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EDITORIAL COMMENT

Although an idiopathic age-related decline in testosterone has

been well described, the etiology of low testosterone levels in

the younger patient can be more elusive. Varicoceles are com-

mon in the general population but have been identi

ﬁ

ed more

frequently in infertile patients. Similarly, hypogonadism is more

common in infertile men, and a shared etiology between

hypogonadism and infertility might be the varicocele. Thus,

the harmful effects of the varicocele, including testicular

hyperthermia and the possible re

ﬂ

ux of toxins, could affect not

only spermatogenesis, but also Leydig cell function, and could

negatively affect testosterone production.

To this end, a small, but growing, body of published data have

described lower testosterone levels in men with varicoceles and

improvement in testosterone levels after varicocele repair.

this study, increases in the serum testosterone level after vari-

cocele repair are reported to be independent of the clinical

varicocele grade.

In this retrospective review of 78 patients

during a 14-year period, a mean increase in the total testos-

terone level of 109 ng/dL was observed 7 months after varico-

cele repair.

Although the theory of varicocele-related hypogonadism has

gained increased credibility with other investigative studies, this

report still leaves several unanswered questions. The title itself is

in contrast to other studies reporting that the varicocele grade

does affect testicular function.

Although the authors report

a mean increase in the testosterone level for every varicocele

grade, the limited power of the study resulting from a cohort of

78 patients,

ﬁ

rst subdivided by varicocele laterality and further

subdivided by varicocele grade, made valid statistical compari-

sons between the subgroups impossible.

Furthermore, the authors de

ﬁ

ned hypogonadism as a testos-

terone level

400 ng/dL, despite the widely accepted Endocrine

Society Guidelines

’

recommended de

ﬁ

nition of 300 ng/dL,

making the study

’

ﬁ

ndings dif

ﬁ

cult to compare with other

published data. Rather than exclude patients with a testosterone

level

400 ng/dL, it would have been interesting to see the data

reported for all the patients with varicocele repair to determine

the threshold at which improvement in the testosterone level

might be realized. Additionally, the study contains no baseline

assessment of hypogonadal symptoms or symptomatic improve-

ment after treatment.

Of greatest concern, however, was the operative indications

for varicocele repair in this cohort. Although most patients

underwent varicocele repairs for infertility, some patients had

only a testosterone level

400 ng/dL as their indication for

surgery. These patients were not analyzed separately to show any

indication-speci

ﬁ

c improvement in their testosterone levels.

Moreover, it appears that most of the

“

infertile

”

men did not

satisfy the 2010 World Health Organization criteria of infer-

tility

for any semen parameter. In fact, the mean total sperm

count for the entire cohort was 158 million.

In conclusion, although demonstrating an improvement in

serum testosterone after varicocele repair, this report also

attempts to justify performing varicocele repair for infertility

when the semen quality is normal and for hypogonadism de

ﬁ

ned

only by a testosterone level

400 ng/dL. Although adding to

the body of knowledge regarding hypogonadism and varicocele,

the results of this study should be interpreted cautiously. Until

more robust data are available, we cannot advocate varicocele

repair for hypogonadism alone.

Robert M. Coward, M.D., and Larry I. Lipshultz, M.D.,

Scott

Department of Urology, Baylor College of Medicine,

Houston, TX

References

1. Fisch H, Hyun G. Varicocele repair for low testosterone.

Curr Opin

Urol

. 2012;22:495-498.

2. Hsiao W, Rosoff JS, Pale JR, et al. Varicocelectomy is associated with

increases in serum testosterone independent of clinical grade.

Urology

. 2013;81:1213-1218.

UROLOGY 81 (6), 2013

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