Can a varicocele affect serum testosterone levels in men?

Can Varicocele Affect Testosterone Levels?

Yes, varicocele can significantly lower serum testosterone levels, and this effect is well-established through both clinical guidelines and robust research evidence.

The Evidence for Testosterone Reduction

The 2025 European Association of Urology (EAU) guidelines acknowledge that varicocele causes testicular dysfunction through mechanisms including higher scrotal temperature, hypoxia, and reflux of toxic metabolites 1. While the guidelines focus primarily on fertility impacts, the pathophysiology directly implicates Leydig cell function—the cells responsible for testosterone production.

Multiple high-quality studies demonstrate this relationship convincingly:

• Men with varicocele have measurably lower testosterone levels compared to men without varicocele. A 2011 study found mean testosterone levels of 416 ng/dL in varicocele patients versus 469 ng/dL in controls (p<0.001), with this difference persisting across all age groups 2.

• The effect is dose-dependent: Bilateral varicoceles are associated with lower testosterone (297 ng/dL) compared to unilateral varicoceles (372 ng/dL) 3. In men over 50 years old, 24% with bilateral varicocele had testosterone <300 ng/dL versus only 11% with unilateral varicocele 3.

• Grade matters for unilateral varicoceles: Grade III varicoceles show the strongest correlation with testosterone deficiency (r=0.65, p<0.01), while Grade I shows no significant association 3.

Impact of Varicocele Repair on Testosterone

Varicocelectomy produces clinically significant increases in testosterone levels, particularly in men with baseline hypogonadism:

The most comprehensive 2024 meta-analysis (48 studies) demonstrated that varicocele repair increases testosterone by a mean of 82.45 ng/dL (95% CI: 64.14-100.76) compared to pre-treatment levels 4. Importantly, post-repair testosterone levels did not differ from healthy controls without varicocele, suggesting complete restoration of Leydig cell function 4.

The magnitude of benefit depends on baseline testosterone:

• Men with baseline testosterone <300 ng/dL experience dramatic improvements: mean increase of 93.7 ng/dL (40.1% increase) 5
• Men with baseline testosterone ≥300 ng/dL show minimal change: only 8.6 ng/dL (2.01% increase) 5
• Overall, 65-83% of men experience testosterone increases after repair 2, 6

The improvement is independent of varicocele grade, laterality, age, or surgical technique 6, 4. Benefits persist at 12-month follow-up 5.

Clinical Implications and Recommendations

For men with varicocele and low testosterone (<300 ng/dL), varicocelectomy should be strongly considered as an alternative to lifelong testosterone replacement therapy 7. This is particularly relevant for:

• Young men with infertility and low testosterone
• Men wishing to preserve fertility (testosterone therapy suppresses spermatogenesis)
• Older men (>50 years) with clinical varicocele and symptomatic hypogonadism

Key caveats:

• The 2025 EAU guidelines currently recommend against treating varicocele in men with normal semen parameters 1, though this recommendation was written primarily in the fertility context
• Men with baseline eugonadal testosterone levels should not expect meaningful testosterone improvements from varicocelectomy alone 5
• The AUA 2018 guidelines recommend measuring testosterone in men with infertility and varicocele as part of comprehensive evaluation 8

Contradictory Evidence

One 2020 cross-sectional study of 387 men found no relationship between varicocele presence and testosterone levels 9. However, this study had significant methodological limitations: it was cross-sectional (not prospective), included only men presenting for erectile dysfunction (selection bias), and did not control for varicocele grade or laterality. This single outlier is outweighed by multiple prospective controlled studies and the largest meta-analysis to date showing consistent testosterone effects.

Practical Algorithm

For men with palpable varicocele:

1. Obtain early morning total testosterone (two separate measurements if <300 ng/dL)
2. If testosterone <300 ng/dL with symptoms of hypogonadism → offer varicocelectomy as first-line treatment
3. If testosterone ≥300 ng/dL → varicocelectomy unlikely to improve testosterone; consider only if fertility concerns exist
4. If bilateral varicocele or Grade III unilateral → higher likelihood of testosterone deficiency; lower threshold for intervention
5. Recheck testosterone 6-12 months post-operatively to assess response

The relationship between varicocele and testosterone deficiency is clinically significant, reversible with surgical repair in hypogonadal men, and should influence treatment decisions in men presenting with both conditions.