I am a young adult male with a one‑year history of low libido, erectile dysfunction, prior watery ejaculate now resolved, small testes on ultrasound (reduced volume), elevated sex hormone‑binding globulin, high‑normal luteinizing hormone, normal‑high follicle‑stimulating hormone, elevated total testosterone, normal sperm concentration, and testes that remain relaxed during erection—does this indicate testicular atrophy and how should I manage fertility for planned children in 3‑4 years?

Your Testicular Volume and Hormonal Profile Do Not Indicate Progressive Atrophy—Focus on Addressing Elevated SHBG and Preserving Current Fertility

Based on your sperm counts (56 and 43 million/mL), testicular volumes (9 mL bilateral), and hormonal pattern, you have oligospermia with compensated testicular function—not testicular atrophy—and your fertility preservation strategy should prioritize identifying and treating the cause of your elevated SHBG while avoiding any interventions that suppress spermatogenesis. 1

Understanding Your Testicular Volume Measurements

Your testicular volume discrepancy between ultrasounds reflects measurement variability, not progressive atrophy:

• Testicular volumes of 9 mL bilaterally place you just below the 12 mL threshold that defines reduced testicular reserve, but this does not indicate active atrophy. 1 The difference between 4 cm length (suggesting ~12-15 mL volume) and the reported 9 mL likely reflects inter-observer variability between the consultant radiologist and sonographer, as ultrasound volume calculations are operator-dependent. 1

• Your sperm concentrations of 56 and 43 million/mL far exceed the WHO lower reference limit of 16 million/mL, confirming that your testes are producing sperm normally despite borderline volume. 1 This pattern indicates compensated testicular function, not failure.

• The relaxed cremasteric reflex during erections is a benign finding unrelated to testicular atrophy or fertility. This reflects autonomic nervous system variation and has no clinical significance for spermatogenesis. 2, 3

Your Hormonal Pattern Indicates Compensated Primary Testicular Dysfunction—Not Progressive Failure

Your hormone profile reveals mild testicular stress with successful compensation:

• FSH 9.9 IU/L (upper normal range) indicates your pituitary is working harder to maintain spermatogenesis, but this level does not predict progressive decline. 1 FSH >7.6 IU/L is associated with some degree of testicular dysfunction, but your normal sperm counts prove your testes are responding adequately. 1

• LH 7.2 IU/L (high-normal) shows your pituitary is compensating for mild testicular resistance, but this is not elevated enough to indicate primary testicular failure. 4 Primary testicular failure typically shows LH >12-15 IU/L with low testosterone—your testosterone of 40 nmol/L (1154 ng/dL) is actually elevated, not low. 4

• Your elevated total testosterone (40 nmol/L) combined with high-normal LH indicates your Leydig cells are functioning well, producing adequate intratesticular testosterone to support spermatogenesis. 1 This pattern argues strongly against progressive testicular failure.

Elevated SHBG Is Your Primary Problem—Not Testicular Atrophy

Your SHBG of 99 nmol/L is severely elevated and is the most likely cause of your sexual symptoms, not testicular dysfunction:

• High SHBG binds testosterone tightly, reducing bioavailable testosterone despite your elevated total testosterone. 5 This explains your low libido and erectile dysfunction—your tissues are not receiving adequate free testosterone even though total testosterone is high.

• Common causes of elevated SHBG include hyperthyroidism, hepatic disease, HIV/AIDS, smoking, aging, and certain medications (anticonvulsants, estrogens, thyroid hormone). 5 You stated "checked all bloods and unknown cause for high SHBG," but this requires systematic re-evaluation:

  • Measure TSH and free T4 to exclude hyperthyroidism or thyroid hormone over-replacement. 5, 1 Even subtle thyroid dysfunction significantly affects SHBG.
  • Obtain comprehensive metabolic panel and liver function tests to exclude hepatic disease. 5
  • Review all medications and supplements—anticonvulsants, thyroid hormone, and even some herbal supplements can elevate SHBG. 5
  • Check HIV status if not recently tested. 5

• Calculate your free testosterone index (total testosterone ÷ SHBG) to quantify bioavailable testosterone. 1 With total testosterone 40 nmol/L and SHBG 99 nmol/L, your free testosterone index is approximately 0.40, which is low-normal to borderline low despite elevated total testosterone. This explains your symptoms.

Your Fertility Prognosis Is Good—But Requires Proactive Protection

Your current sperm counts place you well within the fertile range, but your borderline testicular reserve requires protective strategies:

• Sperm concentrations of 43-56 million/mL exceed the WHO reference limit of 16 million/mL by 2.5-3.5 times, confirming normal fertility potential. 1 With a 3 mL ejaculate volume, your total sperm count is approximately 129-168 million per ejaculate, far exceeding the 39 million threshold. 1

• Your total motile sperm count (assuming 40% motility) would be approximately 52-67 million, which far exceeds the 10 million threshold associated with good natural conception rates. 1 This gives you an excellent prognosis for natural conception within 3-4 years.

• However, your borderline testicular volume (9 mL) and elevated FSH (9.9 IU/L) indicate reduced testicular reserve, meaning you have less margin for error if additional insults occur. 1 You have already frozen sperm, which is the single most important protective action—this provides insurance against any future decline.

Critical Actions to Protect Your Fertility Over the Next 3-4 Years

Immediate Priorities (Next 1-3 Months)

1. Identify and treat the cause of elevated SHBG:

   • Repeat TSH, free T4, and comprehensive metabolic panel. 5, 1
   • Review all medications and supplements with your physician. 5
   • If hyperthyroidism is present, treatment will normalize SHBG and likely resolve your sexual symptoms. 1

2. Calculate free testosterone to confirm bioavailable testosterone deficiency:

   • Measure SHBG and calculate free testosterone index (total testosterone ÷ SHBG). 1 If <0.3, this confirms functional hypogonadism despite elevated total testosterone.

3. Repeat semen analysis in 3 months to establish stability:

   • Single analyses can be misleading due to natural variability. 1 A stable or improving count is reassuring; a declining trend warrants earlier intervention.

Absolute Contraindications—Never Do These

• Never use exogenous testosterone or anabolic steroids. 1 These will completely suppress FSH and LH through negative feedback, causing azoospermia that can take months to years to recover—even after stopping. 1, 6

• Avoid finasteride (Propecia) for hair loss. 2 This can worsen sexual dysfunction and may affect semen parameters in men with borderline testicular reserve.

• Minimize heat exposure to the testes—avoid hot tubs, saunas, and prolonged sitting. 1

Lifestyle Optimization

• Maintain healthy body weight (BMI <25). 5, 1 Obesity and metabolic syndrome impair male fertility and elevate SHBG.

• Smoking cessation if applicable. 5, 1 Smoking elevates SHBG and impairs spermatogenesis.

• Optimize glycemic control if diabetic. 1 Metabolic stress affects the hypothalamic-pituitary-gonadal axis.

When to Seek Fertility Assistance

Your timeline of 3-4 years for children is reasonable, but female partner age is the critical variable:

• If your female partner is under 30, you have an excellent prognosis for natural conception with >90% chance of pregnancy within 2-3 years of trying. 1 Your sperm parameters support expectant management for 6-12 months of timed intercourse.

• If your female partner is over 35, consider earlier fertility evaluation (after 6 months of trying) given age-related decline in female fertility. 1 Your sperm counts support intrauterine insemination (IUI) with ovarian stimulation as a first-line intervention if needed.

• If sperm counts decline below 20 million/mL on repeat testing, proceed directly to IVF/ICSI, which offers superior pregnancy rates compared to empiric hormonal therapy. 1 Your frozen sperm provides backup if fresh samples decline.

Addressing Your Emotional Distress

Your anxiety about testicular atrophy is understandable but not supported by your clinical data:

• Your sperm counts are normal, your testosterone production is robust, and your testicular volumes—while borderline—are stable between measurements when accounting for inter-observer variability. 1

• Your sexual symptoms (low libido, ED) are almost certainly due to reduced bioavailable testosterone from elevated SHBG, not testicular failure. 5 Treating the underlying cause of elevated SHBG should resolve these symptoms.

• The watery semen that has now normalized was likely a temporary phenomenon related to sexual frequency, hydration, or anxiety—not progressive testicular disease. 1

Summary Algorithm

1. Identify cause of elevated SHBG (thyroid, liver, medications) → Treat underlying condition → Expect improvement in sexual symptoms 5
2. Calculate free testosterone index → If <0.3, confirms functional hypogonadism despite high total testosterone 1
3. Repeat semen analysis in 3 months → If stable/improving, continue expectant management → If declining, consider earlier fertility intervention 1
4. Avoid exogenous testosterone, anabolic steroids, and finasteride → These will suppress spermatogenesis 1, 2, 6
5. Optimize lifestyle (weight, smoking cessation, minimize heat exposure) → Protects testicular function 5, 1
6. Begin trying to conceive when ready → If no pregnancy after 6-12 months, proceed to IUI or IVF/ICSI depending on female partner age 1

Your frozen sperm provides excellent insurance, your current sperm counts are normal, and your hormonal pattern indicates compensated testicular function—not progressive failure. Focus on identifying and treating the cause of your elevated SHBG, which is almost certainly responsible for your sexual symptoms. 5, 1