What fertility management steps should I take as a male with well-controlled type 1 diabetes, healthy body mass index (BMI), and controlled hypothyroidism, with a thyroid-stimulating hormone (TSH) level within range, and no modifiable factors?

Next Steps for Male Fertility Management with Well-Controlled Type 1 Diabetes

You should obtain a comprehensive semen analysis as your first priority, followed by targeted hormonal evaluation (FSH, LH, testosterone) and genetic testing if indicated, while simultaneously optimizing your diabetes control and thyroid management to protect your fertility potential. 1, 2

Immediate Diagnostic Evaluation

Semen Analysis

• Obtain at least two semen analyses separated by 2-3 months to establish baseline fertility status and account for natural variability 1, 2
• Single analyses are insufficient for diagnosis given the inherent variability in sperm parameters 3
• Each analysis should include: volume, sperm concentration, total sperm count, progressive motility, total motility, and morphology 1
• The laboratory should centrifuge any sample showing low sperm counts and re-examine the pellet under wet mount microscopy for rare sperm 1

Hormonal Assessment

• Measure serum FSH, LH, and total testosterone on a morning sample to distinguish primary testicular dysfunction from secondary hypogonadism 1, 4
• Check serum prolactin to exclude hyperprolactinemia, which can disrupt gonadotropin secretion 2
• Recheck TSH and free T4 to ensure your thyroid replacement is optimized, as even subtle thyroid dysfunction can impair spermatogenesis 1, 2

Physical Examination Priorities

• Measure testicular volume using a Prader orchidometer (normal >12 mL per testis) 1, 2
• Examine for varicocele on standing examination, as this is a correctable cause of infertility 1
• Assess vas deferens and epididymal consistency 1

Understanding Your Diabetes-Related Fertility Risk

Direct Effects of Type 1 Diabetes

Type 1 diabetes can impair male fertility through multiple mechanisms, even when well-controlled 5, 6:

• Reduced sperm motility: Meta-analysis shows progressive motility is 33.62% lower in men with type 1 diabetes compared to controls 5
• Decreased semen volume: Trend toward lower seminal volume, particularly in men with longer disease duration 5, 7
• Impaired sperm morphology: Significantly lower normal sperm morphology in diabetic men 5, 7
• Lower total sperm count: Some studies show reduced total sperm count, though concentration may be preserved 6

Critical Protective Actions

• Never use exogenous testosterone if you desire fertility—it will completely suppress spermatogenesis through negative feedback, potentially causing azoospermia that takes months to years to recover 1, 2
• Avoid anabolic steroids for the same reason 2
• Maintain HbA1c <7% as optimal glycemic control minimizes oxidative damage to spermatogenesis 1, 6

Thyroid Optimization Strategy

Your controlled hypothyroidism requires careful management for fertility 1, 2:

• If your TSH is in the upper half of the reference range, consider increasing levothyroxine to bring TSH to the lower portion of the reference range 2
• Thyroid hormone directly increases SHBG production, and even subtle over-replacement or under-replacement can significantly affect fertility 2
• Inadequate thyroid replacement can elevate SHBG and impair spermatogenesis through disruption of the hypothalamic-pituitary-gonadal axis 2
• Recheck thyroid function every 3-6 months after any dose adjustment 1

Genetic Testing Indications

Proceed with genetic testing only if your semen analysis reveals 1, 2:

• Azoospermia (no sperm after centrifugation): Obtain karyotype analysis and Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions) 1
• Severe oligospermia (<5 million/mL) with elevated FSH or testicular atrophy: Obtain karyotype and Y-chromosome microdeletion testing 1
• Sperm concentration 0-1 million/mL: 5% risk of Y-chromosome microdeletions 1
• Sperm concentration 1-5 million/mL: 0.8% risk of Y-chromosome microdeletions 1

Fertility Preservation Considerations

When to Consider Sperm Banking

Consider sperm cryopreservation immediately if your semen analysis shows 2:

• Declining sperm parameters on repeat testing
• Testicular volume <12 mL with elevated FSH
• Sperm concentration <15 million/mL with progressive decline

Banking Protocol

• Collect 2-3 separate ejaculates with 2-3 days abstinence between collections 2
• Each collection should be split into multiple vials to allow for staged use 2
• This provides insurance against technical failures, poor post-thaw recovery, or need for multiple treatment attempts 2

Monitoring and Follow-Up

If Initial Semen Analysis is Normal

• Repeat semen analysis every 12-24 months to monitor for progressive decline 2, 5
• Continue optimizing diabetes control (HbA1c <7%) and thyroid function 1
• Maintain healthy BMI and avoid gonadotoxic exposures 1, 2

If Semen Analysis Shows Abnormalities

• Repeat analysis in 3 months to confirm findings 1, 2
• Proceed with hormonal evaluation and genetic testing as indicated above 1
• Consider varicocele repair if clinical varicocele is present with abnormal semen parameters 1, 2
• Discuss assisted reproductive technology (IVF/ICSI) early if female partner age is a concern, as ART offers superior pregnancy rates compared to empiric hormonal therapy 1, 2

Common Pitfalls to Avoid

• Do not delay semen analysis—type 1 diabetes can progressively impair fertility over time, and early baseline assessment is critical 5, 6
• Do not assume normal fertility based on controlled diabetes alone—even well-controlled diabetic men show significant reductions in sperm quality 5, 6
• Do not start testosterone therapy without first banking sperm if you desire future fertility 1, 2
• Do not rely on a single semen analysis—natural variability requires at least two samples for accurate assessment 1, 3