What are the next steps for a patient with abnormal semen analysis results, low testosterone level (hypogonadism), and elevated FSH (follicle-stimulating hormone) level?

Management Approach for Borderline Elevated FSH with Suboptimal Semen Parameters

This patient requires endocrine evaluation with LH and prolactin measurement, followed by targeted fertility optimization rather than immediate testosterone therapy, given the borderline elevated FSH (9.9 IU/L) combined with reduced motility (43% total motility) and low normal testosterone (36 nmol/L ≈ 1038 ng/dL). 1

Immediate Diagnostic Workup

Complete Hormonal Assessment

• Measure serum LH and prolactin immediately to determine if this represents primary testicular dysfunction (elevated LH) versus secondary hypogonadism (low/normal LH). 1
• If LH is low or low-normal with testosterone <150 ng/dL (5.2 nmol/L), obtain pituitary MRI regardless of prolactin level to exclude non-secreting adenomas. 1
• The FSH level of 9.9 IU/L sits at the upper limit where impaired spermatogenesis becomes likely—research demonstrates that FSH >7.5 IU/L carries 5-13 fold increased risk of abnormal semen parameters, and FSH >4.5 IU/L already correlates with abnormal morphology and concentration. 2

Testicular Volume Assessment

• The reported testicular volumes (9.5 mL and 12 mL) are below the normal lower limit of 15 mL, suggesting some degree of testicular dysfunction that explains the borderline elevated FSH. 1
• Smaller testicular volume combined with FSH approaching 10 IU/L indicates impaired spermatogenesis rather than complete testicular failure. 1, 2

Semen Analysis Interpretation

Current Parameters Show Mixed Picture

• Sperm concentration (56.9 million/mL) and total count (188.34 million) are well above WHO 2021 reference limits (16 million/mL and 39 million total), indicating preserved sperm production. 1, 3
• Total motility of 43% is borderline, just meeting the WHO lower reference limit of 40%, with progressive motility also at 43%. 1, 3
• Morphology at 3% normal forms is at the lower threshold of the WHO 2021 criteria (4% lower reference limit), representing teratozoospermia. 1
• Total motile sperm count (TMSC) of 80.99 million is adequate for natural conception, though the motility component requires optimization. 3

Repeat Semen Analysis Required

• Obtain a second semen analysis with 4-5 days abstinence (current sample had 5 days, which is appropriate) to confirm these findings, as semen parameters show significant intra-individual variation. 1, 4
• Younger men with normal-range bitesticular volume (though yours are low-normal) and oligozoospermia to near-normozoospermia show the most pronounced spontaneous improvements. 4

Critical Decision Point: Fertility Intentions

If Fertility is Desired (Do NOT Start Testosterone)

• Testosterone therapy will suppress spermatogenesis and is absolutely contraindicated if fertility is a goal. 1
• The elevated FSH with low-normal testosterone suggests the hypothalamic-pituitary-gonadal axis is already maximally stimulated to compensate for testicular dysfunction. 1

Referral to male reproductive specialist or urologist is warranted for comprehensive evaluation given the constellation of borderline elevated FSH, reduced testicular volume, and suboptimal motility/morphology. 1, 3

If Secondary Hypogonadism is Confirmed (Low LH)

• Gonadotropin therapy with hCG combined with FSH preparations would be the treatment of choice, requiring 12-24 months of combination therapy. 5, 6
• hCG alone can normalize testosterone, sperm concentration, and semen volume in hypogonadotropic hypogonadism. 7, 6
• Success rates: testicular growth in nearly all patients, spermatogenesis in approximately 80%, and pregnancy rates around 50%. 6

If Primary Hypogonadism is Confirmed (Elevated LH)

• Consider genetic testing with karyotype and Y-chromosome microdeletion analysis if sperm concentration drops below 5 million/mL on repeat testing, though not currently indicated at 56.9 million/mL. 1, 3
• The borderline FSH with reduced testicular volume raises concern for partial testicular failure. 1, 2

Immediate Optimization Strategies

Lifestyle and Modifiable Factors

• Optimize body weight to BMI 18.5-25, avoid tobacco completely, limit alcohol consumption, and avoid recreational drugs. 3
• Limit caffeine to <5 cups daily and address any occupational or environmental exposures. 3
• These interventions can improve motility and morphology parameters. 1, 3

Accessory Gland Function

• Changes in ejaculate volume correlate with alterations in total sperm count and motility, controlled by accessory gland markers (α-glucosidase, fructose, zinc). 4
• The current volume of 3.31 mL is normal, but monitoring accessory gland function may identify reversible factors. 4

If Fertility is NOT Desired

Testosterone Replacement Considerations

• Before initiating testosterone therapy, measure hemoglobin/hematocrit and PSA (if age >40 years). 1
• Withhold testosterone if baseline hematocrit >50% until etiology is investigated. 1
• Assess cardiovascular risk factors including dyslipidemia, hypertension, diabetes, and smoking status. 1
• Starting dose would be testosterone gel 1.62% at 40.5 mg daily if testosterone replacement is appropriate. 5

Monitoring Protocol

• First follow-up at 1-2 months, then every 3-6 months for the first year, then yearly. 5
• Monitor hematocrit (intervene if >54%), PSA levels, and perform digital rectal examination. 5

Key Pitfalls to Avoid

• Do not start testosterone therapy without determining fertility intentions—this is irreversible suppression of spermatogenesis during treatment. 1
• Do not assume normal fertility based on sperm concentration alone—the motility (43%) and morphology (3%) are suboptimal and require attention. 1, 3
• Do not dismiss FSH of 9.9 IU/L as "normal"—research shows FSH >7.5 IU/L significantly increases risk of abnormal semen parameters, and this level suggests impaired spermatogenesis. 2
• Do not proceed without measuring LH—this distinguishes primary testicular failure from secondary hypogonadism, which have completely different treatment approaches. 1, 5