Do I need to be concerned about my fertility given my hormone levels, including low/normal free testosterone, slightly elevated Follicle-Stimulating Hormone (FSH), and semen analysis results, before trying to conceive in 2 years?

Your Fertility Status: Reassuring Parameters with Minor Concerns

Based on your hormone levels and semen analysis, you do not need to be significantly concerned about your fertility, though your slightly elevated FSH warrants monitoring and addressing reversible factors before attempting conception in 2 years. 1, 2

Understanding Your Current Results

Your semen analysis shows normal fertility parameters that exceed WHO reference standards:

• Sperm concentration of 42 million/mL far exceeds the lower reference limit of 16 million/mL 1, 2
• Total motile sperm count of 46 million is excellent (WHO lower limit is 39 million total sperm) 1
• Semen volume of 3 mL is normal (reference range 1.5-6 mL) 1
• Motility of 46% meets the WHO lower reference limit of 40% progressive + non-progressive motility 1
• Testicular size of 15 mL and 4 cm length indicates preserved testicular volume, which is reassuring and argues against primary testicular failure 2, 3

The FSH 9.9 IU/L Finding: What It Means

Your FSH level of 9.9 IU/L falls into a borderline elevated range that requires attention but is not alarming:

• FSH >7.6 IU/L is associated with some degree of testicular dysfunction, though your level is only mildly elevated 2, 4
• Men with FSH levels >7.5 IU/L have a five- to thirteen-fold higher risk of abnormal sperm parameters compared to men with FSH <2.8 IU/L 4
• However, your actual semen parameters are normal, which indicates your testes are functioning adequately despite the slightly elevated FSH 2, 5
• FSH levels between 7.6-10 IU/L typically indicate impaired spermatogenesis but not complete absence of sperm production 2, 5
• Up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm, so your situation with normal sperm counts is considerably better 2, 3

Your High SHBG (95 nmol/L): A Key Factor

Your elevated SHBG is likely contributing to your low-normal free testosterone and may be affecting your FSH level:

• High SHBG does not directly impair sperm production because spermatogenesis depends on intratesticular testosterone (ITT), which is 50-100 times higher than serum levels and maintained by LH stimulation 2
• Your LH of 7.3 IU/L is in the normal range, meaning your testes are receiving appropriate signals to produce both ITT and sperm 2
• High SHBG can be caused by hyperthyroidism, liver disease, medications, or metabolic factors 2, 5
• Addressing the underlying cause of elevated SHBG may normalize your hormonal profile 2, 5

Critical Actions Before Attempting Conception in 2 Years

1. Address Reversible Factors Now

Metabolic optimization can normalize FSH levels that are in the borderline range (9-12 IU/L):

• Weight management: If overweight (BMI >25), weight loss through low-calorie diets can reverse obesity-associated hormonal dysfunction and normalize gonadotropins 5
• Physical activity shows similar benefits, with results correlating to exercise duration and weight loss 5
• Avoid acute illness or metabolic stress when retesting hormones, as these can artificially elevate FSH 5

Investigate causes of high SHBG:

• Check thyroid function (TSH, free T4) - thyroid hormone directly increases SHBG production, and even subtle over-replacement or under-replacement significantly affects SHBG levels 2
• Evaluate for liver disease 2
• Review medications that may increase SHBG 5

2. Repeat Hormonal Testing in 3-6 Months

After addressing metabolic factors and investigating SHBG causes:

• Recheck FSH, LH, total testosterone, and SHBG 5
• FSH levels often normalize to 7-9 IU/L once reversible factors resolve 5
• Measure complete hormonal panel including prolactin to evaluate the entire hypothalamic-pituitary-gonadal axis 1, 5

3. Repeat Semen Analysis

• Obtain at least one more semen analysis 2-3 months apart after 2-3 days abstinence 1
• Semen parameters are highly variable biological measures and can fluctuate substantially from test to test 1
• If follow-up shows declining sperm parameters, consider sperm cryopreservation as a protective measure 2

4. Lifestyle Modifications

Implement these changes now to optimize fertility over the next 2 years:

• Avoid tobacco, limit alcohol consumption, and avoid recreational drugs 1
• Maintain healthy weight (BMI 18.5-25) 1
• Limit caffeine to less than 5 cups per day 1
• Avoid gonadal toxin exposure including excessive heat 1
• Review all medications with your physician - some can interfere with testosterone production or hypothalamic-pituitary axis function 5

Critical Pitfalls to Avoid

NEVER take testosterone therapy if you desire fertility - exogenous testosterone will completely suppress spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing azoospermia that can take months to years to recover 1, 2, 5

Do not delay investigation of high SHBG - identifying and treating the underlying cause (thyroid dysfunction, liver disease) may improve your entire hormonal profile 2, 5

Do not assume your current normal semen parameters guarantee future fertility - monitor with repeat testing, especially given the borderline FSH 2, 5

When to Seek Specialist Evaluation

Consider referral to a male reproductive specialist if:

• FSH remains >10 IU/L after addressing reversible factors 2, 5
• Follow-up semen analysis shows declining parameters (concentration <15 million/mL or motility <40%) 1, 2
• SHBG remains elevated without identifiable cause 2
• You develop symptoms of hypogonadism (low libido, erectile dysfunction, fatigue) 1

Genetic Testing Considerations

Genetic testing is NOT currently indicated for you because:

• Karyotype and Y-chromosome microdeletion testing are recommended only when sperm concentration is <5 million/mL or in cases of azoospermia 1, 2, 3
• Your concentration of 42 million/mL is well above this threshold 1, 2
• However, if future semen analysis shows severe oligospermia (<5 million/mL), genetic testing should be performed 1, 2

Bottom Line for Your Situation

Your current fertility potential is good based on normal semen parameters and preserved testicular size. The mildly elevated FSH (9.9 IU/L) and high SHBG (95 nmol/L) warrant investigation and optimization but do not preclude natural conception. With 2 years before attempting conception, you have excellent opportunity to address reversible factors (metabolic optimization, thyroid evaluation, SHBG investigation) that may normalize your hormonal profile. Repeat testing after lifestyle modifications will clarify whether the borderline FSH represents a transient finding or requires closer monitoring. Your normal sperm counts despite the elevated FSH are reassuring and suggest your testes are functioning adequately. 1, 2, 5