3. Steckel J, Dicker AP, Goldstein M. Relationship between varicocele
size and response to varicocelectomy.
J Urol
. 1993;149:769-771.
4. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy
in adult men with androgen de
ciency syndromes: an endocrine
society clinical practice guideline.
J Clin Endocrinol Metab
. 2006;91:
5. Cooper TG, Noonan E, von Eckardstein S, et al. World Health
Organization reference values for human semen characteristics.
Reprod Update
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81: 1217
1218, 2013.
2013 Elsevier Inc.
Varicoceles have been associated with both infertility and low
testosterone levels, and, indeed, a common pathophysiology
might exist between the 2 entities. Varicocelectomy can lead to
improvements in sperm quality and increases in serum testos-
terone levels.
We have previously shown that repair of larger
grade varicoceles leads to greater improvement in sperm
The clinical question addressed by our small study was
whether the clinical grade of varicocele has an effect on
testosterone improvement.
To answer this, we performed a retrospective study of those
patients who presented to our practice with either male infer-
tility or hypogonadism. Although many clinicians currently use
a cutoff of 300 ng/dL, we chose the cutoff of 400 ng/dL because
the testosterone levels in younger men (the average age of the
men in our study was 36 years) are clearly greater than in all the
adult men for whom the 300-ng/dL criterion has been used. A
recent study of normal volunteers found a mean testosterone
level of 756 ng/dL in men aged 18-29 years and 640 ng/dL in
men aged 45-65 years (personal communication from Paduch
DA, February 9, 2013). Also, because of the age-related decline
in serum testosterone levels seen in all men, repair at a greater
threshold might prevent the development of symptomatic
hypogonadism when these men are older. Although using a 400-
ng/dL cutoff might be controversial, many other aspects of
testosterone physiology are not routinely measured (including
androgen receptor levels and receptor isotypes). Additional
research is needed in this area.
With regard to our patient population, we clearly stated our
indications for varicocelectomy, and for most of the men in
our study, infertility was the primary indication for surgery.
Although some men had normal semen parameters, they all had
demonstrated infertility for
1 year, pain, semen analysis ab-
normality, testicular atrophy, or 2 testosterone levels
400 ng/
dL. Furthermore, the semen analysis of these men was not
performed using the 2010 World Health Organization criteria
(the validity and usefulness of which is highly debatable)
; thus,
highlighting a total sperm count of 158 million without refer-
ence to the motility or morphology is meaningless.
Our hypothesis was that the repair of varicoceles would return
men to the normal age-related rate of testosterone decline rather
than the accelerated rate of decline seen in those with untreated
From our previous studies of varicocele grade and
semen parameter improvements,
we did not offer varicocelec-
tomy to those with small unilateral varicoceles. In response to
these data, we have been re-examining our earlier practice of
not repairing unilateral small varicoceles.
It is conceivable that spermatogenesis (mediated by the Ser-
toli and germ cells) responds differently than testosterone pro-
duction (mediated by the Leydig cells) to varicocele-induced
stress and the removal of stress. In conclusion, we agree that
larger, prospective, randomized studies on this are needed.
Wayland Hsiao, M.D.,
Department of Urology, Emory
University, Atlanta, GA
Marc Goldstein, M.D.,
Center for Male Reproductive
Medicine, Population Council, Weill Cornell Medical College,
New York, NY
1. Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy on
serum testosterone levels in infertile men with varicoceles.
J Urol
2. Steckel J, Dicker AP, Goldstein M. Relationship between varicocele
size and response to varicocelectomy.
J Urol
. 1993;149:769-771.
3. Scherr D, Goldstein M. Comparison of bilateral versus unilateral
varicocelectomy in men with palpable bilateral varicoceles.
J Urol
4. Esteves SC, Zini A, Aziz N, et al. Critical appraisal of World Health
s new reference values for human semen characteristics
and effect on diagnosis and treatment of subfertile men.
5. Tanrikut C, Goldstein M, Rosoff JS, et al. Varicocele as a risk factor
for androgen de
ciency and effect of repair.
. 2011;108:
81: 1218, 2013.
2013 Elsevier Inc.
UROLOGY 81 (6), 2013