I'm a male with small testicles (3.1-4cm in length), a left-sided varicocele (2.8mm), and normal sperm parameters (concentration 60 million/ml, motility 60%, morphology 8%), follicle-stimulating hormone (FSH) level of 9.9, luteinizing hormone (LH) level of 7.2, and testosterone level of 40 nmol/l, should I be concerned about testicular atrophy and consider freezing sperm?

Your Fertility Status is Reassuring and Does Not Require Immediate Sperm Freezing

Based on your excellent sperm parameters (60 million/ml concentration, 60% motility, 8% morphology) and normal hormonal profile, you do not need to freeze sperm now, and your testicular size measurements likely reflect technical measurement error rather than true atrophy. 1

Understanding Your Test Results

Your Sperm Parameters Are Excellent

• Your sperm concentration of 60 million/ml is nearly 4 times higher than the WHO lower reference limit of 16 million/ml, placing you well within the normal fertile range 1
• Your motility of 60% and morphology of 8% are both normal and support excellent fertility potential 1
• Your total motile sperm count (approximately 36 million per ejaculate) far exceeds the 10 million threshold associated with good natural conception rates 1
• With these parameters, you have a >90% chance of achieving natural conception within 2-3 years if your female partner is under 30 years old 1

Your Hormone Levels Are Normal

• Your FSH of 9.9 IU/L (range 1-12.4) is within the normal range and does not indicate testicular failure 1
• FSH levels >7.6 IU/L are associated with some degree of testicular dysfunction when accompanied by azoospermia or severe oligospermia, but this does not apply to you since your sperm count is excellent 1
• Your LH of 7.2 IU/L and testosterone of 40 nmol/L (approximately 1150 ng/dL) are both normal, arguing strongly against primary testicular failure 1
• The pattern of normal LH with adequate testosterone indicates your testes are receiving appropriate hormonal signals and responding normally 1

The Testicular Size Discrepancy Is Likely Measurement Error

The dramatic difference between your two ultrasound measurements (4cm vs 3.1cm) over just 4 weeks is almost certainly due to technical measurement error, not true biological change. 2

• True biological change in testicular size over 4 weeks is extremely unlikely in adults unless there is acute pathology like torsion or infection 2
• A 4cm testicular length corresponds to a volume of approximately 15-18ml using proper measurement technique, which is normal 2
• The 3.1cm measurement would correspond to approximately 8-10ml, which would be severely atrophic and completely inconsistent with your excellent sperm parameters 2
• Technical errors in caliper placement during ultrasound commonly lead to incorrect measurements, particularly for the width dimension 2

If your testicular volume were truly 8-10ml (as the 3.1cm measurement suggests), you would likely have severe oligospermia or azoospermia, not a sperm count of 60 million/ml. 1, 2

Addressing Your High SHBG

High SHBG Does Not Directly Impair Sperm Production

• Your SHBG of 92 nmol/L is elevated, but this does not directly impair spermatogenesis 1
• Sperm production depends on intratesticular testosterone (ITT), which is 50-100 times higher than serum levels and is maintained by LH stimulation of Leydig cells 1
• Since your LH is normal (7.2 IU/L), your testes are receiving appropriate signals to produce both ITT and sperm, regardless of high SHBG 1

Potential Causes of High SHBG to Investigate

• Hyperthyroidism directly increases SHBG production and can cause oligospermia and asthenozoospermia that are reversible with treatment 1
• Liver disease can elevate SHBG 1
• Certain medications can increase SHBG 1

You should have your thyroid function checked (TSH, free T4) to exclude hyperthyroidism as a reversible cause of elevated SHBG. 1

Your Left-Sided Varicocele

The 2.8mm Varicocele Is Small and Unlikely to Be Clinically Significant

• Only palpable (clinical) varicoceles warrant treatment, as subclinical (non-palpable, ultrasound-detected only) varicoceles do not improve semen parameters or fertility rates when treated 3
• A 2.8mm varicocele is typically subclinical and not palpable on physical examination 3
• Given your excellent sperm parameters, this small varicocele is not causing significant testicular dysfunction 3

When Varicocele Treatment Is Indicated

• Varicocele repair is indicated for palpable varicoceles with abnormal semen parameters (typically sperm concentration <15 million/ml) 3
• Varicocele repair can improve testosterone levels, reduce FSH, and stabilize testicular volume in men with clinical varicoceles and impaired semen parameters 4, 5
• In your case, with excellent sperm parameters, varicocele repair is not indicated 3

What You Should Do Now

Immediate Actions

1. Do NOT freeze sperm at this time - your current fertility status is excellent and does not warrant cryopreservation 1
2. Request a repeat scrotal ultrasound with explicit attention to proper measurement technique to confirm testicular volume and resolve the measurement discrepancy 2
3. Check thyroid function (TSH, free T4) to exclude hyperthyroidism as a cause of elevated SHBG 1
4. Have a physical examination by a urologist to assess whether your varicocele is palpable and to confirm testicular consistency 3

Monitoring and Follow-Up

• Repeat semen analysis in 6-12 months to establish whether your sperm parameters are stable 1
• If follow-up semen analysis shows declining sperm concentration (approaching 20 million/ml or dropping below 5 million/ml), then consider sperm cryopreservation 1
• Recheck FSH, LH, testosterone, and SHBG after addressing any reversible causes (thyroid dysfunction, metabolic factors) 1

Protective Actions to Maintain Fertility

• Never use exogenous testosterone or anabolic steroids - these will completely suppress spermatogenesis through negative feedback, causing azoospermia that can take months to years to recover 1
• Avoid gonadotoxic exposures (chemotherapy, radiation, certain medications) when possible 1
• Optimize modifiable factors: smoking cessation, maintain healthy body weight (BMI <25), minimize heat exposure to testes 1

Common Pitfalls to Avoid

• Do not panic about the testicular size discrepancy - the dramatic difference between measurements is almost certainly technical error, not true atrophy 2
• Do not pursue varicocele repair based on ultrasound findings alone - only palpable varicoceles with abnormal semen parameters benefit from treatment 3
• Do not start testosterone therapy - this would be catastrophic for your fertility 1
• Do not delay thyroid evaluation - hyperthyroidism is a reversible cause of elevated SHBG and can impair semen quality 1

When to Consider Sperm Cryopreservation in the Future

You should consider sperm banking if any of the following occur:

• Follow-up semen analysis shows declining sperm concentration (approaching 20 million/ml or below 5 million/ml) 1
• You require chemotherapy, radiation therapy, or other gonadotoxic treatment 1
• Repeat ultrasound confirms true testicular atrophy (volume <12ml) with declining sperm parameters 1, 2
• You develop azoospermia or severe oligospermia (<5 million/ml) 1

In your current situation, with excellent sperm parameters and normal hormonal function, immediate sperm cryopreservation is not indicated. 1