What could be causing my testicular atrophy with normal sperm count (60 million per milliliter), slightly elevated Follicle-Stimulating Hormone (FSH) level (9.9), normal Testosterone level (39.9), and normal Luteinizing Hormone (LH) level (7.2)?

Testicular Atrophy with Normal Sperm Count: Evaluation and Management

Understanding Your Clinical Picture

Your hormone profile and sperm count suggest mild testicular dysfunction with preserved spermatogenesis, but the perceived testicular atrophy warrants objective measurement and evaluation for reversible causes. 1

Your FSH of 9.9 IU/L is mildly elevated (normal upper limit typically 7.6 IU/L), which indicates your pituitary is working harder to maintain sperm production, suggesting some degree of testicular resistance or impaired function. 1, 2 However, your sperm count of 60 million/mL is well above the WHO reference limit of 16 million/mL, confirming that you are currently producing sperm normally despite the elevated FSH. 3

Critical First Step: Objective Testicular Measurement

You must obtain objective testicular volume measurement using a Prader orchidometer or scrotal ultrasound, as subjective perception of testicular size is unreliable. 4

• Testicular volumes below 12 mL are definitively considered atrophic and associated with impaired spermatogenesis and increased cancer risk, particularly in men under 30-40 years. 4
• If ultrasound is performed, ensure the radiologist uses the Lambert formula (Length × Width × Height × 0.71) rather than the ellipsoid formula (0.52 coefficient), as the latter systematically underestimates volume by 20-30%. 4
• Normal testicular volume is approximately 15-18 mL, corresponding to a length of about 4 cm. 4

Essential Diagnostic Workup

Complete Hormonal Panel

Measure LH and total testosterone to distinguish primary testicular failure from secondary causes, and check thyroid function as thyroid disorders commonly disrupt the hypothalamic-pituitary-gonadal axis. 1

• Your LH of 7.2 IU/L appears normal-to-mildly elevated, suggesting your pituitary is compensating for some testicular resistance. 1
• Your testosterone of 39.9 (assuming nmol/L, which equals approximately 1150 ng/dL) is high-normal to elevated, making primary testicular failure less likely. 1
• Check TSH and free T4, as both hyperthyroidism and hypothyroidism can elevate FSH and impair spermatogenesis through disruption of the gonadal axis. 1

Repeat Semen Analysis

Obtain at least one additional semen analysis in 2-3 months, as single analyses can be misleading due to natural variability. 3

• Proper collection requires 2-3 days abstinence, analysis within one hour, and transport at room or body temperature. 3
• This establishes whether your sperm parameters are stable or declining. 1

Physical Examination by Urologist

Evaluation for varicocele is essential, as this is a reversible cause of testicular atrophy and elevated FSH. 1

• Varicocele repair can halt progression of testicular atrophy, reduce FSH, and improve testosterone levels. 1
• Check for testicular consistency, size discrepancy between testes (>2 mL or 20% warrants further evaluation), and vas deferens/epididymal abnormalities. 4

Reversible Causes to Address

Metabolic and Lifestyle Factors

• Optimize body weight if BMI >25, as obesity and metabolic syndrome impair male fertility and can elevate FSH. 1
• Avoid heat exposure to the testes (hot tubs, saunas, tight underwear, laptop use on lap). 1
• Smoking cessation if applicable, as smoking impairs spermatogenesis. 1

Medication Review

Never use exogenous testosterone or anabolic steroids if you desire current or future fertility, as these completely suppress spermatogenesis through negative feedback, causing azoospermia that can take months to years to recover. 1

• Review all medications for potential gonadotoxic effects. 1
• Endothelin antagonists (bosentan, sitaxsentan) used for pulmonary hypertension can cause testicular atrophy and male infertility. 5

Genetic Testing Considerations

Genetic testing is NOT currently indicated with your sperm count of 60 million/mL, but would become mandatory if your count drops below 5 million/mL. 1

• Karyotype analysis (to exclude Klinefelter syndrome) and Y-chromosome microdeletion testing are recommended only when sperm concentration falls below 5 million/mL with elevated FSH. 1
• Complete AZFa and AZFb deletions predict near-zero sperm retrieval success. 1

Fertility Preservation Strategy

Given your elevated FSH and perceived testicular atrophy, strongly consider sperm cryopreservation now while parameters remain normal. 1

• Bank 2-3 separate ejaculates with 2-3 days abstinence between collections. 1
• This provides insurance against future decline, as once azoospermia develops, even microsurgical testicular sperm extraction (micro-TESE) only achieves 40-50% sperm retrieval rates. 1
• Men with elevated FSH and reduced testicular reserve are at risk for progressive spermatogenic failure. 1

Monitoring Protocol

Repeat semen analysis every 6-12 months to detect early decline in sperm parameters. 1

• If sperm concentration drops below 20 million/mL or approaches 5 million/mL, urgently proceed with additional sperm banking. 1
• Recheck FSH, LH, testosterone, and thyroid function after 3-6 months of metabolic optimization. 1

Critical Pitfalls to Avoid

• Do not assume normal fertility based solely on current sperm count – your elevated FSH indicates reduced testicular reserve and compensatory pituitary drive. 1, 2
• Do not delay objective testicular measurement – subjective perception is unreliable, and true atrophy requires different management. 4
• Do not start testosterone therapy – this will cause azoospermia and eliminate your current fertility. 1
• Do not ignore varicocele if present – this is the most common reversible cause of progressive testicular damage. 1

When to Seek Urgent Urology Referral

• Palpable testicular mass develops 4
• Rapid testicular atrophy occurs 4
• Sperm concentration drops below 5 million/mL 1
• Confirmed testicular volume <12 mL on ultrasound, especially if age <30 years with history of undescended testicles 4

Bottom Line

Your FSH of 9.9 IU/L with normal sperm count represents a compensated state where your pituitary is working harder to maintain normal spermatogenesis. 1, 2 The key question is whether true testicular atrophy exists (requiring objective measurement) and whether reversible causes (varicocele, thyroid dysfunction, metabolic factors) are present. 1, 4 Sperm banking now provides critical insurance against future decline, as your elevated FSH indicates reduced testicular reserve despite currently normal sperm production. 1