A varicocele, an enlargement of veins inside the scrotum, is associated with lower testosterone levels in men. A 2025 systematic review of 32 studies reported that men with varicocele had lower total testosterone than men without the condition, along with higher FSH and higher LH (Ziouziou et al., 2025). The condition affects an estimated 15-20% of adult males and as many as 40% of men evaluated for infertility.
That association raises a clinical question: when varicocele and low testosterone overlap, should a provider pursue varicocele repair, testosterone replacement, or monitoring alone? The answer depends on lab results, symptoms, fertility goals, and a clinician's evaluation. Direct-pay lab testing through Marek Diagnostics gives clients access to testosterone panels and individual biomarker tests that establish a baseline before any treatment decision is made.
A separate 2025 meta-analysis of 48 studies found a mean total testosterone increase of 82.45 ng/dL after varicocele repair, bringing post-repair levels close to those of men without the condition (Cannarella et al., 2025). That makes varicocele one of the few potentially reversible contributors to lower testosterone, though individual outcomes after repair vary and the decision requires clinical evaluation.
What Is a Varicocele?
A varicocele is a dilation of the pampiniform venous plexus in the spermatic cord. It occurs most often on the left side because of the angle at which the left testicular vein drains into the left renal vein. Varicoceles are graded by physical exam: Grade I is palpable only during a Valsalva maneuver, Grade II is palpable at rest, and Grade III is visible through the scrotal skin. Subclinical varicoceles are detected only by ultrasound and are not palpable.
Most varicoceles cause no symptoms and are found incidentally during a fertility workup or physical exam. Some men report a dull ache or heaviness in the scrotum that worsens with standing or exertion. The condition is not rare. Population studies put prevalence at 15-20% of all adult males, rising to 35% in men with primary infertility and up to 80% in men with secondary infertility (Whelan and Levine, 2016).
The Link Between Varicocele and Lower Testosterone
Multiple studies have documented lower serum testosterone in men with varicocele compared to matched controls. The pooled data from Ziouziou et al. (2025) showed a mean total testosterone difference of -0.71 ng/mL between men with and without varicocele (p=0.004), along with elevated FSH (mean difference 2.18 IU/L, p<0.001) and elevated LH (mean difference 0.63 IU/L, p=0.02). Free testosterone, prolactin, and estradiol did not differ between groups.
Bilateral varicoceles appear to carry a larger effect. A 2025 retrospective analysis of 776 men older than 50 found mean total testosterone of 336 ng/dL in those with at least one varicocele, compared to 472 ng/dL in those without (p<0.01). Men with bilateral varicoceles had the lowest levels at 297 ng/dL, versus 372 ng/dL for unilateral varicocele (p<0.05). Grade III unilateral varicocele showed the strongest association with testosterone below the 300 ng/dL threshold the AUA uses as a diagnostic cut-off (Kim et al., 2025; Mulhall et al., 2018).
Not every man with a varicocele has clinically low testosterone. Most don't. The association is a population-level finding; individual results depend on grade, laterality, duration, and other factors.
How Varicocele Disrupts Testosterone Production
The proposed mechanisms connect venous congestion to Leydig cell damage through a few pathways. Pooling of blood in the pampiniform plexus raises scrotal temperature, which disrupts the counter-current heat exchange that the testes rely on. The resulting thermal stress is thought to impair both spermatogenesis and steroidogenesis.
Venous stasis may also reduce oxygen delivery to the testicular parenchyma. That hypoxic environment is associated with Leydig cell apoptosis and reduced expression of enzymes involved in testosterone synthesis, including StAR protein, 17-alpha-hydroxylase, and 17-beta-hydroxysteroid dehydrogenase. Animal models have confirmed these effects: surgically induced varicocele in rats produced measurable decreases in intratesticular testosterone within 4-8 weeks, and repair partially reversed the decline (Whelan and Levine, 2016).
A third pathway involves reflux of adrenal and renal metabolites (including cortisol) into the spermatic vein, which may further suppress local testosterone production. The elevated FSH and LH levels seen in men with varicocele suggest the hypothalamic-pituitary axis is compensating for reduced testicular output, a pattern consistent with primary testicular dysfunction.
Can Varicocele Repair Raise Testosterone?
In pooled data, yes. The Cannarella et al. (2025) meta-analysis of 48 studies found a mean serum total testosterone increase of 82.45 ng/dL (95% CI 64.14-100.76, p<0.00001) after varicocele repair. Post-repair levels were not statistically different from those of healthy men without varicocele (mean difference -22.01 ng/dL, p=0.35). In the pooled analysis, the increase held regardless of baseline testosterone level, fertility status, follow-up duration, and type of repair.
Earlier data pointed in the same direction. A retrospective review of 67 men who underwent microsurgical subinguinal varicocelectomy found a mean testosterone increase of 115.7 ng/dL (p<0.0001), with improvements observed at every varicocele grade and in both bilateral and unilateral repairs (Hsiao et al., 2013). In those studies, the observed increase tended to be larger among men with lower pre-operative levels. In a review of 28 human studies, 15 showed improved serum testosterone after repair, and the average starting level in studies that found improvement was 326 ng/dL, compared to 535 ng/dL in studies that found none (Whelan and Levine, 2016).
Not every man sees improvement. Some experience modest or no change. Long-term durability data beyond the 6-12 month follow-up periods in these studies remain limited, and varicocele recurrence is reported in surgical series. Providers should frame repair outcomes as variable and individual.
Varicocele Repair vs. Testosterone Replacement: a Comparison
For men with both varicocele and low testosterone, the treatment decision often comes down to repair, testosterone replacement, or watchful monitoring. Each option has a different risk profile and a different effect on fertility.
|
Factor |
Varicocele Repair |
Testosterone Therapy |
Observation |
|
Effect on testosterone |
Mean increase of ~82 ng/dL in pooled data (Cannarella et al., 2025) |
Restores levels during use |
Levels may decline over time in some men |
|
Fertility |
May improve semen parameters |
Suppresses spermatogenesis |
No direct effect on sperm production |
|
Guideline support |
AUA/ASRM supports repair for palpable varicocele with infertility and abnormal semen |
AUA and Endocrine Society recommend for diagnosed deficiency confirmed on two morning draws plus symptoms |
Reasonable when testosterone levels are within the normal range |
|
Duration |
One-time procedure |
Ongoing for duration of use |
No intervention |
|
Monitoring after |
Post-repair labs at 3-6 months |
Regular follow-up labs (hematocrit, testosterone, estradiol) |
Periodic testosterone rechecks |
|
Risk profile |
Surgical or procedural risk, possible recurrence |
Erythrocytosis, blood pressure increase, atrial fibrillation and pulmonary embolism signals in TRAVERSE |
Possible progressive decline without intervention |
The AUA/ASRM guidelines support varicocelectomy in men with a palpable varicocele, infertility, and abnormal semen parameters. The guidelines don't currently list varicocele repair as a standard first-line treatment for isolated testosterone deficiency without infertility. Any treatment decision in this space calls for shared decision-making between the client and a qualified provider, accounting for symptoms, lab findings, fertility goals, and personal preferences.
Testosterone replacement is a separate decision path governed by the AUA and Endocrine Society diagnostic criteria: symptoms consistent with deficiency, confirmed by two early-morning total testosterone measurements consistently below 300 ng/dL, at least 1-3 weeks apart, on the same assay (Mulhall et al., 2018; Bhasin et al., 2018). Exogenous testosterone suppresses spermatogenesis, so fertility goals must be discussed before starting therapy. The TRAVERSE trial (5,246 men, median follow-up of 33 months) showed that testosterone gel was noninferior to placebo for major adverse cardiac events, but higher rates of atrial fibrillation (3.5% vs. 2.4%), pulmonary embolism (0.9% vs. 0.5%), and acute kidney injury (2.3% vs. 1.5%) were observed in the testosterone group (Lincoff et al., 2023). The FDA updated testosterone product labeling in February 2025 to reflect these findings, removing the prior cardiovascular boxed warning but adding a blood pressure warning and retaining the limitation-of-use statement for age-related testosterone decline (FDA, 2025).
How Is a Varicocele Identified During Testosterone Testing?
Physical examination is part of the standard workup. The AUA's testosterone deficiency guideline specifically recommends that the evaluation for testosterone deficiency include testicular examination with attention to varicocele (Mulhall et al., 2018). A palpable varicocele found during this exam may prompt additional consideration of repair, particularly if the man also has fertility concerns.
Subclinical varicoceles (detected only by imaging, not palpable on exam) are a different story. Both the AUA and ASRM recommend against surgical repair of nonpalpable varicoceles detected solely by ultrasound, because evidence for clinical benefit in that group is weaker.
For men who haven't had a physical exam but are ordering labs independently, a low testosterone result paired with elevated LH and FSH (suggesting the testes, not the pituitary, are the source of the problem) is a pattern that should prompt a discussion with a provider about possible testicular causes, varicocele among them. A complete blood count also belongs in the baseline workup, as hematocrit monitoring is required during any future testosterone therapy.
Labs for Varicocele and Testosterone Evaluation
Bloodwork doesn't diagnose a varicocele (that requires a physical exam or imaging), but it does establish the hormonal baseline that drives treatment decisions.
The core markers are total and free testosterone measured by LC-MS and equilibrium dialysis (the reference assay methods), SHBG levels, and LH and FSH. The gonadotropins matter here because they help distinguish between primary testicular failure (LH and FSH elevated, testes not responding) and secondary hypogonadism (LH and FSH low or normal, pituitary not signaling). A varicocele often produces a primary pattern.
Sensitive estradiol is worth including because estradiol can rise relative to testosterone in men with Leydig cell dysfunction, and because it's a monitoring marker if testosterone therapy is later started.
Marek Diagnostics offers bundled lab panels that combine these markers in a single order, and clients can also check normal hormone ranges to understand what their results mean. All testing requires a morning blood draw (before 10 AM, fasting), and a confirmed low result on a single draw should be repeated on a separate morning before any clinical decision is made.
Treatment Options for Varicocele
Three treatment categories exist for varicocele repair: microsurgical varicocelectomy, percutaneous embolization, and open surgical ligation.
Among repair techniques, microsurgical subinguinal varicocelectomy has the most supporting data for both semen parameter improvement and testosterone increase. It allows the surgeon to preserve the testicular artery and lymphatics under magnification, which reduces the risk of testicular atrophy and hydrocele. The majority of studies demonstrating post-repair testosterone increases used a microsurgical approach (Whelan and Levine, 2016).
Percutaneous embolization is a less invasive alternative performed by an interventional radiologist through a small access point. Technical success rates range from 75-90% (Whelan and Levine, 2016), and recovery is typically faster than surgery. The evidence for testosterone improvement after embolization is less consistent than for microsurgical repair. Two early single-center studies showed testosterone increases after embolization, but later studies from other centers did not reproduce those results.
Open surgical approaches (inguinal and retroperitoneal) are still performed but carry higher rates of hydrocele formation and varicocele recurrence compared to the microsurgical technique.
For men who don't meet criteria for repair (normal testosterone, no infertility, subclinical varicocele), periodic monitoring is a reasonable path. Providers can recheck testosterone and semen parameters over time. Understanding how testing works at Marek Diagnostics is a starting point for establishing a monitoring baseline.
Varicocele is a treatable condition that contributes to lower testosterone in a measurable subset of affected men. Lab testing, specifically total and free testosterone with gonadotropins, is the first step in determining whether a varicocele is contributing to a hormonal deficit and what treatment path a provider may recommend.
Disclaimer: This blog post is intended for informational purposes only and should not be considered medical advice. Always consult a healthcare professional before making changes to your health routine.
FAQs
Does having a varicocele mean a man has low testosterone?
Not necessarily. While population data show an association between varicocele and lower testosterone, most men with varicocele don't meet diagnostic criteria for testosterone deficiency. The AUA uses total testosterone consistently below 300 ng/dL on two early-morning draws, combined with symptoms, as a reasonable diagnostic cutoff. A varicocele alone doesn't establish that diagnosis.
Can varicocele repair raise testosterone levels?
Pooled data from 48 studies show a mean total testosterone increase of 82.45 ng/dL after varicocele repair (Cannarella et al., 2025). The increase was independent of baseline testosterone level and type of repair. Individual results vary, and some men see modest or no change.
Is varicocele repair recommended just to treat low testosterone?
Current AUA/ASRM guidelines support repair for men with a palpable varicocele, infertility, and abnormal semen parameters. The guidelines don't list repair as a standard treatment for isolated testosterone deficiency without a fertility indication. Providers may consider it on a case-by-case basis in men with both conditions.
How do total and free testosterone differ when a varicocele is present?
Clinical guidelines rely primarily on total testosterone for diagnosis, confirmed on two separate morning draws. Free testosterone becomes relevant when total testosterone is near the lower limit or when SHBG is altered (obesity, aging, liver disease). Assay methods and reference ranges vary by laboratory, so repeat testing should use the same lab and assay (Bhasin et al., 2018).
What monitoring is needed if testosterone therapy is started in a man with a varicocele?
Standard monitoring applies: follow-up testosterone levels, hematocrit (to watch for erythrocytosis), estradiol, and other labs per guideline recommendations. Fertility plans must be discussed before starting therapy because exogenous testosterone suppresses sperm production. If future fertility is desired, providers may consider alternatives or adjuncts like hCG or enclomiphene.
Can testosterone levels rise after varicocele repair and then decline again?
Limited long-term data exist beyond the 6-12 month follow-up periods in most studies. Varicocele recurrence is reported in surgical series, and age-related testosterone decline continues regardless of repair. Men who undergo repair should plan for periodic lab rechecks in the years that follow.
What are the cardiovascular signals from TRAVERSE that apply to testosterone therapy?
The TRAVERSE trial found that testosterone gel was noninferior to placebo for major adverse cardiac events (7.0% vs. 7.3%), but the testosterone group had higher rates of atrial fibrillation (3.5% vs. 2.4%), pulmonary embolism (0.9% vs. 0.5%), and acute kidney injury (2.3% vs. 1.5%). The FDA's 2025 labeling update reflected these findings. These signals apply to any man considering testosterone therapy, whether or not a varicocele is present (Lincoff et al., 2023; FDA, 2025).
References
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