What are the implications of having a high Follicle-Stimulating Hormone (FSH) level of 9.9, small testicle size, and a sperm production of 60 million per milliliter (mL) on my fertility?

Your Fertility Status is Reassuring Despite Borderline FSH

With a sperm concentration of 60 million/mL, you have normal sperm production that far exceeds the WHO reference limit of 16 million/mL, and your borderline FSH of 9.9 IU/L does not preclude fertility—in fact, your actual sperm count is the most important indicator, not the FSH level alone. 1

Understanding Your Numbers

Your situation demonstrates an important clinical principle: FSH levels alone cannot definitively predict fertility status—up to 50% of men with non-obstructive azoospermia and elevated FSH still have retrievable sperm, and you already have documented normal sperm production. 1

What Your FSH Level Means

• FSH of 9.9 IU/L is borderline elevated (above the 7.6 IU/L threshold) but does not indicate testicular failure 1, 2
• This level suggests your pituitary is working slightly harder to maintain spermatogenesis, indicating some degree of testicular stress but not dysfunction 1
• Men with FSH levels between 7.6-10 IU/L typically have some degree of impaired spermatogenesis efficiency but not necessarily reduced sperm counts 1
• Your sperm count of 60 million/mL proves your testes are responding adequately despite the borderline FSH 1

Small Testicle Size Context

• Testicular volumes <12 mL are considered small and associated with reduced testicular reserve 1
• However, testicular volume does not directly predict sperm presence—even men with small testes can maintain normal spermatogenesis 1
• Your documented sperm count confirms that despite small size, your testes are producing sperm normally 1

Essential Next Steps

Immediate Actions

• Obtain at least two complete semen analyses 2-3 months apart to confirm your parameters are stable and not declining 1, 3
• Measure complete hormonal panel: LH, total testosterone, and SHBG to calculate free testosterone 1, 4
• Check prolactin to exclude hyperprolactinemia, which can disrupt gonadotropin secretion 5, 1
• Evaluate thyroid function (TSH, free T4) as thyroid disorders commonly affect reproductive hormones 1, 4

Physical Examination Priorities

• Testicular consistency and presence of varicocele on standing examination 1, 3
• Body mass index and waist circumference, as obesity directly impacts the hypothalamic-pituitary-gonadal axis 4

Address Reversible Factors

• Weight optimization if BMI >25—obesity and metabolic syndrome impair male fertility, and weight loss can normalize gonadotropins 1, 4
• Smoking cessation and minimizing heat exposure to testes 1
• Evaluate for metabolic stress, acute illness, or medications that could temporarily elevate FSH 4

Critical Pitfalls to Avoid

Never Use Testosterone Therapy

If you desire current or future fertility, never take exogenous testosterone or anabolic steroids—these completely suppress FSH and LH through negative feedback, causing azoospermia that can take months to years to recover. 5, 1, 4, 3

Genetic Testing Indications

• Genetic testing (karyotype and Y-chromosome microdeletions) is only indicated if your sperm concentration drops below 5 million/mL on repeat testing 5, 1, 3
• With your current count of 60 million/mL, genetic testing is not warranted 1

Fertility Preservation Strategy

Consider Sperm Banking

• Given your reduced testicular reserve (small testes + borderline FSH), strongly consider banking 2-3 ejaculates now as insurance against future decline 1
• Once azoospermia develops, even microsurgical testicular sperm extraction only achieves 40-50% retrieval rates 1, 4
• Banking multiple specimens provides backup against technical failures or need for multiple treatment attempts 1

Monitoring Protocol

• Repeat semen analysis every 6-12 months to detect any declining trend 1
• If sperm concentration drops toward 20 million/mL or below, immediately proceed with cryopreservation 1
• Recheck FSH, LH, testosterone after 3-6 months if metabolic optimization is undertaken 1

Treatment Considerations if Parameters Decline

If Future Testing Shows Worsening

• FSH analogue treatment may improve sperm concentration in idiopathic infertility with FSH <12 IU/L, though benefits are modest 1, 4, 3
• Selective estrogen receptor modulators or aromatase inhibitors have limited benefits compared to assisted reproductive technology 1, 4
• IVF/ICSI offers superior pregnancy rates and should be discussed early if parameters worsen 1, 4

Varicocele Evaluation

• Physical examination should specifically assess for varicocele, as repair can improve semen parameters and testosterone levels 1
• Varicocele repair is indicated if you have a palpable varicocele with documented oligospermia 1

Your Fertility Outlook

Your total motile sperm count (approximately 36 million per ejaculate assuming 60% motility and 3 mL volume) far exceeds the 10 million threshold associated with good natural conception rates. 1

• Couples with male TMSC >10 million have excellent natural conception probability 1
• Female partner age is the most critical factor determining conception success 1
• With a female partner under 30, you have >90% chance of achieving pregnancy within 2-3 years of trying 1

The combination of borderline FSH with small testes indicates you have reduced testicular reserve, but your current sperm production is normal and sufficient for natural conception. The key is monitoring for decline and protecting your fertility through lifestyle optimization and avoiding gonadotoxic exposures. 1, 4