10. Schlegel PN, Goldstein M. Anatomical approach to varicocelec-
Semin Urol
. 1992;10:242-247.
11. Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year
. 1977;10:446-449.
12. Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy
on serum testosterone levels in infertile men with varicoceles.
J Urol
. 1995;154:1752-1755.
13. Zini A, Azhar R, Baazeem A, et al. Effect of microsurgical varico-
celectomy on human sperm chromatin and DNA integrity:
a prospective trial.
Int J Androl
. 2011;34:14-19.
14. Abdel-Meguid TA, Al-Sayyad A, Tayib A, et al. Does varicocele
repair improve male infertility? An evidence-based perspective from
a randomized, controlled trial.
Eur Urol
. 2011;59:455-461.
15. Luo DY, Yang G, Liu JJ, et al. Effects of varicocele on testosterone,
apoptosis and expression of StAR mRNA in rat Leydig cells.
Asian J
. 2011;13:287-291.
16. Hsiao W, Rosoff JS, Pale JR, et al. Older age is associated with
similar improvements in semen parameters and testosterone after
subinguinal microsurgical varicocelectomy.
J Urol
. 2011;185:
17. Cayan S, Kadioglu A, Orhan I, et al. The effect of microsurgical
varicocelectomy on serum follicle stimulating hormone, testos-
terone and free testosterone levels in infertile men with varicocele.
. 1999;84:1046-1049.
18. Tanrikut C, Goldstein M, Rosoff JS, et al. Varicocele as a risk factor
for androgen de
ciency and effect of repair.
. 2011;108:
19. Sathya Srini V, Belur Veerachari S. Does varicocelectomy improve
gonadal function in men with hypogonadism and infertility?
Analysis of a prospective study.
Int J Endocrinol
. 2011;2011:916380.
20. Younes AK. Improvement of sexual activity, pregnancy rate, and
low plasma testosterone after bilateral varicocelectomy in impo-
tence and male infertility patients.
Arch Androl
. 2003;49:219-228.
21. Zohdy W, Ghazi S, Arafa M. Impact of varicocelectomy on gonadal
and erectile functions in men with hypogonadism and infertility.
J Sex Med
. 2011;8:885-893.
22. Hudson RW, Perez-Marrero RA, Crawford VA, et al. Hormonal
parameters in incidental varicoceles and those causing infertility.
Fertil Steril
. 1986;45:692-700.
23. Steckel J, Dicker AP, Goldstein M. Relationship between varico-
cele size and response to varicocelectomy.
J Urol
. 1993;149:769-771.
24. Culha M, Mutlu N, Acar O, Baykal M. Comparison of testicular
volumes before and after varicocelectomy.
Urol Int
. 1998;60:
25. Takahara M, Ichikawa T, Shiseki Y, et al. Relationship between
grade of varicocele and the response to varicocelectomy.
Int J Urol
26. Okuyama A, Fujisue H, Matsui T, et al. Preoperative parameters
related to the improvement of semen characteristics after surgical
repair of varicocele in subfertile men.
Eur Urol
. 1988;14:442-446.
27. Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal
varicocelectomy with delivery of the testis: an artery and lymphatic
sparing technique.
J Urol
. 1992;148:1808-1811.
28. Zini A, Boman J, Jarvi K, et al. Varicocelectomy for infertile couples
with advanced paternal age.
. 2008;72:109-113.
29. Ishikawa T, Fujisawa M. Effect of age and grade on surgery for
patients with varicocele.
. 2005;65:768-772.
Although an idiopathic age-related decline in testosterone has
been well described, the etiology of low testosterone levels in
the younger patient can be more elusive. Varicoceles are com-
mon in the general population but have been identi
ed more
frequently in infertile patients. Similarly, hypogonadism is more
common in infertile men, and a shared etiology between
hypogonadism and infertility might be the varicocele. Thus,
the harmful effects of the varicocele, including testicular
hyperthermia and the possible re
ux of toxins, could affect not
only spermatogenesis, but also Leydig cell function, and could
negatively affect testosterone production.
To this end, a small, but growing, body of published data have
described lower testosterone levels in men with varicoceles and
improvement in testosterone levels after varicocele repair.
this study, increases in the serum testosterone level after vari-
cocele repair are reported to be independent of the clinical
varicocele grade.
In this retrospective review of 78 patients
during a 14-year period, a mean increase in the total testos-
terone level of 109 ng/dL was observed 7 months after varico-
cele repair.
Although the theory of varicocele-related hypogonadism has
gained increased credibility with other investigative studies, this
report still leaves several unanswered questions. The title itself is
in contrast to other studies reporting that the varicocele grade
does affect testicular function.
Although the authors report
a mean increase in the testosterone level for every varicocele
grade, the limited power of the study resulting from a cohort of
78 patients,
rst subdivided by varicocele laterality and further
subdivided by varicocele grade, made valid statistical compari-
sons between the subgroups impossible.
Furthermore, the authors de
ned hypogonadism as a testos-
terone level
400 ng/dL, despite the widely accepted Endocrine
Society Guidelines
recommended de
nition of 300 ng/dL,
making the study
ndings dif
cult to compare with other
published data. Rather than exclude patients with a testosterone
400 ng/dL, it would have been interesting to see the data
reported for all the patients with varicocele repair to determine
the threshold at which improvement in the testosterone level
might be realized. Additionally, the study contains no baseline
assessment of hypogonadal symptoms or symptomatic improve-
ment after treatment.
Of greatest concern, however, was the operative indications
for varicocele repair in this cohort. Although most patients
underwent varicocele repairs for infertility, some patients had
only a testosterone level
400 ng/dL as their indication for
surgery. These patients were not analyzed separately to show any
c improvement in their testosterone levels.
Moreover, it appears that most of the
men did not
satisfy the 2010 World Health Organization criteria of infer-
for any semen parameter. In fact, the mean total sperm
count for the entire cohort was 158 million.
In conclusion, although demonstrating an improvement in
serum testosterone after varicocele repair, this report also
attempts to justify performing varicocele repair for infertility
when the semen quality is normal and for hypogonadism de
only by a testosterone level
400 ng/dL. Although adding to
the body of knowledge regarding hypogonadism and varicocele,
the results of this study should be interpreted cautiously. Until
more robust data are available, we cannot advocate varicocele
repair for hypogonadism alone.
Robert M. Coward, M.D., and Larry I. Lipshultz, M.D.,
Department of Urology, Baylor College of Medicine,
Houston, TX
1. Fisch H, Hyun G. Varicocele repair for low testosterone.
Curr Opin
. 2012;22:495-498.
2. Hsiao W, Rosoff JS, Pale JR, et al. Varicocelectomy is associated with
increases in serum testosterone independent of clinical grade.
. 2013;81:1213-1218.
UROLOGY 81 (6), 2013