L range, though this represents biological variation rather than the norm. 2

Your Elevated SHBG (90)

Your SHBG of 90 is significantly elevated, which binds testosterone and reduces bioavailable testosterone. 1 This can contribute to:

• Low libido and erectile dysfunction symptoms you're experiencing 1
• Metabolic stress on the hypothalamic-pituitary-gonadal axis 3

Essential Next Steps (In Order of Priority)

1. Obtain Comprehensive Semen Analysis

You must have at least two semen analyses separated by 2-3 months after 2-7 days of abstinence. 1, 2 Single analyses are insufficient due to natural variability. 1 The lab must centrifuge the sample and examine the pellet microscopically—this is the only way to definitively diagnose azoospermia. 4

2. Complete Your Hormonal Workup

Measure the following alongside repeat FSH: 1, 2

• Prolactin (to exclude hyperprolactinemia, which can elevate FSH) 3
• Thyroid function (TSH, free T4—thyroid disorders commonly disrupt reproductive hormones) 3
• Repeat testosterone and calculate free testosterone given your elevated SHBG 3

3. Address Reversible Factors Before Making Definitive Diagnosis

Your borderline FSH (10.5 IU/L) may normalize to 7-9 IU/L once reversible factors are addressed: 3

• Metabolic optimization: Weight management if BMI >25, as obesity suppresses the HPG axis 3
• Thyroid correction if abnormal 3
• SHBG reduction strategies: Weight loss and metabolic optimization can lower SHBG 3

Recheck FSH, testosterone, and SHBG after 3-6 months of metabolic optimization. 3

4. Physical Examination Priorities

You need focused examination for: 2, 4

• Testicular volume and consistency (testicular atrophy suggests non-obstructive azoospermia) 1
• Presence of varicocele 2
• BMI and waist circumference (metabolic parameters directly impact HPG axis) 3

5. Genetic Testing (If Semen Analysis Shows Severe Oligospermia or Azoospermia)

If your sperm count is <5 million/mL or you're azoospermic: 5, 1

• Karyotype analysis (to detect Klinefelter syndrome, translocations) 5, 1
• Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) 5, 1

Complete AZFa and AZFb deletions have almost zero likelihood of sperm retrieval and would contraindicate testicular sperm extraction. 1

Critical Management Pitfalls to Avoid

Never Take Testosterone Therapy

Exogenous testosterone will further suppress your spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing complete azoospermia. 6, 3 The FDA label explicitly warns that "exogenous administration of androgens may lead to azoospermia." 6

This is the most common and devastating mistake made when managing men with fertility concerns and low libido. 3

Don't Accept Reassurance That FSH 10.5 Is "Normal"

While some labs report upper limits of 12-15 IU/L, the clinically relevant threshold for testicular dysfunction is >7.6 IU/L. 1, 2 Your level warrants full investigation. 2

Treatment Considerations (After Diagnosis Confirmed)

If You Have Oligospermia (Not Azoospermia):

• FSH analogue treatment may improve sperm concentration, pregnancy rate, and live birth rate in idiopathic infertility 2, 3
• Clomiphene citrate (a selective estrogen receptor modulator) can increase FSH and testosterone—one study showed 10.9% of non-obstructive azoospermia patients achieved sperm in ejaculate after treatment 7
• Aromatase inhibitors may help given your elevated SHBG, though benefits are limited compared to assisted reproductive technology 3

If You Have Confirmed Azoospermia:

• Microdissection testicular sperm extraction (micro-TESE) successfully retrieves sperm in up to 50% of non-obstructive azoospermia cases, even with elevated FSH 1
• Medical optimization with clomiphene citrate, hCG, and human menopausal gonadotropin before micro-TESE increased successful sperm retrieval from 33.6% to 57% in one multicenter study 7

Your Low Semen Volume

Low semen volume combined with your hormone profile raises additional considerations: 1

• Normal semen volume with elevated FSH is characteristic of non-obstructive azoospermia 1
• Low semen volume could suggest partial obstruction or retrograde ejaculation—this needs evaluation 4

Bottom Line Probability Estimate

Given your specific profile:

• FSH 10.5 IU/L (elevated, indicating testicular dysfunction) 1
• Normal-high testosterone (suggests preserved Leydig cell function) 3
• Elevated SHBG (reduces bioavailable testosterone, explains symptoms) 1
• Low semen volume (needs clarification) 1

Your probability of azoospermia is approximately 30-50%, with severe oligospermia being equally likely. 1, 8 However, this is an educated estimate—only semen analysis can provide the definitive answer. 1, 2

The encouraging news: even if you are azoospermic, your normal testosterone suggests you have a reasonable chance (up to 50%) of successful sperm retrieval with micro-TESE. 1