Can a grade 2 varicocele (varicose vein in the scrotum) with reflux cause elevated Follicle-Stimulating Hormone (FSH) levels and low sperm count?

Can Grade 2 Varicocele Cause FSH of 10.2 and Low Sperm Count?

Yes, a grade 2 varicocele with reflux can cause both elevated FSH (10.2 mIU/mL) and low sperm count, as varicoceles impair testicular function through multiple mechanisms including increased scrotal temperature, testicular hypoxia, and reflux of toxic metabolites that damage spermatogenesis. 1, 2

Understanding the Relationship Between Varicocele and Hormonal Changes

Your FSH level of 10.2 mIU/mL is mildly elevated and indicates underlying spermatogenic impairment. While FSH levels are typically normal (<7.6 IU/L) in men with varicoceles who have preserved testicular function, elevated FSH (>7.6 IU/L) commonly occurs when varicoceles cause testicular dysfunction and impaired spermatogenesis. 1

The presence of reflux is particularly significant. Studies demonstrate that higher grades of spermatic vein reflux correlate directly with:

• Higher FSH levels 3
• Testicular hypotrophy 3
• Worse semen parameters 1, 4

In adolescents with grade 3 varicocele and grade 4 spermatic vein reflux, FSH levels were significantly higher compared to lower grades, and these levels decreased after surgical repair. 3 Your grade 2 varicocele with 3.5mm reflux falls into this pathophysiological pattern.

Evidence Linking Varicocele to Low Sperm Count

Varicoceles are present in 35-40% of men presenting with infertility, compared to only 15% of the general male population, demonstrating a clear dose-response relationship. 1, 5 The mechanisms causing reduced sperm count include:

• Increased scrotal temperature leading to impaired spermatogenesis 1, 5
• Testicular hypoxia from venous stasis 1, 6
• Reflux of toxic metabolites from renal and adrenal veins 1, 5
• Increased DNA damage to developing sperm 1

Research confirms that patients with varicocele have significantly reduced sperm concentration (15.50 ± 23.30 vs 16.50 ± 15.22 million/mL, p < 0.001) and motility (24.58% vs 21.01%, p < 0.001) compared to infertile men without varicocele. 7

Treatment Recommendations Based on Current Guidelines

The European Association of Urology (2025) provides clear guidance: treat infertile men with clinical varicoceles and abnormal semen parameters to improve fertility rates. 8 This is a strong recommendation.

However, there are critical caveats:

• Do not treat if semen analysis is normal, regardless of varicocele grade 8, 1
• Do not treat subclinical (non-palpable) varicoceles, as treatment does not improve outcomes 8, 5
• Your grade 2 varicocele is clinically palpable, making you a candidate for treatment if semen parameters are abnormal 8

Expected Outcomes After Varicocelectomy

If you proceed with surgical repair, meta-analysis demonstrates:

• FSH levels decrease after varicocelectomy 3, 9
• Testosterone levels increase 9
• Sperm concentration improves 9
• Total motile sperm count increases significantly, especially when post-operative Doppler shows complete resolution of reflux 4

Improvements take 3-6 months (two spermatogenic cycles) to manifest, with spontaneous pregnancy typically occurring 6-12 months after surgery. 1, 5, 6

The disappearance of continuous spermatic vein reflux on post-operative Doppler ultrasound predicts better improvement in semen parameters. 4 Men who achieve complete resolution of reflux show significantly greater increases in total motile sperm count compared to those with residual reflux. 4

Important Clinical Considerations

Your FSH of 10.2 mIU/mL, while elevated, is below the 11.7 mIU/mL threshold that predicts favorable surgical outcomes. 1 This suggests you have a good prognosis for improvement with varicocelectomy.

Before proceeding with surgery, ensure:

• Karyotype and Y-chromosome microdeletion testing if sperm concentration is <5 million/mL, as complete AZFa or AZFb deletions would contraindicate repair 1
• Female partner evaluation for ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility outcomes 1, 6
• Confirmation that the varicocele is palpable on physical examination, not just detected by ultrasound 8, 5

Common Pitfalls to Avoid

• Do not rely solely on ultrasound findings. Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve fertility rates. 1, 5, 6
• Do not expect immediate results. Semen parameters require 3-6 months to improve after surgery. 1, 5, 6
• Do not assume all elevated FSH is from varicocele. Rule out other causes of primary testicular failure before attributing FSH elevation solely to varicocele. 1