What are the implications and treatment options for a 20-50 year old male with bilateral testicular atrophy, normal sperm count, and normal testosterone levels?

Bilateral Testicular Atrophy with Normal Sperm Count and Testosterone

Your bilateral testicular atrophy with preserved fertility and hormonal function represents a reassuring but uncommon scenario that requires cancer risk stratification and long-term monitoring rather than immediate intervention. 1, 2

Understanding Your Situation

Your case is paradoxical because testicular volumes below 12 mL are definitively considered atrophic and typically associated with impaired spermatogenesis and elevated FSH levels above 7.6 IU/L. 1, 3 However, your normal sperm count and testosterone indicate that despite reduced testicular size, your remaining testicular tissue is functioning adequately. 3

The critical issue is not your current fertility or hormonal status—it's your significantly elevated cancer risk. 1, 2

Immediate Risk Assessment Required

High-Priority Risk Factors to Evaluate:

• Age under 30-40 years with testicular volume <12 mL carries a ≥34% risk of testicular intraepithelial neoplasia (TIN) if testicular cancer develops, and if untreated, invasive testicular tumor develops in 70% of TIN-positive testes within 7 years. 1, 2

• History of cryptorchidism (undescended testicles) is the single most important risk factor—this substantially increases cancer risk and mandates closer surveillance. 4, 1, 2

• Testicular microcalcifications on ultrasound increase testicular cancer risk 18-fold in patients with testicular atrophy. 3

• Size discrepancy between testes >2 mL or 20% warrants ultrasound evaluation to exclude pathology, regardless of absolute volume. 1

Required Diagnostic Workup

Mandatory Initial Testing:

• Scrotal ultrasound with high-frequency probes (>10 MHz) using standardized three-dimensional measurements (length, width, height) calculated with the Lambert formula (Length × Width × Height × 0.71). 1, 2 The traditional ellipsoid formula systematically underestimates volume and may lead to inappropriate classification. 1

• Complete hormonal panel: FSH, LH, total testosterone, and consider SHBG to calculate free testosterone. 1 Even with normal testosterone, the FSH level is critical—elevated FSH (>7.6 IU/L) with testicular atrophy strongly suggests underlying spermatogenic stress despite your current normal sperm count. 3

• Tumor markers (AFP, β-HCG, LDH) should be obtained before any surgical intervention if testicular cancer is suspected. 2

Additional Testing Based on Risk Factors:

• If you are under 30 years old with history of cryptorchidism: Contralateral testicular biopsy is strongly indicated given the 34% TIN risk. 1, 2

• Karyotype testing if sperm concentration drops below 5 million/mL, as chromosomal abnormalities occur in 10% of these patients. 1

• Y-chromosome microdeletion testing if sperm concentration is <1 million/mL or azoospermia develops. 3

Management Strategy

If You Are Age <30 Years with History of Cryptorchidism:

Refer for testicular biopsy immediately—this is non-negotiable given your >34% risk of TIN. 1, 2 The European Association of Urology strongly recommends contralateral testicular biopsy in patients with testicular cancer who have volumes <12 mL, especially those under 30 years. 1

If You Are Age >30 Years WITHOUT History of Cryptorchidism:

• Teach yourself testicular self-examination and perform it monthly—you have increased cancer risk with smaller volumes. 1, 2

• Annual physical examination with attention to both testes for any masses, changes in consistency, or further size reduction. 2

• Repeat semen analysis every 1-2 years to monitor for declining sperm parameters, as this would indicate progressive testicular dysfunction. 3

• Annual testosterone monitoring, as bilateral atrophy may eventually lead to hypogonadism requiring replacement therapy. 2

If Testicular Microcalcifications Are Present on Ultrasound:

You should be offered testicular biopsy due to the 18-fold increased risk of testicular germ cell tumors. 3

Fertility Preservation Considerations

Sperm cryopreservation should be discussed now, particularly given bilateral testicular pathology. 2 While your current sperm count is normal, the combination of bilateral atrophy and elevated FSH (if present) indicates reduced testicular reserve—meaning you have less capacity to compensate if additional stressors occur. 1

Common Pitfalls to Avoid

• Do not assume normal fertility parameters mean you can defer cancer surveillance—these are independent issues. 1, 2

• Do not treat subclinical varicoceles found on ultrasound—only palpable varicoceles improve fertility outcomes after repair. 3

• Do not use a single semen analysis to make long-term decisions—natural variability requires repeat testing if parameters decline. 3

• Ensure ultrasound measurements use the Lambert formula (0.71 coefficient), not the traditional ellipsoid formula (0.52 coefficient), which systematically underestimates volume. 1

When to Seek Urgent Urology Referral

• Palpable testicular mass develops 1
• Rapid testicular atrophy occurs 1
• Severe oligospermia (<5 million/mL) develops 1
• Testosterone levels decline into hypogonadal range 2

Underlying Causes to Investigate

• Chronic medication use (opioids, corticosteroids, anabolic steroids) can suppress the hypothalamic-pituitary-gonadal axis. 3

• Systemic diseases (HIV/AIDS, diabetes, prior chemotherapy, testicular radiation) can cause progressive testicular damage. 3

• History of testicular torsion, even if remote, causes ischemic atrophy. 5

• Myotonic dystrophy can present with testicular atrophy and hypogonadism before neurological manifestations appear. 6