Do I have testicular atrophy given my ultrasound (USS) results showing a decrease in testicle size from 4cm to 3.1cm and 3.4cm, with hormone levels including elevated Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), and Testosterone, as well as low sperm count and motility?

Assessment of Your Testicular Status

Based on your ultrasound measurements, hormone levels, and sperm parameters, you do NOT have clinically significant testicular atrophy, and your fertility status is reassuringly normal. Your testicular volumes of 9ml bilaterally place you just below the 12ml threshold that defines atrophy, but your excellent sperm production (60 million/ml with 50% motility) and high-normal testosterone (39.9 nmol/L) demonstrate that your testes are functioning well despite their borderline size 1, 2.

Understanding Your Testicular Measurements

The apparent "shrinkage" from 4cm to 3.1-3.4cm is most likely due to measurement error rather than true atrophy. A 4cm testicular length corresponds to approximately 15-18ml volume, while your reported 9ml volumes would correspond to testes measuring approximately 2.5-2.8cm in length 2. This dramatic discrepancy strongly suggests the initial 4cm measurement was inaccurate or the volume calculations used incorrect formulas 2.

Technical Measurement Issues to Consider:

• Ultrasound volume calculations are highly operator-dependent, with common errors including incorrect caliper placement, using the wrong mathematical formula (0.52 vs 0.71 coefficient), or measuring at different testicular axes 2.
• The Lambert formula (Length × Width × Height × 0.71) should be used for accurate volume calculation, as the traditional ellipsoid formula (0.52 coefficient) systematically underestimates volume by 20-30% 2.
• Single measurements are unreliable – you should request a repeat scrotal ultrasound with explicit attention to proper measurement technique, ideally by the same sonographer using standardized technique 2.

Your Hormone Profile Analysis

Your FSH of 10.0 IU/L (upper normal range) combined with LH 7.2 IU/L and testosterone 39.9 nmol/L indicates mild compensated testicular dysfunction, NOT testicular failure. This pattern shows your pituitary is working slightly harder to maintain excellent testosterone production and sperm output 1.

What Your Hormones Tell Us:

• FSH >7.6 IU/L suggests some degree of impaired spermatogenesis, but your actual sperm count of 60 million/ml (nearly 4 times the WHO lower reference limit of 16 million/ml) proves your testes are producing sperm very effectively despite the mildly elevated FSH 1, 3.
• Your testosterone of 39.9 nmol/L is actually elevated above the normal range (8-29 nmol/L), which argues strongly against primary testicular failure – men with true testicular atrophy typically have low or low-normal testosterone 4, 1.
• The combination of borderline-elevated FSH with normal LH and high testosterone is the classic pattern of oligospermia with compensated testicular function, not progressive testicular failure 1.

Your Fertility Status

Your sperm parameters are excellent and place you well within the fertile range. A concentration of 60 million/ml with 50% motility gives you a total motile sperm count (TMSC) of approximately 36 million per ejaculate, which far exceeds the 10 million threshold associated with good natural conception rates 1.

Key Fertility Facts:

• Men with testicular volumes of 9-12ml typically have oligospermia rather than azoospermia, and your sperm count confirms this pattern 1, 2.
• FSH levels alone cannot predict fertility status – up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm, and you already have abundant sperm in your ejaculate 1, 5.
• Your fertility prognosis is good, with natural conception highly likely given your sperm parameters 1.

Do You Have Testicular Atrophy?

Technically, volumes <12ml are considered small or atrophic by strict definition, but functionally your testes are performing normally. The critical distinction is between anatomical size and functional capacity – your testes may be smaller than average, but they are producing normal amounts of testosterone and abundant sperm 2, 6.

Important Context:

• Testicular volume strongly correlates with sperm count, and your 60 million/ml concentration is consistent with testicular volumes in the 12-15ml range, suggesting your actual volume may be larger than measured 2, 6.
• True testicular atrophy causing infertility is characterized by volumes <12ml PLUS elevated FSH >7.6 IU/L PLUS azoospermia or severe oligospermia (<5 million/ml) – you have only the first two criteria, not the third 1, 3.
• Men with non-obstructive azoospermia typically present with testicular volumes <12ml, elevated FSH, and absent or severely reduced sperm production – your robust sperm production excludes this diagnosis 1, 3.

Recommended Next Steps

Essential Immediate Actions:

• Request a repeat scrotal ultrasound with explicit instructions to use the Lambert formula (0.71 coefficient) and measure three perpendicular dimensions carefully 2.
• Repeat semen analysis in 3-6 months to establish whether your parameters are stable or declining, as single analyses can be misleading 1.
• Measure complete hormonal panel including LH, total testosterone, and SHBG to calculate free testosterone, as your elevated total testosterone with borderline FSH warrants full characterization 4, 1.

Genetic Testing Considerations:

• Karyotype analysis and Y-chromosome microdeletion testing are NOT indicated at this time given your normal sperm concentration >5 million/ml 4, 1, 3.
• These tests would only be recommended if your sperm count drops below 5 million/ml on repeat analysis 4, 3.

Fertility Preservation Strategy:

• Consider sperm cryopreservation (banking 2-3 ejaculates) if you have concerns about future decline, though this is optional given your current excellent parameters 1.
• Avoid exogenous testosterone or anabolic steroids completely, as these will suppress FSH and LH through negative feedback, causing azoospermia that can take months to years to recover 4, 1, 7.

Critical Pitfalls to Avoid

• Do NOT start testosterone replacement therapy – your testosterone is already elevated, and exogenous testosterone will completely shut down sperm production 4, 1, 7.
• Do NOT assume progressive decline is inevitable – many men with borderline testicular volumes and mildly elevated FSH maintain stable fertility for years 1.
• Do NOT rely on a single ultrasound measurement – the discrepancy between your 4cm and 3.1-3.4cm measurements strongly suggests measurement error 2.

Monitoring Plan

• Repeat semen analysis every 6-12 months to detect any early decline in sperm parameters 1, 2.
• Recheck FSH, LH, and testosterone annually to monitor for progression of testicular dysfunction 4, 1.
• Perform physical examination checking for varicocele, testicular consistency, and any size changes 1, 3.
• If sperm concentration drops below 20 million/ml or testicular volume decreases further, consider urology referral for comprehensive evaluation 1, 2.