Operating characteristics of follicle stimulating hormone in azoospermic men

In a retrospective cohort study of azoospermic patients, the full operating characteristics of follicle stimulating hormone were determined to allow for proper education of patients and individualized treatment based on specific risk.

Matthew S. Christman, M.D., Suzanne R. Gudeman, M.D., Justin J. Nork, D.O., Rustin C. Walters, M.D., James O. L’Esperance, M.D., Donald S. Crain, M.D.

Volume 101, Issue 5, Pages 1261–1265


To validate factors predictive of nonobstructive azoospermia (NOA) and to determine the operating characteristics of FSH for predicting NOA.

Retrospective cohort study.

Tertiary care military treatment facility.

One hundred forty azoospermic males undergoing infertility evaluation.

Standard evaluation included history and physical, hormonal workup, and genetic evaluation. Diagnostic testicular biopsy was offered to characterize patients as obstructive azoospermia (OA) or NOA.

Main Outcome Measure(s):
Semen volume, semen fructose, FSH, T, E2, PRL, testicular atrophy.

Seventy-eight of 140 azoospermic patients underwent a biopsy. The ability to predict NOA based on logistic regression was statistically significant for FSH and testicular atrophy. On multivariate analysis, only FSH remained predictive of NOA. The area under the FSH receiver operating characteristic curve was 0.847, which is significant. The cut point of FSH with the highest likelihood ratio of predicting NOA on biopsy was ≥12.3 mIU/mL.

FSH remains the best predictor of NOA. With full knowledge of the operating characteristics of FSH in this population, a patient can be properly educated and treatment can be individualized, based on the specific risk associated with that subject’s measured FSH.

  • Although FSH can be utilized as predictor of NOA diagnosis, it serves poorly as the predictor for sperm retrieval outcome. This article validated previous work of Dr Neiderberger’s “7.6 and 4.6” rule using FSH and testicular size for the evaluation of azoospermic patients. Advancement in genetics will hopefully give us a useful marker that is both diagnostic and therapeutic in the treatment of NOA

  • Carlos Balmori

    There remains a lack of data in the article about the description of the biopsy technique.

    The development of microTESE is providing better results for retrieving
    sperm and FSH levels might not be the only reason to choose the option to perform a biopsy.

    Our experience is similar to the one that was published for Ramasamy in 2009 (High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction. Fertil Steril. 2009 Aug;92(2):590-3).

  • Great article that sets the biopsy threshold for the general urologist seeing the infertile male with azoospermia. If the FSH is >= 12.3 mIU/mL, then a general testicular biopsy to obtain a diagnosis prior to referral to the Male Fertility specialist is not necessary. Hopefully this will limit the number of non therapeutic testicular biopsies performed in men with NOA before they come to see us.
    What would be great is if the FSH level could predict the underlying pathology that resulted in the NOA (sertoli only, hypospermatogeneis, maturation arrest – early/late, etc.). A review of our series of men with NOA at my previous institution did not result in any breakpoints of FSH at which we could predict the underlying pathology and therefore predict the sperm retrieval rates on MicroTESE. I remember Dr. Schlegel presenting his data on this at a recent meeting.

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