I'm a 20-50 year old male with normal sperm count (60 million/ml) and follicle-stimulating hormone (FSH) level (9.9, range 1-12.4), but I have small testicles, could this affect my fertility?

Small Testicles with Normal Sperm Count and FSH: Fertility Assessment

Your fertility is likely preserved despite small testicular size, as evidenced by your normal sperm count (60 million/ml) and borderline-normal FSH (9.9 IU/L), though you have reduced testicular reserve that warrants monitoring and protective measures. 1

Understanding Your Current Status

Your clinical picture presents an important paradox that requires careful interpretation:

• Sperm count of 60 million/ml significantly exceeds the WHO lower reference limit of 16 million/ml, confirming current normal sperm production despite small testicular size 1
• FSH of 9.9 IU/L falls in the borderline-elevated range (normal reference 1-12.4 IU/L), suggesting your pituitary is working harder to maintain spermatogenesis, indicating reduced but not absent testicular reserve 2, 3
• Small testicular size (likely <12ml based on your concern) represents reduced testicular reserve, meaning you have less capacity to compensate if additional stressors occur, though this has not yet impaired your sperm production 1

The key insight: FSH levels between 7.6-10 IU/L typically indicate some degree of impaired spermatogenesis but not necessarily complete absence of sperm production, and your normal sperm count confirms this 4. Research shows men with FSH >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, but this represents increased risk, not certainty 3.

Critical Testicular Volume Thresholds

Understanding testicular size is essential for your prognosis:

• Testicular volumes <12ml are definitively considered atrophic and associated with impaired spermatogenesis risk 1
• Mean testicular volume strongly correlates with total sperm count and sperm concentration, with volumes of 15-18ml associated with normal spermatogenesis 1
• Critical volume thresholds from research: mean sperm density enters the oligozoospermic range when testicular volume falls below 10ml, length below 3.5cm, depth below 1.75cm, or width below 2.5cm 5
• Total testicular volume (both testes combined) below 20ml by ultrasound or below 30ml by Prader orchidometer indicates subnormal total sperm count 6

Your normal sperm count suggests your testicular volume, while small, has not yet crossed these critical functional thresholds.

Essential Next Steps for Complete Evaluation

Immediate Diagnostic Workup

Measure complete hormonal panel to fully characterize your hypothalamic-pituitary-testicular axis 1:

• LH and total testosterone to distinguish primary testicular dysfunction from secondary causes 2
• Calculate free testosterone using SHBG, as elevated SHBG can reduce bioavailable testosterone even with normal total testosterone 4
• Check thyroid function (TSH, free T4), as thyroid disorders commonly affect reproductive hormones and can elevate FSH 4
• Measure prolactin to exclude hyperprolactinemia, which can disrupt gonadotropin secretion 4

Physical Examination Priorities

Evaluation by a male reproductive specialist focusing on 1:

• Varicocele presence on standing examination - clinical varicoceles with abnormal semen parameters warrant repair, which can improve testosterone, reduce FSH, and stabilize testicular volume 4
• Testicular consistency and any size discrepancy >2ml or 20% between testes, which warrants scrotal ultrasound to exclude pathology 1
• Epididymal abnormalities and vas deferens patency 2

Genetic Testing Considerations

Genetic testing is NOT currently indicated for you because it's only recommended when sperm concentration is <5 million/ml 2, 4. However, if your sperm count declines below this threshold on future testing, you would need:

• Karyotype analysis to exclude Klinefelter syndrome and chromosomal abnormalities 2
• Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions), which becomes mandatory if concentration drops <1 million/ml 2

Risk of Progression and Protective Actions

Factors That Could Accelerate Decline

Absolutely avoid these fertility-destroying exposures 4:

• Exogenous testosterone or anabolic steroids will completely suppress spermatogenesis through negative feedback, causing azoospermia that can take months to years to recover - this is the single most important pitfall to avoid 4
• Chemotherapy or radiotherapy can cause additional impairment for up to 2 years following treatment 4
• Gonadotoxic medications should be avoided when possible 4

Optimize modifiable factors 4:

• Maintain healthy body weight (BMI <25), as obesity and metabolic syndrome impair male fertility 4
• Smoking cessation and minimizing heat exposure to testes 4
• Optimize diabetes control if present, as metabolic stress affects the hypothalamic-pituitary-gonadal axis 4

Monitoring Strategy

Repeat semen analysis every 6-12 months to detect early decline in sperm parameters, as single analyses can be misleading due to natural variability 4. Consider sperm cryopreservation if follow-up shows declining trend, especially if approaching 20 million/ml or dropping below 5 million/ml 4.

Fertility Preservation Considerations

Banking 2-3 ejaculates is strongly recommended if 4:

• You anticipate any gonadotoxic exposures (chemotherapy, radiation, certain medications)
• Follow-up semen analysis shows declining sperm concentration
• You want insurance against future deterioration given your reduced testicular reserve

The rationale: once azoospermia develops, even microsurgical testicular sperm extraction (micro-TESE) only achieves 40-50% sperm retrieval rates 4. Banking now, while sperm production is normal, provides optimal fertility preservation.

Conception Probability and Timeline

Your current fertility status is excellent for natural conception:

• Sperm concentration of 60 million/ml places you well within the normal fertile range 4
• Total motile sperm count (TMSC) likely exceeds 10 million, the threshold associated with good natural conception rates 4
• If female partner is under 30 with good fertility, you have >90% chance of achieving pregnancy within 2-3 years of trying 4

Seek fertility assistance if 4:

• No conception after 12 months of timed intercourse (or 6 months if female partner >35 years)
• Female partner has known fertility factors
• Semen parameters decline on repeat testing

Important Caveats

FSH levels alone cannot definitively predict fertility status - men with maturation arrest on testicular histology can have normal FSH and testicular volume despite severe spermatogenic dysfunction 2. Your normal sperm count is the definitive evidence that spermatogenesis is currently adequate.

Testicular volume and FSH represent your testicular reserve, not your current function - think of it like having a smaller gas tank that's currently full. You can drive normally now, but you have less reserve if problems develop 1.

If varicocele is found on examination, repair is strongly indicated given your borderline testicular reserve, as it can halt progression of testicular atrophy and potentially reverse some damage 4.