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Varicoceles and Low Testosterone

A varicocele is defined as abnormally dilated scrotal veins.  We have known for quite some time that varicoceles can have an adverse effect on sperm parameters, sperm DNA, and on male fertility.  Fifteen percent of fertile men in the general population have varicoceles and around 40% of men that go to the doctor with infertility present with varicoceles.  Recently, we have learned that varicoceles can not only have an adverse impact on a man’s fertility potential, but also on his testosterone production, the other job of the testicle.  There are 481,000 new cases of low testosterone in American men between the ages of 40 and 69 each year.  By the age of 35, men can lose between 1-2% of their testosterone a year.  By age 50, 30% of men are already below the normal range and at age 60, 60% of men have low testosterone.  There are an estimated 13 million men in the US with low testosterone and it is estimated that less than 5% are being treated.  So, what’s the big deal?  Why is it bad to have low testosterone.  Low testosterone can cause a gamut of symptoms and detrimenal effects on men’s health including: decreased rigidity of erections, decreased sex drive, depressed mood, irritability, decreased energy, increaesd fatigue, lack of motivation, sleep disturbances, decreased spatial cognition, difficulty concentrating, hot flashes, subfertility, increased fat mass, decreased muscle mass, decreased bone mineral density, decreased exercise tolerance, and deterioration of hair and nails.  Yup, that’s all.  That one little hormone does an awful lot for us guys.  Until recently, we have only had the option of treating a man’s low testosterone with long term therapy including patches and gels that go on the skin, injections into the muscle, or testosterone pellet insertion under the skin.  In men who want to preserve their fertility potential, there are other oral and injectable medicines that can be taken to increase testosterone levels while allowing the testicles to continue sperm production.  Direct testosterone replacement, on the other hand, shuts down sperm production.  With any one of these option, we are typically talking about long term therapy with possible side effects.
What about men who have varicoceles and low testosterone?  First of all, it appears that varicoceles do decrease testosterone production by the testicles.  In a recent study of 325 men with clinical varicoceles (varicoceles that can be felt on exam, not ones that had to be found by ultrasound)  were compared to controls without varicoceles, and men with varicoceles had significantly lower testosterone levels.  70% of men with varicoceles improved their testosterone levels after undergoing a surgical varicocelectomy.  This is typically a day surgery which takes around 45 minutes and is done through a 2 inch incision in the groin.  In this study, the 70% improved their testosterone levels by a mean of 178 ng/dl, which woud normalize the testosterone levels in the majority of men that I see in my practice with low testosterone.  30% of the men had no increase in their testosterone levels, while 41% had a greater than 50% increase, 19% increased their levels by between 51% and 100%, and 10% increased by greater than 100% of their level.  There was no association of their response by age, laterality, or grade (severity) of the varicocele.  
Another study including 67 men with low testosterone and a clinical varicocele revealed a mean increase of 115 ng/dl after their varicocele was repaired.  Keep in mind, the endocrine society considers a level above 300 ng/dl as normal, so this is a relatively impressive response.
I am offering varicocelectomy as a primary treatment options for low testosterone in my practice.  This is a procedure for which men should seek out doctors who do high volumes of with microsurgical training for the best results.  That being said, it needs to be considered that we do not have long term data on this effect yet.  We do not know how long after varicocelectomy the testosterone is going to remain normalized.  Is this a long term solution or is this buying time for a man until he has to eventually get on testosterone replacement threrapy in the future?  Either way, this seems to be a very attractive alternative for many men with clincial varicoceles and low testosterone.

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