Do varicoceles (varicose veins in the scrotum) raise Follicle-Stimulating Hormone (FSH) levels?

Varicoceles and FSH Levels

Varicoceles can raise FSH levels, particularly in higher-grade varicoceles (grade 3) and those with testicular hypotrophy, with studies showing significantly elevated FSH in these patients compared to those with lower-grade varicoceles. 1

Relationship Between Varicoceles and Hormonal Changes

• Varicoceles affect approximately 15% of the general male population but are present in 35-40% of men presenting with infertility, indicating a significant association between varicocele and fertility issues 2, 3
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites 2, 4
• FSH levels are typically higher in patients with clinical grade 3 varicocele compared to those with grade 1-2 varicocele, particularly when accompanied by testicular hypotrophy and grade 4 spermatic vein reflux 1

Hormonal Profile in Varicocele Patients

• Patients with varicocele often show contradictory hormonal profiles in studies, but many demonstrate:

  • Higher FSH and LH levels compared to normal controls 4, 5
  • Lower testosterone levels, especially in those with hypogonadism 6, 5
  • Decreased Inhibin-B levels, indicating reduced Sertoli cell function 4

• The magnitude of FSH elevation correlates with:

  • Clinical grade of varicocele (higher in grade 3) 1
  • Presence of testicular hypotrophy 1
  • Severity of spermatic vein reflux 1

Effects of Varicocele Repair on Hormonal Parameters

• After varicocelectomy, patients typically show:

  • Significant reduction in FSH levels, particularly in those who had elevated levels before surgery 1, 6, 7
  • Improvement in testosterone levels, especially in hypogonadal patients 6, 7
  • Decrease in LH levels 6, 7

• These hormonal changes parallel improvements in semen parameters, which typically take approximately 3-6 months (two spermatogenic cycles) to show enhancement 2, 8

Clinical Implications

• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles is not associated with improvement in either semen parameters or fertility rates 9, 3
• Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as treatment of men with normal semen analysis or subclinical varicoceles is not recommended regardless of hormonal status 2, 8
• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 2

Pitfalls and Caveats

• Hormonal evaluation alone should not be the sole criterion for varicocele treatment; clinical findings and semen parameters should guide management decisions 9, 3
• Not all patients with varicocele will have elevated FSH levels; hormonal changes are more pronounced in those with higher-grade varicoceles and testicular hypotrophy 1
• After varicocelectomy, hormonal improvements may take several months to manifest, similar to the timeline for semen parameter improvements 2, 8