What should a male with low testosterone, impaired semen analysis, and potential testicular atrophy do?

Management of Oligoasthenoteratozoospermia with Elevated Gonadotropins and Perceived Testicular Atrophy

This patient has primary testicular dysfunction with impaired spermatogenesis and should undergo immediate genetic testing (karyotype and Y-chromosome microdeletion analysis) while avoiding exogenous testosterone therapy entirely, as it would completely suppress his remaining sperm production. 1, 2

Understanding the Clinical Picture

This patient's hormonal pattern reveals primary testicular failure:

• Elevated FSH (9.5 IU/L, above the 7.6 IU/L threshold) with elevated LH (7 IU/L) indicates the pituitary is maximally stimulating failing testes 1, 2
• The testosterone level of 42 nmol/L (~1210 ng/dL) appears elevated because the high LH is driving compensatory Leydig cell hyperfunction, but this cannot overcome the spermatogenic failure 2
• Perceived testicular atrophy combined with elevated FSH strongly suggests progressive primary testicular dysfunction 1
• The semen parameters show oligoasthenoteratozoospermia (low count at 50 million/mL when normal is >15 million/mL, borderline motility at 50%, and severely abnormal morphology at 4%) 1

Immediate Diagnostic Workup Required

Genetic testing is mandatory and should not be delayed:

• Karyotype testing is recommended for males with primary infertility and sperm concentration <50 million/mL when accompanied by elevated FSH or testicular atrophy 1
• Y-chromosome microdeletion testing should be performed, as microdeletions occur in 5% of males with severe oligozoospermia and determine whether sperm retrieval attempts would be futile 1, 2
• Obtain two complete semen analyses 2-3 months apart after 2-7 days of abstinence to confirm the pattern and assess variability 2
• Measure serum prolactin to exclude hyperprolactinemia, which can disrupt gonadotropin secretion 2
• Physical examination must document testicular volume bilaterally and assess for varicocele 1

Critical Management Decisions

What he must AVOID:

• Exogenous testosterone therapy is absolutely contraindicated if fertility is desired or may be desired in the future, as it completely suppresses spermatogenesis through negative feedback on the hypothalamus and pituitary 2, 3
• Despite his elevated testosterone level, testosterone replacement would worsen his fertility by shutting down his remaining sperm production 2, 4

Fertility preservation options:

• Intracytoplasmic sperm injection (ICSI) with ejaculated sperm offers superior pregnancy rates and should be discussed immediately, especially considering female partner age 2
• With 50 million sperm/mL, he currently has sufficient sperm for ICSI procedures 2
• Sperm cryopreservation should be offered now, as his testicular function appears to be deteriorating (perceived shrinkage) 1

Potential medical interventions:

• Clomiphene citrate (25-50 mg every other day) may improve spermatogenesis in select cases by increasing endogenous FSH and LH, though his gonadotropins are already elevated 5
• Aromatase inhibitors may improve sperm concentration by decreasing estrogen production and improving the testosterone-to-estradiol ratio, though evidence is limited 2
• These medical therapies are most effective when gonadotropins are low or normal, not already elevated as in this case 3, 5

Prognosis and Counseling

Genetic testing results will determine the path forward:

• Complete AZFa or AZFb deletions on the Y-chromosome indicate futile prognosis for sperm retrieval 2
• Klinefelter syndrome (47,XXY) or other karyotype abnormalities are the most common genetic causes of this presentation 1
• If genetic testing is normal, his prognosis for ICSI success with current sperm parameters is reasonable, but progressive testicular atrophy suggests declining function 1, 2

Monitoring and Follow-up

• Repeat semen analysis every 3-6 months to monitor for further deterioration 2
• Serial testosterone, LH, and FSH measurements to track progression 2
• Testicular ultrasound with volume measurements to objectively document atrophy 1
• Urgent referral to reproductive urology for comprehensive evaluation and fertility planning 6