What are the potential causes and treatment options for my sudden onset of erectile dysfunction (ED), low libido, yellow semen, and very low semen volume, along with perceived testicular atrophy, given my lab results showing elevated Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) levels, low testosterone, and abnormal semen analysis, as well as a varicocele on the left side?

Assessment of Your Clinical Situation

Your hormone profile and clinical findings suggest compensated primary testicular dysfunction with oligospermia rather than complete testicular failure, and your left-sided varicocele is likely contributing to progressive testicular damage that warrants urgent intervention. 1, 2

Understanding Your Current Status

Hormone Profile Interpretation

Your laboratory results reveal a concerning but not catastrophic pattern:

• FSH 10.4 IU/L (upper normal range) indicates your pituitary is working harder to stimulate sperm production, reflecting mild-to-moderate testicular dysfunction. This level is elevated above the 7.6 IU/L threshold that suggests impaired spermatogenesis, but remains well below the >35 IU/L that would indicate complete primary testicular failure. 2, 3

• LH 7.0 IU/L (upper normal range) shows your pituitary is also compensating for some degree of testicular resistance, but the fact that LH remains within normal limits argues against complete primary testicular failure. 2

• Testosterone 35 nmol/L (approximately 1009 ng/dL) is actually in the high-normal to elevated range, making primary testicular failure unlikely. This preserved testosterone production indicates your Leydig cells (testosterone-producing cells) are still functioning adequately despite the spermatogenic impairment. 2

This pattern—mildly elevated FSH with normal LH and adequate testosterone—is the classic presentation of compensated primary testicular dysfunction with oligospermia, not azoospermia. 2

Semen Analysis Findings

Your semen analysis shows oligospermia with impaired quality but not complete absence of sperm:

• Sperm concentration 56 million/mL significantly exceeds the WHO lower reference limit of 16 million/mL, placing you well within the normal fertile range for concentration alone. 2

• Total motile sperm count (TMSC) approximately 92.4 million (56 million/mL × 3.3 mL × 50% motility) far exceeds the 10 million threshold associated with good natural conception rates. 2

• Morphology 5% is at the WHO lower reference limit of 4%, indicating borderline normal forms. 2

Your current sperm parameters support natural conception potential, though the declining testicular volume raises concern about progressive deterioration. 2

Testicular Volume Assessment

The ultrasound findings are the most concerning aspect:

• Initial measurement: 4 cm length suggests borderline testicular volume. 3

• Follow-up measurement 6 weeks later: 3.1-3.4 cm length, 9-12 mL volume confirms testicular atrophy, as volumes <12 mL are definitively considered atrophic and associated with impaired spermatogenesis. 3

• The documented decrease in size over 6 weeks is particularly worrying and suggests active, progressive testicular damage rather than stable chronic atrophy. 3

• Left-sided varicocele 3.4 mm is a grade 3 (large) varicocele that is directly contributing to testicular dysfunction through multiple mechanisms including elevated scrotal temperature, testicular hypoxia, and reflux of toxic metabolites. 4, 5

Primary Causes of Your Presentation

Varicocele as the Likely Culprit

Your grade 3 left varicocele is the most probable cause of your progressive testicular atrophy and declining function. 4, 5

• Varicoceles are present in 15% of normal males but 35-40% of men with infertility, and higher varicocele grade (grade 3) is associated with worse semen parameters and greater testicular dysfunction. 4

• Grade 3 bilateral varicoceles have been shown to cause significant reduction in testicular volume, with left testicular volume being particularly affected, and are associated with elevated FSH levels and reduced testosterone. 6

• The pathophysiology involves elevated scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased oxidative stress leading to DNA damage. 4, 5

• Varicoceles can cause hormonal alterations including decreased testosterone, elevated FSH and LH, and lower inhibin-B levels reflecting impaired Sertoli cell function. 5, 7

Other Potential Contributing Factors

While varicocele is the primary concern, other factors warrant evaluation:

• Yellow semen may indicate infection, though your semen analysis showed no white blood cells. Subclinical infection or inflammation could still contribute. 1

• Sudden onset 8 months ago suggests an acute trigger rather than longstanding congenital condition. Consider whether any medications, supplements (especially anabolic steroids or testosterone), toxin exposures, or systemic illness preceded symptom onset. 1, 2

• Low semen volume (3.3 mL is at the lower end of normal, with 1.5 mL being the WHO lower limit) could suggest partial ejaculatory duct obstruction or androgen deficiency affecting accessory gland function, though your testosterone level argues against the latter. 2

Critical Next Steps

Immediate Actions Required

1. Genetic Testing (Mandatory Before Any Intervention)

You must obtain karyotype analysis and Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) immediately, as chromosomal abnormalities occur in approximately 4% of men with sperm counts <5 million/mL. While your count is higher, the combination of elevated FSH and testicular atrophy warrants this evaluation. 2, 4

• Complete AZFa or AZFb deletions predict near-zero sperm retrieval success and would contraindicate varicocele repair. 2, 4
• AZFc deletions are associated with variable presentation but still allow potential benefit from varicocele repair. 2

2. Sperm Cryopreservation (Urgent)

You should bank sperm immediately—ideally 2-3 separate ejaculates with 2-3 days abstinence between collections—before any intervention or further decline occurs. 2

• Your current sperm parameters are adequate for cryopreservation and future assisted reproductive technology. 2
• Banking multiple ejaculates provides insurance against technical failures, poor post-thaw recovery, or need for multiple treatment attempts. 2
• Once azoospermia develops, even microsurgical testicular sperm extraction (micro-TESE) only achieves 40-50% sperm retrieval rates. 2

3. Repeat Semen Analysis

Perform at least one additional semen analysis in 2-3 months to establish whether parameters are stable or declining, as single analyses can be misleading due to natural variability. 2, 3

Varicocele Repair Consideration

Varicocelectomy is strongly indicated in your case given the combination of:

• Clinical (palpable) grade 3 varicocele 4
• Documented testicular atrophy with progressive volume loss 4, 3
• Elevated FSH indicating testicular dysfunction 4, 7
• Desire for fertility preservation 4

Expected outcomes from varicocele repair:

• Testosterone improvement: Meta-analysis shows mean increase of 82.45 ng/dL after varicocele repair, with restoration to levels comparable to healthy controls. 7

• FSH reduction: Significant decrease in FSH levels (mean -1.43 IU/L) after repair, indicating improved testicular function. 7

• Testicular volume stabilization: Varicocele repair may halt progressive atrophy, though volume recovery is variable. 4

• Semen parameter improvement: Takes 3-6 months (two spermatogenic cycles) to manifest. 4

Your FSH level of 10.4 IU/L is below the 11.7 mIU/mL threshold that predicts favorable surgical outcomes, suggesting you are a good candidate for varicocele repair. 4

Critical Medications to Avoid

Never use exogenous testosterone or anabolic steroids if you desire current or future fertility. These agents completely suppress FSH and LH through negative feedback on the hypothalamus and pituitary, causing azoospermia that can take months to years to recover—and may never fully recover given your already compromised testicular reserve. 1, 2, 4

Addressing Your Specific Concerns

Fertility Prognosis

Your current fertility potential is good but at risk of progressive decline:

• Your TMSC of approximately 92 million far exceeds the 10 million threshold for good natural conception rates. 2
• With a female partner under 30 years old, you would have >90% chance of achieving pregnancy within 2-3 years of trying under normal circumstances. 2
• However, the documented progressive testicular atrophy over 6 weeks is alarming and suggests ongoing damage that could lead to severe oligospermia or azoospermia if left untreated. 3

Risk of Progression to Azoospermia

Your risk of developing azoospermia is elevated but not inevitable:

• Men with FSH levels >7.6 IU/L have a 5-13 fold higher risk of abnormal sperm concentration, but this indicates reduced counts, not necessarily complete absence. 2
• The combination of grade 3 varicocele, progressive testicular atrophy, and elevated FSH places you at significant risk for continued deterioration. 4, 6
• Varicocele repair can halt this progression and potentially reverse some damage, particularly if performed before irreversible testicular injury occurs. 4, 7

Testicular Volume Discrepancy

The difference between your two ultrasound measurements (4 cm initially, then 3.1-3.4 cm six weeks later) likely represents:

• True progressive atrophy occurring over the 6-week interval, which is concerning and suggests active ongoing damage. 3
• Measurement variability between operators or techniques, though a change of this magnitude is unlikely to be purely technical. 2
• Different measurement protocols (length alone vs. ellipsoid volume calculation). 3

The fact that both measurements show volumes <12 mL confirms true testicular atrophy regardless of the exact measurement. 3

Treatment Algorithm

Step 1: Obtain genetic testing (karyotype and Y-chromosome microdeletions) immediately. 2, 4

Step 2: Bank 2-3 ejaculates for sperm cryopreservation before any intervention. 2

Step 3: If genetic testing shows no complete AZFa or AZFb deletions, proceed with varicocelectomy (preferably microsurgical or laparoscopic approach). 4

Step 4: Repeat semen analysis and hormonal evaluation (FSH, LH, testosterone) at 3 and 6 months post-operatively to assess response. 4, 7

Step 5: If semen parameters remain abnormal or decline further despite varicocele repair, consider assisted reproductive technology (IVF/ICSI) rather than empiric hormonal therapy, as ART offers superior pregnancy rates. 2

Step 6: If azoospermia develops despite intervention, microsurgical testicular sperm extraction (micro-TESE) offers 40-50% sperm retrieval rates even with elevated FSH. 2

Common Pitfalls to Avoid

• Do not delay sperm banking while pursuing diagnostic workup or awaiting surgery—your testicular function is declining and you may lose this window. 2

• Do not accept reassurance based solely on "normal" testosterone levels—your testosterone is maintained through compensatory LH elevation, but this does not protect against progressive spermatogenic failure. 2, 8

• Do not treat subclinical varicoceles if ultrasound identifies additional non-palpable varicoceles—only clinical (palpable) varicoceles benefit from repair. 4

• Do not use empiric hormonal therapy (clomiphene, FSH injections, aromatase inhibitors) as first-line treatment—these have limited benefits that are outweighed by ART advantages, and varicocele repair addresses the underlying cause. 2, 4

• Do not assume stable testicular function—your documented volume loss over 6 weeks indicates active progression requiring urgent intervention. 3