Should I be concerned about my fertility with a sperm concentration of 46 million/ml, motility of 46%, and normal morphology, given my hormone levels, including Follicle-Stimulating Hormone (FSH) of 10.1, Luteinizing Hormone (LH) of 7.5, Sex Hormone-Binding Globulin (SHBG) of 99 nmol, and testosterone of 39.9 nmol/l?

Your Fertility Parameters Are Reassuring Overall

Your semen analysis shows parameters that are within or near normal ranges, and while your FSH is in the upper-normal range and SHBG is elevated, these findings do not preclude natural conception in the 2-3 year timeframe you're planning. 1, 2

Understanding Your Semen Analysis Results

Your sperm parameters fall within acceptable ranges according to WHO criteria:

• Sperm concentration of 46 million/mL exceeds the WHO lower reference limit of 16 million/mL, placing you well above the threshold for normal fertility 1, 2
• Total sperm count (46 million/mL × 3 mL = 138 million) significantly exceeds the WHO reference of 39 million per ejaculate 3
• Motility of 46% is borderline but acceptable, as WHO considers progressive motility >32% as normal 2
• Normal morphology indicates no structural concerns with sperm shape 1

Interpreting Your Hormone Levels

FSH Level of 10.1 IU/L

Your FSH is in the upper-normal range but not definitively abnormal:

• FSH levels >7.5 IU/L are associated with increased risk of abnormal semen parameters, but this is a statistical association, not an absolute predictor 4
• Research shows FSH >4.5 IU/L correlates with some semen abnormalities, but your actual sperm concentration is normal, which is what ultimately matters 4
• FSH reflects testicular function: your level suggests mild stress on spermatogenesis but not testicular failure, which would typically show FSH >12-18 IU/L 1, 3

SHBG of 99 nmol/L

Your elevated SHBG (typically normal range 18-54 nmol/L) affects testosterone availability:

• High SHBG binds testosterone, reducing bioavailable testosterone despite your total testosterone of 39.9 nmol/L (approximately 1150 ng/dL) being in normal-high range 5
• This may explain the slightly elevated FSH as your body compensates for reduced free testosterone 6

LH Level of 7.5 IU/L

Your LH is in the upper-normal range, consistent with your FSH pattern, suggesting mild compensatory increase in pituitary drive 6

Testicular Size Consideration

Your testicular length of 4.1 cm bilaterally is at the lower end of normal (normal range typically 4.5-5.5 cm):

• Smaller testicular volume can correlate with reduced sperm production capacity 1
• However, your actual sperm output (46 million/mL) demonstrates adequate function despite size 2
• This finding, combined with upper-normal FSH, suggests your testes are working harder to maintain adequate sperm production 4

What You Should Do Now

Immediate Actions

1. Obtain a confirmatory semen analysis in 1-3 months to verify these parameters, as semen quality varies significantly between samples 1, 2

2. Calculate your free testosterone using an online calculator with your total testosterone, SHBG, and albumin to assess bioavailable testosterone 5

3. See a male reproductive specialist (urologist specializing in male infertility) for physical examination focusing on:

   • Presence of varicocele (dilated scrotal veins that impair sperm production) 1
   • Vas deferens consistency and presence 7
   • Epididymal examination 7

Lifestyle Optimization (Start Now for 2-3 Year Timeline)

• Avoid heat exposure to the scrotum (hot tubs, saunas, laptop on lap, tight underwear) 1
• Smoking cessation if applicable, as smoking reduces sperm concentration and motility 1, 7
• Weight optimization if BMI is elevated, though BMI alone doesn't strongly predict fertility 5
• Avoid anabolic steroids or testosterone supplementation, which will suppress sperm production 1, 3
• Review medications with your physician, particularly SSRIs which can reduce motility 5

Testing NOT Currently Indicated

• Genetic testing (karyotype, Y-chromosome microdeletion) is only recommended for sperm concentration <5 million/mL, which does not apply to you 2, 3
• Sperm DNA fragmentation testing could be considered if you experience failed conception attempts or recurrent pregnancy loss, but is not indicated now 1

Prognosis for Natural Conception

Your fertility potential for natural conception in 2-3 years is good, with the following caveats:

• Your sperm parameters are adequate for natural conception, though the borderline motility and upper-normal FSH suggest you're not at peak fertility 2, 4
• Fertility is a couple's issue: your female partner's fertility status is equally important and should be evaluated when you begin trying to conceive 1, 7
• The 2-3 year timeline works in your favor, as it allows time for lifestyle modifications to potentially improve parameters 1

Important Caveats

• Semen parameters are highly variable: a single analysis cannot definitively predict fertility, which is why repeat testing is essential 1, 2
• Your elevated FSH and smaller testicular size suggest reduced testicular reserve: while current production is adequate, this may decline faster with age than in men with more robust baseline function 4, 6
• Men with abnormal semen parameters have higher rates of other health conditions: use this as motivation for overall health optimization 1

When to Escalate Care

Seek immediate specialist evaluation if:

• Repeat semen analysis shows declining parameters 1
• You develop symptoms of low testosterone (decreased libido, erectile dysfunction, fatigue) 1
• You and your partner fail to conceive after 12 months of regular unprotected intercourse 1