Is sperm freezing recommended for a patient with testicular atrophy but a normal sperm count?

Testicular Atrophy with Normal Sperm Count: Sperm Banking Recommendation

Yes, sperm cryopreservation should be strongly recommended for patients with testicular atrophy even when current sperm counts are normal, because testicular atrophy (volume <12 ml) in men under 40 years carries a ≥34% risk of testicular intraepithelial neoplasia (TIN) and represents progressive testicular failure that threatens future fertility. 1

Primary Concern: High Risk of Malignancy

• Testicular atrophy is a major risk factor for occult testicular cancer, with patients having testicular volume <12 ml and age <40 years demonstrating a ≥34% risk of harboring TIN in the affected testis 1
• If TIN remains untreated, it progresses to invasive testicular cancer in 70% of cases within 7 years 1, 2
• The atrophic testis may already contain undiagnosed germ cell malignancy or represent a "burned out tumor" with only scar tissue remaining 1

Secondary Concern: Progressive Fertility Decline

• Testicular atrophy indicates ongoing testicular failure, and current normal sperm counts do not guarantee future fertility 3, 4
• Men with ipsilateral testicular hypotrophy demonstrate significantly lower total motile sperm counts (80 ± 5.2 × 10⁶) compared to those without atrophy (126 ± 7.8 × 10⁶, p = 0.0018) 4
• Sperm parameters can fluctuate widely between ejaculates, and a currently normal count may deteriorate unpredictably 3, 5

Recommended Clinical Algorithm

Immediate Actions:

• Offer semen analysis and sperm cryopreservation before any diagnostic or therapeutic intervention 1
• Perform hormonal evaluation: total testosterone, LH, and FSH 1
• Consider contralateral testicular biopsy to detect TIN, particularly if the patient is under 40 years with testicular volume <12 ml 1, 2

Sperm Banking Threshold:

• Bank sperm immediately regardless of current normal count when testicular atrophy is present 3
• The European Association of Urology recommends sperm freezing when there is documented progressive testicular failure, which testicular atrophy represents 3
• Collect at least 3 ejaculates if feasible to maximize stored samples 1

If Malignancy is Discovered:

• Sperm banking must occur before orchiectomy or chemotherapy 1
• If urgent chemotherapy is required, diagnosis may proceed based on clinical picture and tumor markers alone, but sperm should be banked first if time permits 1
• Post-chemotherapy sperm quality is significantly worse than pre-treatment (p = 0.001), making pre-treatment banking critical 1

Critical Pitfalls to Avoid

Do not reassure the patient based solely on current normal sperm count - testicular atrophy represents underlying pathology that threatens both oncologic and reproductive outcomes 3, 4

Do not delay biopsy indefinitely - while surveillance is an option, 70% of untreated TIN cases progress to invasive cancer within 7 years 1

Do not perform contralateral biopsy within 2 years of chemotherapy if the patient ultimately requires treatment, as chemotherapy can eradicate TIN and biopsy results would be unreliable 1

Cost-Benefit Considerations

• While sperm freezing costs approximately €70,000 in European healthcare systems and only 9% of samples are eventually used 3, the context of testicular atrophy fundamentally changes this calculation
• The standard cost-benefit analysis applies to men with normal testicular volume and stable fertility - not to men with testicular atrophy who face both cancer risk and progressive testicular failure 3
• Sperm cryopreservation is the most cost-effective fertility preservation strategy available 1

Patient Counseling Points

• Explain that testicular atrophy is not benign - it signals either ongoing testicular damage or occult malignancy 1, 2
• Discuss that if TIN is detected and treated with radiotherapy (20 Gy), the testis will become azoospermic, making banked sperm the only option for biological fatherhood 1, 2
• Emphasize that fertility potential is often already compromised in men with testicular atrophy, independent of any intervention 1, 2
• Frozen sperm maintains excellent viability with no significant DNA damage from cryopreservation 6, 7, 8