Can varicoceles (varicose veins of the spermatic cord) cause elevated Follicle-Stimulating Hormone (FSH) levels?

Varicoceles Can Cause Elevated FSH Levels

Yes, varicoceles can cause elevated follicle-stimulating hormone (FSH) levels, and surgical repair of varicoceles can significantly reduce these elevated FSH levels. 1, 2

Pathophysiology of Varicocele 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 3, 4
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 3
• Varicoceles can impair Leydig cell and Sertoli cell function, leading to hormonal imbalances including elevated FSH levels 5
• The negative impact on testicular function can trigger the hypothalamic-pituitary axis to increase FSH production as a compensatory mechanism 2

Evidence of FSH Elevation in Varicocele Patients

• Patients with varicocele typically show significantly higher FSH levels compared to healthy controls without varicocele 1
• The elevation in FSH is thought to be a compensatory response to impaired spermatogenesis and testicular dysfunction caused by varicocele 5
• Higher varicocele grade (grade 3) is associated with worse semen parameters, greater testicular dysfunction, and more pronounced hormonal abnormalities 3

Effect of Varicocele Repair on FSH Levels

• After varicocelectomy, patients experience significantly lower FSH levels compared to their pre-treatment values (mean decrease of 1.43 IU/L) 1
• Meta-analysis data shows that serum FSH levels decrease by approximately 0.48 ng/dL after varicocelectomy 2
• The decrease in FSH following varicocele repair suggests improvement in testicular function and spermatogenesis 6
• Hormonal improvements typically parallel the timeline for semen parameter improvements, taking approximately 3-6 months (two spermatogenic cycles) to show enhancement 3, 7

Clinical Implications and Treatment Considerations

• Treatment of varicocele should be targeted to men with clinical varicoceles and abnormal semen parameters 7
• 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 3
• Treatment of subclinical (non-palpable) varicocele is not effective at improving hormonal parameters or fertility rates 3, 4
• Varicocele repair has been shown to improve not only FSH levels but also other hormonal parameters including testosterone and LH 1, 8

Monitoring After Varicocele Repair

• Monitor hormonal parameters after varicocelectomy, as improvements typically take up to two spermatogenic cycles (3-6 months) 3, 7
• The decrease in FSH levels after varicocelectomy is more pronounced in patients with initially higher FSH levels 2
• The improvement in hormonal parameters correlates with improvements in semen quality and potentially fertility outcomes 6

Caveats and Considerations

• The quality of evidence regarding varicocele treatment and its effect on hormonal parameters is generally moderate 3
• Individual response to varicocele repair may vary, and not all patients will experience normalization of FSH levels 5
• The timing of surgery may influence outcomes, with earlier intervention potentially preventing permanent testicular damage 3
• Patients with hypogonadal testosterone levels (<280 ng/dL) may experience more significant hormonal improvements after varicocelectomy compared to eugonadal patients 8