What are the implications and management options for a male of reproductive age with bilateral testicular atrophy, normal sperm count and testosterone levels, but elevated Follicle-Stimulating Hormone (FSH) levels?

Bilateral Testicular Atrophy with Normal Sperm Count and FSH 9.8 IU/L

Your FSH level of 9.8 IU/L with bilateral testicular atrophy warrants immediate evaluation for testicular intraepithelial neoplasia (TIN) and consideration of contralateral testicular biopsy, as men under 40 with testicular atrophy have a 34% risk of TIN, which progresses to invasive testicular cancer in 70% within 7 years if untreated. 1

Understanding Your Clinical Picture

Your presentation is unusual but not impossible. While FSH 9.8 IU/L falls within the laboratory reference range (1-12.4 IU/L), research demonstrates that FSH levels >7.6 IU/L are associated with testicular dysfunction and significantly increased risk of abnormal semen parameters 2. The combination of bilateral testicular atrophy with preserved sperm count suggests you may have:

• Compensated testicular dysfunction - Your pituitary is producing more FSH to maintain adequate sperm production despite reduced testicular reserve 2, 3
• Early-stage testicular pathology - Testicular atrophy in reproductive-age men is not normal and requires investigation for underlying causes including TIN 1

Immediate Priority: Rule Out Testicular Cancer Risk

Contralateral testicular biopsy should be strongly considered given your bilateral testicular atrophy, especially if you are under 40 years old 1. The European consensus guidelines specifically identify testicular atrophy (volume <12 ml) in men under 40 as the highest risk category for TIN, with up to 34% prevalence 1.

• If TIN is detected and left untreated, invasive testicular cancer develops in 70% of cases within 7 years 1
• The sensitivity and specificity of a single random biopsy for detecting TIN is very high 1
• You should be informed about this risk and offered biopsy, with the final decision being yours based on whether you prefer active surveillance versus definitive diagnosis 1

Essential Diagnostic Workup

Confirm Your Semen Parameters Are Stable

• Obtain at least two semen analyses separated by 2-3 months after 2-7 days of abstinence 1, 4
• Single analyses can be misleading due to natural variability, and your FSH level suggests you may have declining testicular reserve 4
• Document sperm concentration, total motile sperm count, morphology, and volume 1

Complete Hormonal Assessment

• Measure total testosterone, LH, and prolactin alongside your FSH to evaluate the entire hypothalamic-pituitary-gonadal axis 1, 4
• Check SHBG to calculate free testosterone, as total testosterone alone may not reflect bioavailable hormone levels 4
• Evaluate thyroid function (TSH, free T4) as thyroid disorders commonly affect reproductive hormones and can cause testicular dysfunction 4

Physical Examination Priorities

• Document testicular volume bilaterally using orchidometer or ultrasound - volumes <12 ml confirm atrophy 1
• Assess for varicocele on physical examination 1
• Measure BMI and waist circumference as metabolic parameters directly impact the HPG axis 4

Testicular Ultrasound

• 7.5 MHz transducer testicular sonography should be performed to evaluate testicular size, echotexture, and rule out masses 1
• This imaging is essential given your bilateral atrophy to exclude occult testicular pathology 1

Genetic Testing Considerations

If repeat semen analysis shows sperm concentration <5 million/mL or severe oligospermia, proceed with:

• Karyotype analysis to exclude Klinefelter syndrome (47,XXY) and other chromosomal abnormalities 1, 5
• Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) 1, 5

Understanding Your Prognosis

The good news is that 30% of men with azoospermia, testicular atrophy, and FSH levels 3+ times normal still have mature sperm on testicular biopsy 6. Your situation is actually more favorable since you currently have sperm in your ejaculate. However:

• FSH levels >7.5 IU/L carry a 5- to 13-fold higher risk of abnormal semen parameters compared to FSH <2.8 IU/L 2
• Your FSH of 9.8 IU/L indicates your pituitary is working harder to maintain spermatogenesis, suggesting reduced testicular reserve 4, 2
• Men with elevated FSH and testicular atrophy are at risk for progressive spermatogenic failure 5

Critical Management Decisions

If You Desire Future Fertility

• Consider sperm cryopreservation now as a protective measure, especially if follow-up analyses show declining trends 5
• Collect at least 2-3 ejaculates if possible for optimal preservation 5
• Once azoospermia develops, even microsurgical testicular sperm extraction only achieves 40-50% retrieval rates 4, 5

Address Reversible Factors Before Repeat Testing

• Weight optimization if BMI >25 - weight loss through low-calorie diets can reverse obesity-associated secondary hypogonadism and normalize gonadotropins 4
• Smoking cessation and minimizing heat exposure to testes 5
• Optimize thyroid function if TSH is abnormal, as even subtle thyroid dysfunction can impair spermatogenesis 4
• Evaluate for drugs/substances that interfere with testosterone production 4

What to Absolutely Avoid

Never start testosterone therapy if fertility is a current or future concern - exogenous testosterone will completely suppress spermatogenesis through negative feedback on the hypothalamus and pituitary, potentially causing azoospermia that takes months to years to recover 4, 5, 7.

Follow-Up Timeline

• Repeat complete hormonal panel (FSH, LH, testosterone, SHBG, prolactin, thyroid function) after addressing metabolic factors 4
• Repeat semen analysis in 3-6 months to establish whether parameters are stable or declining 5
• If FSH normalizes to 7-9 IU/L after metabolic optimization, continue lifestyle modifications 4
• If parameters remain abnormal or worsen, consider fertility preservation counseling and assisted reproductive technology consultation 4

When to Consider Treatment

• FSH analogue treatment may be considered for idiopathic infertility with FSH <12 IU/L to improve sperm concentration, though benefits are modest 4, 7
• Selective estrogen receptor modulators (SERMs) or aromatase inhibitors may be used but have limited benefits compared to assisted reproductive technology 4, 7
• Assisted reproductive technology (IVF/ICSI) offers superior pregnancy rates and should be discussed early, especially considering female partner age 4, 5

Common Pitfalls to Avoid

• Do not reassure yourself that FSH of 9.8 is "normal" without further workup - this level with bilateral atrophy warrants thorough investigation 4
• Do not delay testicular biopsy discussion if you are under 40 with testicular atrophy - the TIN risk is substantial 1
• Do not assume stable fertility - men with abnormal semen parameters have higher rates of testicular cancer and increased mortality compared to fertile men 5