Do I need to freeze my sperm immediately if I plan to try to conceive in 2 years given my testicular size discrepancy and normal fertility parameters?

Sperm Freezing Is Not Urgently Needed in Your Case

Based on your current semen parameters (60 million/ml concentration, 50% motility) and stable results over 3 months, immediate sperm cryopreservation is not indicated, despite your testicular size discrepancy. However, your testicular atrophy warrants urgent evaluation for occult malignancy before any fertility preservation decisions.

Critical First Step: Rule Out Testicular Cancer

Your 7ml testicular volume represents significant atrophy and creates a major concern that supersedes fertility preservation timing:

• Testicular volume <12ml in men under 40 years carries a ≥34% risk of harboring testicular intraepithelial neoplasia (TIN), which progresses to invasive cancer in 70% of cases within 7 years if untreated 1
• You require immediate hormonal evaluation (total testosterone, LH, FSH—which you've completed) and consideration of contralateral testicular biopsy to detect TIN, particularly given your testicular volume <12ml 1
• The atrophic testis may already contain undiagnosed germ cell malignancy 1

Your Current Fertility Parameters Do Not Warrant Immediate Freezing

Your semen analysis results are reassuring:

• Sperm concentration of 60 million/ml far exceeds the threshold for natural conception and is considered adequate for assisted reproduction 1
• Sperm freezing is only recommended when at least one total sperm count from two analyses is <1 million (10^6), not 60 million 1, 2
• Your 50% motility and stable parameters over 3 months indicate no progressive testicular failure requiring urgent cryopreservation 1
• Only 9% of cryopreserved sperm samples are eventually used in assisted reproductive technology, while 23% are disposed of unused 1

Evidence-Based Thresholds for Sperm Banking

The literature provides clear guidance on when freezing becomes necessary:

• When at least one total sperm count is <100,000 (10^5), the risk of azoospermia during an ICSI attempt is 52%, versus only 3% when all counts are ≥100,000 2
• Sperm freezing should be proposed when total sperm count falls below 1 million to avoid cancellation of ICSI attempts 2, 3
• Your count of 60 million/ml is 60-fold higher than this threshold 2

Recommended Clinical Algorithm

Step 1: Complete malignancy workup immediately:

• Urological consultation for testicular examination 1
• Consider testicular biopsy of the smaller testis if you're under 40 years old 1
• Testicular ultrasound to evaluate for masses 1

Step 2: Monitor fertility parameters:

• Repeat semen analysis in 6-12 months to establish whether sperm parameters are stable or declining 1
• If subsequent analysis shows total sperm count dropping below 1 million, then proceed with cryopreservation 1, 2

Step 3: If TIN or cancer is detected:

• Bank sperm immediately before any treatment (orchiectomy, chemotherapy, or radiotherapy), as these interventions will compromise or eliminate fertility 4, 1
• Collect at least 3 ejaculates if feasible to maximize stored samples 1
• Sperm should be collected before initiation of treatment because quality and DNA integrity may be compromised after a single treatment 4

Important Caveats

• If radiotherapy (20 Gy) is required for TIN treatment, the testis will become azoospermic, making banked sperm the only option for biological fatherhood 1
• The freezing process itself causes damage to sperm genetic integrity, resulting in decreased concentration and progressive motility after thawing 1, 5
• Sperm cryopreservation costs approximately €70,000 in European healthcare systems, and the likelihood of needing frozen sperm is extremely low in men with your current adequate concentration and motility 1

Why Your 2-Year Timeline Doesn't Change This Recommendation

• Your elevated testosterone (36 nmol/L, above the reference range of 8-29) and borderline-high FSH (9.9, range 1-12) suggest your remaining testicular tissue is functioning adequately 1
• Two stable semen analyses 3 months apart demonstrate no progressive decline requiring urgent preservation 1
• Natural conception remains highly feasible with your current parameters over the next 2 years 1

The priority is investigating the cause of your testicular atrophy, not rushing to freeze sperm that may never be needed. If malignancy is discovered, then immediate banking before treatment becomes essential 4, 1.