What's the next step in my treatment for testicular atrophy given my normal ultrasound results?

Next Steps After Normal Ultrasound in Testicular Atrophy

Your normal ultrasound does not rule out testicular atrophy or its underlying causes—proceed immediately with hormonal evaluation (FSH, LH, testosterone), semen analysis, and consider genetic testing if sperm counts are severely reduced. 1

Understanding What "Normal Ultrasound" Actually Means

A "normal" ultrasound report can be misleading in testicular atrophy cases. Testicular atrophy is objectively defined as testicular volume less than 12 mL, and this should have been documented on your ultrasound if present 2. However, sonographers may not always explicitly state "atrophy" in the report even when volumes are reduced, focusing instead on ruling out masses, torsion, or structural abnormalities 2.

Critical Points About Your Ultrasound:

• Verify the actual testicular volumes measured—if they reported volumes less than 12 mL, you have confirmed atrophy regardless of whether they used that term 1, 2
• Ultrasound primarily excludes acute surgical emergencies (torsion, tumors, infections) but does not assess the functional capacity of your testes to produce sperm 3, 1
• Men with testicular atrophy have an 11.9-fold higher cancer risk, particularly with history of cryptorchidism or family history, so document any microcalcifications or suspicious findings 2

Mandatory Next Steps: Hormonal Evaluation

Order morning blood tests on at least two separate occasions measuring 1:

• FSH (Follicle-Stimulating Hormone): Elevated FSH above 7.6 IU/L strongly suggests spermatogenic failure and primary testicular dysfunction 1, 4
• LH (Luteinizing Hormone): Helps distinguish primary testicular failure (elevated LH) from secondary hypogonadism (low/normal LH) 1
• Total testosterone: Low testosterone with elevated LH/FSH confirms primary testicular failure 1
• SHBG (Sex Hormone-Binding Globulin): Calculate free testosterone, as elevated SHBG can reduce bioavailable testosterone even with normal total levels 1

Interpreting Your Hormone Results:

If FSH >7.6 IU/L with testicular atrophy: This indicates significant spermatogenic impairment, though up to 50% of men may still have retrievable sperm via microsurgical testicular sperm extraction (micro-TESE) 1, 4

If FSH 7.6-12 IU/L: Expect oligospermia (reduced sperm count) rather than complete azoospermia, but genetic testing becomes mandatory if sperm concentration drops below 5 million/mL 1, 4

If low/low-normal LH with low testosterone: This suggests secondary hypogonadism from pituitary dysfunction—measure prolactin immediately 1

Essential: Semen Analysis

Obtain at least two semen analyses separated by 2-3 months to establish baseline fertility status 1. Single analyses are misleading due to natural variability, and you need to know whether you have:

• Normal sperm production (≥16 million/mL concentration, ≥39 million total count per WHO criteria) 1
• Oligospermia (reduced but present sperm)
• Azoospermia (complete absence of sperm) 4

Critical Timing Consideration:

If any sperm are present, bank 2-3 separate ejaculate samples immediately before parameters potentially decline further 1. Once azoospermia develops, even micro-TESE only achieves 40-50% sperm retrieval rates 1.

Genetic Testing: When It's Mandatory

Proceed with genetic testing if 1, 4:

• Sperm concentration <5 million/mL with elevated FSH
• Confirmed azoospermia or severe oligospermia
• Testicular volume <12 mL with elevated FSH

Required tests include 1:

1. Karyotype analysis: Screens for Klinefelter syndrome (47,XXY), the most common chromosomal cause of testicular atrophy and spermatogenic failure
2. Y-chromosome microdeletion testing (AZFa, AZFb, AZFc regions): Complete AZFa or AZFb deletions predict near-zero sperm retrieval success and contraindicate testicular sperm extraction

Evaluate for Reversible Causes

Before concluding your testicular atrophy is permanent, rule out these treatable conditions 1:

Medications Causing Testicular Suppression:

• Exogenous testosterone or anabolic steroids: Causes reversible testicular atrophy and azoospermia through negative feedback—discontinue immediately if fertility is desired 1
• Opioids, corticosteroids: Suppress the hypothalamic-pituitary-gonadal axis 1

Systemic Conditions:

• Thyroid dysfunction: Hyperthyroidism causes asthenozoospermia, oligozoospermia, and teratozoospermia—all reversible with treatment 1
• Varicocele: Palpable varicoceles contribute to progressive testicular damage; repair can halt atrophy progression and improve semen parameters 1
• Metabolic syndrome/obesity: Weight loss and metabolic optimization can normalize gonadotropins 1

Physical Examination Priorities:

• Check for varicocele on standing examination—grade 3 varicoceles are strongly associated with progressive testicular damage 1
• Assess for cryptorchidism history—the single most important cancer risk factor and cause of atrophy 1
• Measure testicular volumes with Prader orchidometer if ultrasound volumes weren't clearly documented 1

Cancer Surveillance Requirements

Men with testicular atrophy require ongoing monitoring 3, 1:

• Testicular volumes <12 mL carry 34% risk of testicular intraepithelial neoplasia (TIN) in men under age 40 3
• If untreated, invasive testicular tumor develops in 70% of TIN-positive testes within 7 years 3
• Perform monthly testicular self-examination for early detection of masses 1
• Consider testicular biopsy if you have testicular microcalcifications on ultrasound plus atrophy 1

Treatment Algorithm Based on Fertility Goals

If Fertility Is Desired NOW:

1. Never start exogenous testosterone—it will cause complete azoospermia that takes months to years to recover 1
2. If secondary hypogonadism (low LH/FSH with low testosterone): Start hCG injections to stimulate testosterone production and spermatogenesis, add FSH analogues if sperm counts remain low after testosterone normalizes 1
3. If palpable varicocele with abnormal semen parameters: Varicocele repair can improve sperm concentration, motility, morphology, and halt testicular atrophy progression 1
4. If non-obstructive azoospermia with elevated FSH: Micro-TESE offers 40-60% sperm retrieval rates; it's 1.5 times more successful than conventional TESE 1, 4

If Fertility Is NOT Currently Desired:

• Testosterone replacement therapy is appropriate only after fertility goals are abandoned 1
• Continue cancer surveillance with regular self-examination 1

Common Pitfalls to Avoid

Do not treat subclinical varicoceles found only on ultrasound—only palpable varicoceles improve fertility outcomes after repair 1

Do not rely on FSH levels alone to predict fertility—men with maturation arrest can have normal FSH despite severe spermatogenic dysfunction 1, 4

Do not delay sperm banking if parameters are declining—once azoospermia develops, retrieval success drops to 40-50% even with micro-TESE 1

Do not assume normal ultrasound means normal fertility—functional assessment requires hormonal evaluation and semen analysis 1