Can Grade 2 Varicoceles Cause Low Sperm Count and Elevated FSH?
Yes, grade 2 varicoceles can cause low sperm count, but they typically do not cause elevated FSH unless there is underlying testicular dysfunction or spermatogenic failure. 1
Varicocele and Sperm Count
Grade 2 varicoceles are clearly associated with impaired fertility and abnormal semen parameters:
Varicoceles are present in 35-40% of men presenting with infertility, demonstrating a strong correlation between varicocele presence and fertility problems. 2
The pathophysiology involves multiple mechanisms that damage testicular function, including elevated scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage. 1, 2
However, most men with grade 2 varicoceles maintain normal or near-normal sperm counts. In a study of 28 men with grade 2 varicocele, the mean sperm concentration was 80.89 million/mL (range 22-210 million/mL), with no patients having counts below 20 million/mL. 3
Higher varicocele grades (grade 3) are associated with worse semen parameters, but grade 2 varicoceles show similar sperm parameters to grade 3 without statistically significant differences. 3
Varicocele and FSH Levels
The relationship between varicocele and FSH is more nuanced:
Men with grade 2 varicoceles do not typically have elevated FSH levels unless they have concurrent impaired spermatogenesis or testicular dysfunction. 1
FSH levels are typically normal (less than approximately 7.6 IU/L) in men with varicoceles who have normal testicular function and semen parameters. 1
Elevated FSH (>7.6 IU/L) is more commonly associated with spermatogenic failure or non-obstructive azoospermia rather than varicocele alone. 1
Some studies have documented higher FSH and LH levels in varicocele patients that normalize after varicocelectomy, though results in the literature are contradictory. 4
After varicocele repair, FSH levels significantly decrease (mean decrease of 1.43 IU/L), suggesting that varicocele can contribute to FSH elevation in some patients. 5
Clinical Algorithm for Evaluation
When encountering a patient with grade 2 varicocele, low sperm count, and elevated FSH:
First, rule out other causes of FSH elevation before attributing it solely to the varicocele. 1 Elevated FSH suggests primary testicular dysfunction that may be independent of or only partially related to the varicocele.
FSH elevation in men with varicoceles should prompt evaluation for testicular dysfunction or spermatogenic failure. 1
In men with non-obstructive azoospermia and varicocele, baseline FSH <10.06 mIU/mL predicts a higher likelihood (82% sensitivity, 81.8% specificity) of finding ejaculated spermatozoa after varicocele repair. 6
Treatment Considerations
Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as the European Association of Urology and American Urological Association strongly recommend this approach to improve fertility rates. 1, 2
Improvements in semen parameters and hormonal parameters typically take 3-6 months (two spermatogenic cycles) after varicocelectomy. 1, 7
Varicocele repair increases serum total testosterone levels (mean increase of 82.45 ng/dL) and decreases FSH levels, restoring them toward normal ranges. 5
Important Caveats
The presence of elevated FSH with a grade 2 varicocele suggests more significant testicular dysfunction than would be expected from the varicocele alone. 1 This combination warrants thorough evaluation for other causes of testicular failure.
Treatment of subclinical (non-palpable) varicoceles is not effective and should not be pursued. 2, 7
The risks and benefits of varicocele repair must be discussed fully with patients, particularly when FSH is elevated, as this may indicate limited potential for improvement. 1, 7