My serum testosterone is normal but my doctor confirmed testicular atrophy; what steps should I take?

Testicular Atrophy with Normal Testosterone: Evaluation and Management

You need a comprehensive hormonal evaluation (FSH, LH, free testosterone, prolactin) and semen analysis to determine whether your testicular atrophy represents compensated testicular dysfunction or early primary testicular failure, because normal serum testosterone does not exclude significant testicular pathology. 1, 2, 3

Understanding Your Clinical Situation

Your presentation—confirmed testicular atrophy with normal serum testosterone—suggests one of two scenarios:

Compensated Testicular Function

• Your pituitary is producing elevated LH and FSH to maintain normal testosterone despite reduced testicular reserve 3
• Testosterone remains normal but at the cost of increased hormonal drive 3
• Spermatogenesis may already be impaired even though testosterone appears adequate 3

Early Primary Testicular Failure

• Testicular volumes below 12 mL are definitively considered atrophic and associated with impaired spermatogenesis 2, 3
• FSH levels typically exceed 7.6 IU/L when testicular dysfunction is present 3, 4
• This pattern predicts progressive decline in both testosterone production and fertility 2, 3

Essential Diagnostic Workup

Immediate Laboratory Testing

Obtain morning (08:00-10:00 h) blood work on two separate occasions: 2, 3

• FSH and LH levels to distinguish compensated function (elevated gonadotropins) from true hypogonadism 1, 3
• Total testosterone with SHBG to calculate free testosterone, as SHBG alterations can mask true androgen status 1, 3
• Prolactin to exclude hyperprolactinemia as a secondary cause 1, 2

Critical interpretation: If FSH exceeds 7.6 IU/L with testicular atrophy, you have primary testicular dysfunction with reduced spermatogenic capacity, even if testosterone remains normal. 2, 3, 4

Fertility Assessment

Obtain at least two semen analyses 2-3 months apart: 2, 3

• Testicular volume strongly correlates with total sperm count and sperm concentration 2
• Single analyses are misleading due to natural variability 3
• If sperm concentration falls below 5 million/mL, genetic testing (karyotype and Y-chromosome microdeletion analysis) becomes mandatory 1, 2

Imaging Considerations

Scrotal ultrasound is indicated if: 2

• Size discrepancy between testes exceeds 2 mL or 20% 2
• You have a history of cryptorchidism (undescended testicles) 2, 5
• Physical examination reveals masses, varicocele, or epididymal abnormalities 2

Cancer Risk Stratification

Your age and testicular volume determine cancer surveillance intensity:

High-Risk Criteria (Requiring Heightened Surveillance)

• Age under 30-40 years with testicular volume <12 mL: ≥34% risk of intratubular germ cell neoplasia if testicular cancer develops 2
• History of cryptorchidism: 3.6-7.4 times higher risk of germ cell tumors 2, 5
• Untreated intratubular germ cell neoplasia: ~70% progress to invasive cancer within 7 years 2

If you meet high-risk criteria, urology referral for possible testicular biopsy is warranted, particularly if you are under 30 years old with a history of undescended testicles. 2

Fertility Preservation Strategy

If You Have Any Interest in Future Fertility

Never start testosterone replacement therapy if fertility matters to you—exogenous testosterone completely suppresses FSH and LH, causing azoospermia that can take months to years to recover. 3, 4, 6

Consider sperm cryopreservation now if: 2, 3

• FSH is elevated (>7.6 IU/L) 2, 3
• Semen analysis shows declining parameters 3
• You have bilateral testicular atrophy 2

Banking protocol: Collect 2-3 separate ejaculates with 2-3 days abstinence between collections, as once azoospermia develops, even microsurgical testicular sperm extraction only achieves 40-50% retrieval rates. 2, 3

Identifying Reversible Causes

Evaluate for Modifiable Factors

Check thyroid function (TSH, free T4): 3

• Thyroid dysfunction disrupts the hypothalamic-pituitary-gonadal axis 3
• Correction of thyroid disorders can normalize gonadotropins 3

Assess metabolic parameters: 3

• Obesity (BMI >25) and metabolic syndrome impair testicular function 3
• Weight loss and metabolic optimization may improve hormonal parameters 3

Review medication history: 4, 7

• Anabolic steroids or exogenous testosterone cause testicular atrophy through negative feedback 4, 7
• Chronic opioid use suppresses GnRH secretion 2
• Discontinuation allows gradual recovery over months to years 7

Evaluate for varicocele on physical examination: 3

• Palpable varicoceles with abnormal semen parameters warrant surgical repair 3
• Varicocelectomy can halt progression of testicular atrophy and improve fertility 3

Monitoring Protocol

Follow-Up Timeline

Repeat hormonal testing in 6-12 months: 3

• Establish whether FSH/LH levels are stable or rising 3
• Rising FSH indicates progressive testicular failure 3

Repeat semen analysis every 6-12 months: 2, 3

• Monitor for declining sperm concentration, motility, or morphology 2, 3
• If concentration drops below 20 million/mL or approaches 5 million/mL, urgently consider sperm banking 3

Teach testicular self-examination: 2

• Monthly self-checks for masses or rapid size changes 2
• Immediate urology referral if palpable mass develops 2

Common Pitfalls to Avoid

Critical Errors in Management

1. Assuming normal testosterone means normal testicular function: Compensated dysfunction can maintain testosterone while spermatogenesis fails 3

2. Starting testosterone therapy without fertility counseling: This is the single most devastating error—exogenous testosterone causes azoospermia 3, 6

3. Delaying sperm banking until azoospermia develops: Once sperm production ceases, retrieval rates drop to 40-50% even with microsurgical extraction 2, 3

4. Ignoring the cancer risk in young men with small testes and cryptorchidism history: This combination mandates intensified surveillance and possible biopsy 2

When to Refer to Specialists

Immediate urology referral if: 2

• Palpable testicular mass develops 2
• Rapid testicular atrophy occurs 2
• Age <30 years with volume <12 mL and cryptorchidism history 2

Endocrinology referral if: 1, 2

• Prolactin is persistently elevated 1
• LH is low or low-normal with low testosterone (secondary hypogonadism) 1
• Complex hormonal patterns require specialized interpretation 1

Reproductive urology/andrology referral if: 3

• Semen analysis shows severe oligospermia (<5 million/mL) 3
• You desire fertility with declining sperm parameters 3
• Varicocele repair is being considered 3