I have a low sperm count of 50 million per milliliter (mL) in a semen volume of 3.3 mL, elevated Follicle-Stimulating Hormone (FSH) level of 10.4, and small testicles, could I have testicular atrophy?

Assessment of Testicular Atrophy with Your Clinical Parameters

Based on your sperm count of 50 million/mL, semen volume of 3.3 mL, FSH of 10.4 IU/L, and small testicles, you likely have borderline testicular atrophy with reduced testicular reserve, though not complete testicular failure. 1

Understanding Your Testicular Status

Your clinical picture suggests impaired but not absent spermatogenesis:

• Testicular volumes below 12 mL are definitively considered atrophic and associated with impaired spermatogenesis 2
• Your FSH of 10.4 IU/L is elevated above the 7.6 IU/L threshold that indicates testicular dysfunction, but this level is consistent with oligospermia rather than complete testicular failure 1
• Men with FSH levels >7.5 IU/L have a five- to thirteen-fold higher risk of abnormal sperm concentration compared to men with FSH <2.8 IU/L 3

The combination of small testicles and elevated FSH indicates reduced testicular reserve, meaning your testes have less capacity to compensate if additional stressors occur (medications, illness, environmental exposures) 1

Your Sperm Parameters in Context

Your sperm count of 50 million/mL with 3.3 mL volume gives you approximately 165 million total sperm, which is:

• Above the WHO lower reference limit of 16 million/mL for concentration 1
• However, the elevated FSH suggests your testicular function is working harder to maintain this output 1
• Testicular volume strongly correlates with total sperm count and sperm concentration, and smaller volumes predict declining function 4, 5, 6

Critical Next Steps

Immediate Evaluation Required:

• Measure LH and total testosterone to distinguish primary testicular failure from secondary hypogonadism 1
• Check prolactin to exclude hyperprolactinemia, which can elevate FSH 1
• Assess thyroid function (TSH, free T4) as thyroid disorders commonly affect reproductive hormones 1
• Obtain repeat semen analysis in 3-6 months to determine if parameters are stable or declining 1

Genetic Testing Considerations:

• Karyotype analysis is recommended if sperm concentration drops below 5 million/mL to exclude Klinefelter syndrome and other chromosomal abnormalities 1
• Y-chromosome microdeletion testing is mandatory if concentration falls below 1 million/mL 1

Physical Examination Priorities:

• Evaluate for varicocele on standing examination, as repair can improve fertility in men with clinical varicoceles and abnormal semen parameters 1
• Assess testicular consistency and check for size discrepancy >2 mL or 20% between testes, which warrants scrotal ultrasound 2

Fertility Preservation Strategy

Given your reduced testicular reserve, strongly consider sperm cryopreservation now:

• Bank at least 2-3 ejaculates to provide backup samples and maximize future fertility options 1
• Once azoospermia develops, even microsurgical testicular sperm extraction (micro-TESE) only achieves 40-50% sperm retrieval rates 1
• Collect 2-3 separate ejaculates with 2-3 days abstinence between collections, splitting each into multiple vials for staged use 1

Critical Actions to Protect Fertility

Absolute Contraindications:

• Never use exogenous testosterone or anabolic steroids - these completely suppress spermatogenesis through negative feedback and can cause azoospermia that takes months to years to recover 1
• Avoid gonadotoxic medications when possible 1

Modifiable Risk Factors:

• Smoking cessation - directly impairs spermatogenesis 1
• Maintain healthy body weight (BMI <25) - obesity and metabolic syndrome impair male fertility 1
• Minimize heat exposure to testes - avoid hot tubs, saunas, laptop computers on lap 1
• Optimize diabetes control if applicable - metabolic stress affects the hypothalamic-pituitary-gonadal axis 1

Monitoring and Follow-Up

Repeat semen analysis every 6 months to detect early decline in sperm parameters 1

Red Flags Requiring Urgent Urology Referral:

• Palpable testicular mass develops 1
• Rapid testicular atrophy occurs 1
• Severe oligospermia (<5 million/mL) develops 1
• Progressive decline in sperm concentration on serial analyses 1

Treatment Options if Parameters Decline

• Varicocelectomy can halt progression of testicular atrophy and potentially reverse some damage if clinical varicocele is present 1
• Assisted reproductive technology (IVF/ICSI) offers superior pregnancy rates compared to empiric hormonal therapy 1
• Micro-TESE offers 40-50% sperm retrieval rates even with elevated FSH if azoospermia develops 1

Important Caveats

• FSH levels alone cannot definitively predict fertility status - up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm 1
• Biofunctional sperm parameters (DNA fragmentation, chromatin compactness) worsen with decreasing testicular volume, even when conventional parameters appear acceptable 4
• Your current sperm count suggests you are not yet at the point of complete testicular failure, but the elevated FSH and small testicles indicate vulnerability to further decline 1, 3