Is a modest drop in sperm concentration from 55 to 43 million per milliliter over two months, with normal follicle‑stimulating hormone, luteinizing hormone, and testosterone levels, clinically significant in a man with baggy scrotal skin and small‑appearing testes?

Your Sperm Parameters and Hormone Levels Are Reassuring

The modest drop in sperm concentration from 55 to 43 million/mL over two months is not clinically significant, and your hormone profile (FSH 9.8, LH 7.2, testosterone 40 nmol/L) indicates preserved testicular function with normal spermatogenesis. 1

Understanding Your Sperm Count

Your current sperm concentration of 43 million/mL substantially exceeds the WHO lower reference limit of 16 million/mL, placing you well within the normal fertile range. 2 The 12 million/mL decrease you observed falls within normal biological variation—sperm parameters naturally fluctuate by 20–30% between samples due to abstinence duration, illness, stress, and measurement variability. 2 Single comparisons between two analyses can be misleading, which is why repeat testing over 6–12 months is recommended to establish true trends rather than reacting to normal fluctuation. 2

Your Hormone Profile Indicates Normal Testicular Function

FSH Level of 9.8 IU/L

Your FSH sits in the upper-normal range but does not indicate testicular failure. While research shows that FSH >7.6 IU/L is associated with a five- to thirteen-fold higher risk of abnormal sperm parameters compared to FSH <2.8 IU/L 3, this statistical association applies to populations with documented oligospermia or azoospermia—not to men like you with sperm counts exceeding 40 million/mL. 2

The critical distinction: FSH >7.6 IU/L predicts non-obstructive azoospermia only when accompanied by testicular atrophy and absent or severely reduced sperm production. 2 Your documented normal sperm count of 43 million/mL confirms that your testes are producing sperm effectively despite the borderline-elevated FSH. 2

LH and Testosterone Levels

Your LH of 7.2 IU/L (upper-normal range) and testosterone of 40 nmol/L (high-normal to elevated) argue strongly against primary testicular failure. 2 In primary testicular dysfunction, you would expect both LH and FSH to be markedly elevated with low testosterone—a pattern you do not have. 2 Your hormone profile instead suggests mild compensatory pituitary stimulation with preserved Leydig cell function and adequate testosterone production. 2

Addressing Your Physical Concerns

Baggy Scrotal Skin

Scrotal skin laxity is a normal anatomical variant influenced by temperature regulation, age, and individual anatomy. It does not correlate with testicular function or sperm production. 1 The cremasteric reflex causes the scrotum to contract in cold environments and relax in warm conditions—this is protective physiology, not pathology.

Small-Appearing Testicles

Testicular volume is the critical measurement, not subjective appearance. Volumes below 12 mL are definitively considered atrophic and associated with impaired spermatogenesis, elevated FSH, and increased risk of intratubular germ cell neoplasia. 1 However, you have not reported measured testicular volumes.

If you are concerned about testicular size:

• Obtain formal measurement using a Prader orchidometer during physical examination or scrotal ultrasound with three perpendicular dimensions (length, width, height) to calculate volume using the Lambert formula: Length × Width × Height × 0.71. 1
• Testicular volumes ≥15–18 mL are associated with normal spermatogenesis and adequate fertility potential. 1
• A size discrepancy between testes >2 mL or 20% warrants ultrasound evaluation to exclude pathology such as varicocele or masses. 1

What You Should Do Next

Monitor, Don't Panic

• Repeat semen analysis in 3–6 months to establish whether your parameters are stable or declining, as single comparisons are unreliable. 2
• If your sperm concentration remains >20 million/mL on repeat testing, no further intervention is needed. 2

Physical Examination

Schedule evaluation by a urologist or male reproductive specialist to assess:

• Testicular volume using a Prader orchidometer (volumes <12 mL require further workup). 1
• Presence of varicocele on standing examination—palpable varicoceles with abnormal semen parameters are an indication for surgical repair. 4
• Testicular consistency and epididymal/vas deferens abnormalities. 2

Protect Your Fertility

• Avoid exogenous testosterone or anabolic steroids completely—these suppress FSH and LH through negative feedback, causing azoospermia that can take months to years to recover. 2
• Optimize modifiable factors: smoking cessation, maintain healthy body weight (BMI <25), minimize heat exposure to the testes (avoid hot tubs, prolonged sitting, laptop use on lap). 2
• Consider sperm cryopreservation only if follow-up semen analysis shows declining concentration approaching 20 million/mL or dropping below 5 million/mL. 2

When to Worry

Seek urgent urology referral if:

• Palpable testicular mass develops. 1
• Rapid testicular atrophy occurs (>2 mL volume loss over 6 months). 1
• Sperm concentration drops below 5 million/mL on repeat testing—this would trigger genetic testing (karyotype and Y-chromosome microdeletion analysis). 2

Common Pitfalls to Avoid

• Do not overinterpret single semen analyses—natural variability of 20–30% is expected. 2
• Do not assume FSH elevation equals testicular failure—your normal sperm count proves otherwise. 2
• Do not start testosterone therapy if you desire current or future fertility—it will suppress spermatogenesis. 2
• Do not delay female partner evaluation if you are actively trying to conceive—female age is the most critical factor determining conception success. 2