Higher Grade Varicoceles Show Greater FSH Decreases After Repair
Higher grades of varicocele repair do cause greater decreases in FSH levels, particularly in patients with grade 3 varicocele and grade 4 spermatic vein reflux. 1
Relationship Between Varicocele Grade and FSH Changes
- Higher clinical grades of varicocele (grade 3) are associated with significantly higher FSH levels compared to lower grades (grades 1-2), indicating more severe testicular dysfunction in higher-grade varicoceles 1
- Patients with grade 3 varicocele, testicular hypotrophy, and grade 4 spermatic vein reflux demonstrate the highest FSH levels before repair, and consequently show the greatest reduction in FSH levels after surgical correction 1
- The mean decrease in serum FSH after varicocelectomy ranges from 0.1 to 4.8 ng/dL, with an average reduction of 0.48 ng/dL across all grades 2
Hormonal Changes After Varicocele Repair
- Varicocelectomy significantly decreases serum FSH levels in patients with varicocele, which may be related to improvement in testicular function 3
- These hormonal improvements parallel improvements in semen parameters, which typically take up to two spermatogenic cycles (approximately 3-6 months) to show improvement 4
- Along with FSH reduction, varicocele repair also leads to decreased LH levels and increased testosterone and inhibin B levels, further indicating improved testicular function 3
Clinical Implications
- The decrease in FSH levels after varicocelectomy is more pronounced in patients with initially higher FSH levels, suggesting that those with more severe testicular dysfunction may benefit more from the procedure 5
- Serum FSH concentration is an independent predictor of successful varicocele repair outcome, with lower preoperative FSH levels (<11.7 mIU/mL) associated with better fertility outcomes 6
- Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, regardless of hormonal status, as treatment of men with normal semen analysis or subclinical varicoceles is not recommended 4, 7
Mechanism of Action
- The reduction in FSH levels after varicocele repair likely reflects improved function of Sertoli cells and restoration of the hypothalamic-pituitary-gonadal axis feedback mechanism 2
- Higher grade varicoceles cause greater testicular dysfunction through mechanisms including higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites 7
- Correction of these pathological processes leads to proportionally greater improvement in testicular function and consequently greater normalization of FSH levels in higher-grade varicoceles 1, 3
Important Caveats
- While FSH levels may decrease more significantly in higher-grade varicoceles, varicocele grade alone is not predictive of fertility outcomes after repair 6
- Combined testicular volume and preoperative FSH levels are more reliable predictors of successful fertility outcomes than varicocele grade alone 6
- Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve fertility rates regardless of hormonal changes 7