Is a normal sperm count likely with elevated FSH and SHBG?

Likelihood of Normal Sperm Count with Elevated FSH and SHBG

Based on the hormone profile presented (FSH 10.2 IU/L, LH 7.7 IU/L, total testosterone 45 nmol/L, SHBG 90 nmol/L), the patient most likely has oligospermia (reduced sperm count) rather than a normal sperm count, though complete azoospermia is unlikely. 1

Understanding the Hormone Pattern

The FSH level of 10.2 IU/L is moderately elevated and indicates some degree of testicular dysfunction:

• FSH >7.6 IU/L is associated with a 5- to 13-fold increased risk of abnormal sperm concentration compared to men with FSH <2.8 IU/L, depending on the specific semen parameter 2
• Men with FSH levels >4.5 IU/L show significantly increased risk of abnormal semen analyses, particularly affecting sperm concentration and morphology 2
• The most likely scenario is oligospermia with sperm concentration between 1-15 million/mL rather than normal counts (>16 million/mL) or complete azoospermia 1

Why Complete Azoospermia is Unlikely

Several factors argue against complete testicular failure:

• The LH level of 7.7 IU/L is only mildly elevated, not markedly high, which would be expected in primary testicular failure 1
• FSH of 10.2 IU/L is elevated but well below the >12.1 IU/L threshold (95th percentile) that has strong predictive value for severe subfertility 1
• Up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm, indicating that FSH alone cannot definitively predict complete absence of sperm 1, 3

Impact of Elevated SHBG

The SHBG of 90 nmol/L is elevated but does not directly impair sperm production:

• Spermatogenesis depends on intratesticular testosterone (ITT), which is 50-100 times higher than serum levels and maintained by LH stimulation of Leydig cells, independent of circulating SHBG 3
• High SHBG may reduce bioavailable testosterone in circulation, but if LH is normal (as it is here at 7.7 IU/L), the testes are receiving appropriate signals to produce both ITT and sperm 3
• Elevated SHBG can be caused by hyperthyroidism, liver disease, or medications—addressing reversible causes is essential before making definitive conclusions about fertility 3

Essential Next Steps

Perform at least two semen analyses separated by 2-3 months to confirm actual sperm count, as hormone levels alone cannot definitively predict fertility status 1, 4

Additional recommended evaluations:

• Calculate free testosterone index using total testosterone and SHBG to assess bioavailable testosterone 3
• Check thyroid function (TSH, free T4) as thyroid disorders commonly affect reproductive hormones and can elevate SHBG 1, 3
• Measure serum prolactin to exclude hyperprolactinemia, which can disrupt gonadotropin secretion 3
• Physical examination focusing on testicular size and consistency—normal-sized testes with FSH of 10 suggest better prognosis than atrophic testes 1

Genetic Testing if Severe Oligospermia Confirmed

If semen analysis reveals sperm concentration <5 million/mL:

• Karyotype analysis to exclude chromosomal abnormalities like Klinefelter syndrome 1, 3
• Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) is mandatory if sperm concentration <1 million/mL 1, 3

Critical Treatment Considerations

Never prescribe exogenous testosterone if fertility is desired—it suppresses LH and FSH through negative feedback, eliminating intratesticular testosterone production and causing azoospermia that can take months to years to recover 1, 3, 4

If oligospermia is confirmed and fertility is desired:

• Assisted reproductive technology (IVF/ICSI) offers superior pregnancy rates compared to empiric hormonal therapy and should be discussed early 1, 3
• FSH analogues may improve sperm concentration in idiopathic infertility, though benefits are measurable but limited 1, 4
• Selective estrogen receptor modulators (SERMs) and aromatase inhibitors have limited benefits that are outweighed by ART advantages 1, 4

Important Caveats

• FSH levels show natural variation among healthy men, with some individuals maintaining levels in the 10-12 IU/L range while maintaining normal fertility 1
• Men with maturation arrest on testicular histology can have normal FSH and testicular volume despite severe spermatogenic dysfunction 1, 4
• Lifestyle factors such as smoking, poor diet, and environmental exposures may temporarily affect FSH levels 1
• Weight normalization and metabolic optimization may improve hormonal parameters in some cases 1