Impact of Grade 2 Bilateral Varicocele on FSH Levels
Bilateral grade 2 varicoceles are not specifically associated with a quantified increase in FSH levels, but higher grade varicoceles (grade 3) with testicular hypotrophy are associated with significantly elevated FSH levels compared to lower grades.
Varicocele and Hormonal Changes
- Varicocele is present in approximately 15% of the normal male population, but this percentage increases to 25% in men with abnormal semen analysis and 35-40% in men presenting with infertility, demonstrating a clear correlation between varicocele and fertility issues 1
- The pathophysiology of varicocele involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 1
- Higher grade varicoceles (grade 3) with testicular hypotrophy and grade 4 spermatic vein reflux are associated with significantly higher FSH levels compared to lower grade varicoceles 2
FSH Levels in Varicocele Patients
- Studies have shown that patients with grade 3 varicocele, testicular hypotrophy, and grade 4 spermatic vein reflux have higher FSH levels compared to patients with lower grade varicoceles 2
- FSH elevation is more pronounced in cases where varicocele has led to testicular damage, as FSH levels typically rise in response to impaired spermatogenesis 1
- When evaluating elevated FSH in a patient with varicocele, it's essential to rule out other causes of FSH elevation before attributing it solely to the varicocele 1
Changes in FSH After Varicocele Treatment
- After varicocelectomy, FSH levels may decrease, particularly in patients who had elevated levels before surgery 3
- In hypogonadal patients with varicocele, there was no significant decrease in mean FSH levels after varicocelectomy, although testosterone levels improved significantly 3
- FSH improvements typically parallel improvements in semen parameters, which generally take up to two spermatogenic cycles (approximately 3-6 months) to show improvement 4
Clinical Implications for Grade 2 Bilateral Varicoceles
- The American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) guidelines do not specifically quantify FSH elevation based on varicocele grade 5
- 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 4
- Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these subclinical varicoceles is not helpful 5
Diagnostic Considerations
- When FSH is elevated (>7.6 IU/L) in the presence of testicular atrophy, non-obstructive azoospermia is more likely the cause rather than obstructive azoospermia 5
- In men with normal testicular volume, normal semen volume, and FSH <7.6 IU/L without evidence of epididymal engorgement, a testis biopsy may be considered for diagnostic purposes 5
- Karyotype testing should be recommended for males with primary infertility and azoospermia or sperm concentration <5 million sperm/mL when accompanied by elevated FSH, testicular atrophy, or a diagnosis of impaired sperm production 5
Treatment Outcomes
- Bilateral varicocelectomy for bilateral varicoceles has shown comparable improvements in semen parameters to unilateral varicocelectomy for unilateral varicoceles 6
- After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months) 1
- Varicocelectomy may lead to the presence of sperm in the ejaculate for men with azoospermia, especially for those with a histological diagnosis of hypospermatogenesis 1