Should a patient with small atrophied testicles, normal sperm count (100 million per milliliter), 50% motility, 5% morphology, and slightly elevated Follicle-Stimulating Hormone (FSH) level (9.9) consider sperm cryopreservation?

Should This Patient Freeze Sperm?

Yes, this patient should strongly consider sperm cryopreservation despite currently normal sperm count, as the combination of testicular atrophy and borderline-elevated FSH (9.9 IU/L) indicates compromised testicular function with significant risk of progressive decline in semen quality over time. 1

Understanding the Clinical Picture

The patient presents with a concerning constellation of findings:

• Testicular atrophy suggests underlying testicular dysfunction and reduced spermatogenic capacity 2, 3
• FSH 9.9 IU/L is elevated above the threshold of 7.6 IU/L, which is associated with a five- to thirteen-fold higher risk of abnormal sperm parameters compared to men with FSH <2.8 IU/L 4
• Current sperm parameters (100 million/mL concentration, 50% motility) appear adequate now, but this may not persist 1
• 5% morphology is already borderline abnormal (WHO lower reference limit is 4%), indicating some degree of spermatogenic impairment 3

The critical insight is that FSH levels are negatively correlated with spermatogonia numbers—higher FSH indicates the pituitary is compensating for reduced testicular function, signaling progressive testicular failure 3, 1. Men with FSH >7.6 IU/L are at substantially higher risk for developing oligospermia (sperm count <15 million/mL) and decreased total motile sperm over time 1.

Why Freeze Now Rather Than Wait

The American Society for Reproductive Medicine recommends that men with elevated FSH levels (>7.6 IU/L) freeze multiple sperm samples while parameters are still normal, as this provides insurance against future decline 1. Several compelling reasons support immediate cryopreservation:

• Testicular atrophy is irreversible and indicates ongoing loss of spermatogenic tissue 2, 3
• Semen quality can deteriorate unpredictably, and once parameters decline significantly, the window for optimal preservation may close 1
• Cryopreserved sperm performs equally well as fresh sperm in ICSI procedures, so there is no reproductive disadvantage to using frozen samples 1, 5
• The American Urological Association recommends collecting at least three ejaculates if total motile count is adequate, with each collection aliquoted to obtain >5 million total motile sperm per sample 2

Evidence Supporting Fertility Preservation

The 2025 ASCO guidelines emphasize that sperm cryopreservation is the most effective method of fertility preservation in postpubertal males 2. While these guidelines focus on cancer patients, the principle applies to any man with evidence of progressive testicular dysfunction 2.

Even one collection is important to obtain if possible, and sperm should be cryopreserved in multiple aliquots from a single sample to facilitate options for multiple cycles of insemination or IVF 2. Studies demonstrate that frozen-thawed testicular sperm achieves fertilization rates of 58.4%, embryo transfer rates of 83%, and ongoing pregnancy rates of 20.8% 5.

Addressing Reversible Factors First

Before proceeding with cryopreservation, the patient should undergo evaluation for potentially reversible causes of testicular dysfunction:

• Complete hormonal panel: Measure LH, total testosterone, SHBG, and prolactin to evaluate the entire hypothalamic-pituitary-gonadal axis 1
• Thyroid function: Check TSH and free T4, as thyroid dysfunction can disrupt gonadotropin secretion and impair spermatogenesis 3, 1
• Metabolic assessment: Evaluate BMI and waist circumference, as obesity can elevate FSH and impair spermatogenesis 1
• Genetic testing: If sperm count drops below 5 million/mL on repeat analysis, obtain karyotype and Y-chromosome microdeletion testing 3

Weight loss and metabolic optimization can normalize gonadotropins and improve testosterone levels in functional hypogonadism 3. However, these interventions take months to show effect, and cryopreservation should not be delayed while pursuing optimization 1.

Critical Pitfalls to Avoid

Never start exogenous testosterone therapy if fertility is desired, as it will completely suppress spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing azoospermia that takes months to years to recover 2, 3, 1. This is the single most important counseling point for men with borderline testicular function.

Additionally, FSH levels alone cannot definitively predict fertility status—up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm with testicular sperm extraction 3. However, the goal is to preserve optimal-quality sperm now rather than rely on surgical retrieval later, which is more invasive and has lower success rates 2.

Practical Recommendations

Freeze at least three separate ejaculate samples over several days, with each collection aliquoted to obtain total motile count >5 million per sample 2, 1. This provides sufficient material for multiple ICSI cycles if needed in the future.

Repeat semen analysis every 6-12 months to monitor for decline, as changes in semen parameters take time to manifest and may not be apparent on a single analysis 6, 3. If parameters worsen significantly, consider additional cryopreservation before further deterioration occurs 1.

Discuss assisted reproductive technology (IVF/ICSI) early with the female partner, as this offers superior pregnancy rates compared to empiric hormonal therapy and should be part of family planning discussions 3, 1.