Whereas in the infertile male a semen analysis is easily obtained with well-established norms, the same cannot be said of the adolescent. How should a varicocele be determined, by physical exam or ultrasound? How can a unilateral varicocele cause bilateral dysfunction? Every year the young boy embarrassingly sees a doctor because he has an abnormality of one of his male organs. This is an important area for research in adolescents with a varicocele. If this is further documented in adults, it may be true in teens as well and indeed, might be an indication for early surgery. Recent evidence in adults suggests that varicocele may be a cause of hypogonadism. These veins return blood from your testicles to your body. The spermatic cord is a band of tissues that holds your testicles in place. They may cause mild discomfort, aches or pains. Results from a study with a sensitive assay system that calculated the activities of the five enzymes in the testosterone biosynthetic pathway showed that testosterone production was inhibited at the 17-α-hydroxylase step (20) (Figure 1). The suggested etiology of varicocele-induced effects includes anatomical changes such as venous pooling, higher scrotal temperature, oxidative stress, hypoxia, backflow of metabolites from the adrenal gland, increase of CO2 and nitric oxide, autoimmunity, and damage of Leydig cells (16–18). Various hypotheses have been proposed to describe the negative effect of varicocele on testicular function. There is a correlation among male sterility, ipsilateral testicular atrophy, and clinically detectable, rather than non-detectable, varicocele (11). In a non-randomized surgical series of 40 pubertal boys, mean age 14.5, with grade 2 and 3 varicoceles, 24 underwent surgery and 16 were observed (by the choice of the parents). The repair of varicoceles considered "subclinical" or in men with normal seminal parameters was not recommended. Infertile men with varicoceles were found to have decreased testicular volume, impaired sperm quality, and decline of Leydig cell secretion. In the adult the main indications for intervention are infertility and abnormal semen analysis, both unavailable in most teens. About the role of other hormones in patients with varicocele, a significantly lower concentrations of AMH was found in subfertile men, as a result of Sertoli cells damage, without differences related to the grades of subfertility. In fact, although in published literature the correlation between varicocele and infertility is no longer so close, gonadotropins impairment could at least in part explain the alteration of spermatogenesis. Evaluation of FSH and LH levels may be necessary at the first diagnosis of varicocele especially if the patient is seeking medical attention for infertility. A meta-analysis by Tian et al. showed higher FSH and LH levels in varicocele-bearing patients that significantly lowered after surgery (34). A varicocele (VAIR-ick-oh-seal) is a common disorder that enlarges the veins in your scrotum. A healthcare provider can diagnose a varicocele and recommend the proper treatment. However, they’re a common cause of infertility. Prospective, long term, randomized trials are needed to help elucidate the benefit of varicocele repair on hypogonadal adolescent males. Consideration should be given to measuring T levels in adolescents with a varicocele. In 2011, Goldstein published a series of 110 infertile men with clinical varicoceles in whom pre- and post-operative T measurements were available.
