Treatment of Moderate-to-Large Varicoceles with Hypogonadism and Impaired Semen Parameters
Microsurgical varicocelectomy is the primary treatment for men with moderate-to-large palpable varicoceles who have both hypogonadism and abnormal semen parameters, as this approach can improve both testosterone levels and semen quality while preserving future fertility potential. 1, 2, 3
Primary Treatment Recommendation
The European Association of Urology strongly recommends treating infertile men with clinical (palpable) varicoceles and abnormal semen parameters with microsurgical varicocelectomy to improve fertility rates. 1, 3
Microsurgical subinguinal or inguinal varicocelectomy is the optimal surgical technique in most cases, offering superior outcomes compared to laparoscopic approaches or radiological embolization. 4
For hypogonadal men with varicoceles, varicocele repair offers a distinct advantage over testosterone replacement therapy: it preserves fertility potential while addressing both hormonal deficiency and semen abnormalities. 5
Expected Outcomes and Timeline
Hormonal Improvements
Varicocele repair leads to significant increases in serum testosterone levels in hypogonadal men with clinical varicoceles. 5
Sex hormone-binding globulin (SHBG) levels decrease significantly after varicocelectomy, with mean reductions of approximately 32.72 nmol/L post-surgery. 1
Hormonal improvements parallel semen parameter improvements, typically requiring 3-6 months (two complete spermatogenic cycles) to manifest. 1, 2
Semen Parameter Improvements
After varicocelectomy, improvements in semen volume, concentration, motility, and morphology typically become evident within 3-6 months. 2, 4
Varicocele repair improves sperm DNA quality by reducing oxidative stress-induced damage, which is a sensitive biomarker of sperm quality. 6
Total and total motile sperm counts improve following surgical correction. 7
Patient Selection Criteria
Who Should Receive Treatment
Men with palpable (clinical) varicoceles combined with abnormal semen parameters and/or documented hypogonadism. 1, 2, 3
Men with otherwise unexplained infertility where the female partner has good ovarian reserve. 3
Consider treatment in men with failure of assisted reproductive techniques, including recurrent pregnancy loss and failure of embryogenesis. 3
Who Should NOT Receive Treatment
Men with subclinical (non-palpable) varicoceles detected only by ultrasound should not undergo treatment, as repair does not improve semen parameters or fertility rates in this population. 1, 2, 3
Men with normal semen analysis should not be treated regardless of hormonal status. 1
Routine ultrasonography to identify non-palpable varicoceles is discouraged. 1, 2, 3
Diagnostic Workup Before Treatment
Perform thorough physical examination to confirm a palpable varicocele (prominent pampiniform plexus). 2, 3
Obtain comprehensive semen analysis evaluating volume, concentration, motility, and morphology. 2
Measure serum testosterone, FSH, and LH levels to document hypogonadism and assess testicular function. 2, 8
Scrotal Doppler ultrasound may be used to confirm varicocele grade and evaluate blood flow patterns, particularly in obese patients where physical examination is difficult. 3
Important Clinical Caveats
Elevated FSH Considerations
Elevated FSH levels (>7.6 IU/L) in men with varicoceles indicate spermatogenic failure or testicular dysfunction, not simply the presence of varicocele alone. 1
FSH elevation should prompt thorough evaluation for other causes of testicular dysfunction before attributing it solely to varicocele. 1
Special Populations
For couples where the female partner has limited ovarian reserve, time spent waiting for sperm recovery after varicocelectomy (3-6 months) may negatively impact overall fertility outcomes and should be factored into treatment decisions. 1
In adolescents, the European Association of Urology strongly recommends surgery when varicocele is associated with persistent testicular size difference (>2 mL or 20%), confirmed on two visits 6 months apart. 1, 3
Post-Treatment Monitoring
Monitor semen parameters and hormonal levels at 3-6 months post-varicocelectomy to assess treatment response. 1, 2
If infertility persists after 6 months despite varicocele repair, consider assisted reproductive technology, especially in older couples. 4
Use scrotal ultrasound after repair to confirm procedural success and absence of recurrence. 3
Alternative to Testosterone Replacement
Varicocele repair should be strongly considered as first-line treatment over exogenous testosterone replacement in hypogonadal men who desire future fertility, as testosterone therapy suppresses spermatogenesis. 5
Both approaches address hypogonadism, but only varicocelectomy preserves and potentially improves fertility. 5