A meta-analysis by Li et al. which included most of these studies, evaluated the effect of surgical varicocele repair on improving Leydig cells function. In particular treating infertile men with clinical varicocele, abnormal semen parameters, or otherwise unexplained infertility in a couple in which the female partner has a good ovarian reserve, to improve the fertility rate, is considered a strong recommendation. The impact of varicocele on semen production and fertility is known, but the relationship between clinical varicocele and impaired hormonal production is not clear. If left untreated over many years, varicoceles can sometimes cause the testicle to shrink or affect testosterone levels . While varicocele is the most common surgically correctable risk factor for male infertility, not all males with varicocele experience infertility. A varicocelectomy can repair a varicocele and sometimes improve your fertility. Medical experts don’t understand what role varicoceles play in infertility.
The recent adult literature suggests that hypogonadism may also be an indication for repair in adults and it seems that this should be studied in adolescents. Though T levels increased post-operatively in all, only three trials showed a statistically significant increase. Not all studies have shown the improvement seen in the previous two studies. When patients were stratified by pre-operative T of less than or more than 400 ng/dL, without stratification by age, men with the lower T had significant increases (mean 309 to 431 ng/dL, P29).
In a case-control study, Garolla et al. evaluated 40 patients with left varicocele, 20 obese men and 20 healthy control subjects for a series of parameters such as testicular volume, hormones, sperm parameter and 24-h scrotal temperature monitoring by a cutaneous thermochip. Nine clinical trials evaluated alteration of serum FSH and LH levels in a cohort of 312 patients before and after varicocelectomy. A recent study including 100 patients (50 hypogonadal and 50 eugonadal) with varicocele of all grades, showed a significant difference in pre- and post-varicocelectomy testosterone concentrations in hypogonadal patients but not in eugonadal ones (33). On the other hand, some studies have demonstrated an inhibition of testicular C-17,20-lyase activity, enzyme involved in testosterone production (21) (Figure 1).
Talk to a healthcare provider if you suspect you have infertility. The higher temperature affecting both testicles may affect sperm count or production. However, many people with varicoceles have no problems achieving pregnancy. Varicoceles can contribute to about 40% of all cases of male infertility. If a varicocele doesn’t bother you, you may not need treatment. Varicoceles are usually painless but can sometimes cause testicular pain, which may come and go.
A certain amount of evidence suggests that varicocele impairs testicular Leydig cells function with, in addition to its probable effects on semen alteration, a meaningful decrease in testosterone production (24, 25). Leydig cells are the testicular site of testosterone production and their possible damage by varicocele toxic environment, may lead to a decrease of testosterone and rise of LH serum levels, due to the lack of negative feedback to pituitary gonadotrophic cells (Figure 2). The impact of varicocele on semen production and fertility is known, but the relationship between clinical varicocele and impaired hormonal production is not clear; it has been hypothesized that the degree of varicocele may be inversely correlated with testosterone production (13, 14). Some studies confirmed a decrease of testosterone levels and higher FSH and LH levels that normalize after varicocelectomy, others found lower than normal levels of dihydrotestosterone due to decreased activity of epididymal 5-α-reductase. And for some men, varicoceles can affect sperm production and fertility .

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