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varicocele and infertility

My husband was diagnosed as being azoospermic with very high fsh and lh and normal testosterone (although a bit on the low side).  He has a varicocele on the left side which has been there since he was young.  Our urologist stated that he could try varicocele ligation and testicular biopsy but doubts whether this will change the result.  Our endocrinologist and gynaecologist disagreed with him and they think that we should go ahead with the biopsy and varicocele ligation.  Of course when my husband heard what the urologist had to say he did not want to have the operation because since he sounded so sure of himself there was no point in going through the surgeries.  I have been doing a lot of research and found that the varicocele may actually be the reason for his infertility as it is quite big.  What I am not sure about is whether it would cause his hormone levels to go high.

Does anyone know whether varicocele cause high fsh and lh levels?  If my husband had to do the surgery and he manages to obtain a sperm count, is it possible for him to relapse back to azoospermia?  Any advice in the matter would be greatly appreciated because I am just going crazy about all this.
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Avatar universal
Hello,
      I pretty well understand your state of confusion, but let us hope everything will finally clear up. FSH can be high as it is controlled by the level of Inhibin, which is an index of spermatogenesis. Your doctor may be going by the physical characteristics of your partner which may represent syndrome like Klinefelter. Nevertheless, I think biopsy is the first thing to do before you could face a wall with genetic testing and get discouraged by it. The best thing you should do is to go to a Good fertility clinic for further consultation instead of getting stuck with your urologist.

Have a look at the following link:
  
https://www.cornellurology.com/clinical-conditions/male-infertility/sperm-retrieval-techniques/management-of-men-with-non-obstructive-azoospermia/    

I would advise you to get in touch with them or similar clinics if possible.

Good luck,
Solace
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Avatar universal
Hello,
      What is the level of his testosterone? Normally the levels of  LH and FSH will be high if the testosterone level is determined to be low by the brain. It therefore implies that the problem is mainly with the testes. Varicocele does affect the sperm production in the testes as it increases the temperature of the scrotum, thus interfering with the functions of the other healthy testicle also. There are medical reports which confirms that the treatment of varicocele  does in fact reverses the condition in both the testicles.

But, ensure that the operation is done in a good hospital, as the doctor should be well experienced in the procedure, as other wise many complications can result from the operation.

I would send you the links to some of those medical articles in the next post for your reference.  
Good luck,
Solace
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Avatar universal
Thanks for your reply.  My Husband's testosterone level is 11.6 nmol/L (range 9.9-27.8) so although it is in the normal range it is still quite low.We will be going for karyotyping to determine whether this is caused by a genetic disorder.  We went to a good urologist but he seems to think that his infertility is not because of the varicocele and he thinks that my husband has sertoli cell only syndrome.  I have no idea as to why he came to that conclusion since the only way to know if he has SCO is through a testicular biopsy which my husband has not done yet.  At first I thought it was because varicoceles do not affect fsh and lh levels but I found some conflicting reports stating that they actually could.  This whole infertility ordeal is so complex and it's such a nightmare.  

Thanks for your help.
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Avatar universal
Thanks a lot for the link.  It is really helpful.

I just hope that my husband does not chicken out of the biopsy in the last minute.  It's going to be tough and I really don't know what to expect because he will have to do the biopsy and a varicocele ligation in one so I don't know whether he will be in a lot of pain.  He is totally scared of hospitals and needles.

I have always been of the opinion that we should try everything we can and see what works out.  On the other hand my husband gets totally brainwashed by what one doctor says and he is easily discouraged.  So maybe we should go to a fertility clinic instead and see what they have to say.

Many thanks for your advice.
Helpful - 0
Avatar universal
Hello,
     There are many useful information in the link I sent you.

1. Even if sperm is not seen in the ejaculate by normal testing, they try to recover viable sperms by centrifuge, and if successful the same could be used in IVF and no more problems for your partner.

2. If your age is below 38 years, the first thing that they do is to remove the varicocele and see if the sperm is seen in the ejaculate. But it requires a waiting period of minimum six months after the operation and that is why your age is important, which affects your fertility period. If the post operative ejaculate contains sperm, once again the steps ahead are easier.

3. Another technique they do is to determine the ratio of testosterone to estrogen and if found less than 16, they treat the condition with aromatise inhibition drug to improve the ratio. Apparently, this ratio improves the spermatogenesis and possibly sperms will start showing up in the ejaculate after the treatment. By the way, is your partner having an obese body ?, and if so, his estrogen level could be high.

4. As per the article, they do not go for biopsy just for testing purposes, but rather they do it at the time of ICSI, so that extra biopsy can be avoided.

5. On the genetic side,some specific Y deletion condition almost excludes possibility of finding sperm in the testes, so in such cases, they would advise the couples to be prepared for donor sperms if the testicular biopsy fails to yield any viable sperm.

6. They also employ an improved technique called microdisection which improves the chances of finding sperm in a single test compared to normal biopsy, which may have to be repeated many times.

Please read the article thoroughly, so that you will be better prepared when you go to a clinic.

Solace  

      
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Avatar universal
Thanks a lot for the information.  Luckily we are still both young I am 32 and my husband is 31 so we are still in time.  As to whether he has an obese body, he has never been obese.  On the contrary, lately he started exercising and he lost way too much weight - weight which he did not need to lose.

We will just have to take it step by step.  The problem is that I don't know how much more my husband can take of all this.  Just now he told me that he is sick of all the blood tests and all doctors and he can't stand them anymore.  So sometimes I think that something is going to snap in him and he will just give up on all of this and refuse to go further with any other tests/biopsies and anything else which may be required.  We discussed the options at length and we decided that we are not going for donor sperm or adoption.  My husband does not feel comfortable with any of those options and probably neither do I.  Which is why I feel that we should exhaust all options before we can accept the situation.

It is such an exhausting and devastating process to go through.
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Avatar universal
Hello,
   Sorry to learn that you have to put in extra efforts to instill confidence in your partner while yourselves are going through all these issues.I only hope that your persistence will pay off at the end. I am specifically writing this note to highlight some points which I felt should have been included in the previous post.
1. As regards the need for genetic testing, as advised by your Urologist, now I feel could be important as it is less invasive compared to Biopsy and varicocele repair. As per the article given in the earlier post, two defects of the Y chromosomes, viz., total  AZFa or AZFb deletions, if present, would almost rule out any possibility of finding a sperm in the testes. On the other hand, any other defect even if present, does not stop one from going ahead with testicular sperm extraction  and subsequent procedures; only one risk factor being any Y chromosome defect would be passed on to a boy born out of the procedure. So, I would advise you to consider Karyotyping as the   next diagnostic step.

2. Another important aspect that came up in my mind is the high level of LH that you have mentioned, I can understand why FSH could be high due to problems with spermatogenesis.. As I feel his T level is not that low to justify very high level of LH , if you do not mind, can you please tell me what  is his LH level? I am only wondering if it could point to some problem with the pituitary. Did they check his TSH and prolactin levels? Also, very low level of estrogen ( aromatise deficiency) can also contribute to problems with sperm production and in such cases, LH level could also be raised. There fore, measurement of Estrogen is also important.

3. In any case, since the age factor is favourable, I would think that the repair of varicocele should be considered and biopsy could be replaced by microdissection procedure to be done only after you decide on ICSI procedure.

4.By the way, there are many food items that are said to improve the spermatogenesis, and there is no harm in including them in the daily food intake. You can Google and get more details.  It is said that zinc and follic acid together has got a positive effect on both T level and spermatogenesis.
You may look at this aspect especially if he is vegetarian. In any case, try to include ZINC rich food in his diet. Alternative medicines also offer some herbal solutions to stimulate sperm production. While you do not have to totally depend on them for a solution, you could still try them as a short term supportive line, since they do not have any major side effects. In the Indian system of medicine Ayurveda, they use Asparagus, Ashwagandha and Shilajit for treatment of azoospermia. You can Google and get more details on them. While you should not get stuck up in this line of treatment, such routes may be considered as a parallel help line.

Sorry for the long post, but I sincerely hope you would get some benefit out of these inputs.

Regards,

Solace    
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Avatar universal
Thanks for your support.

1. Yes in fact I think that having the karyotyping is the next step to take.  We have an appointment set for tomorrow to do that.  Hopefully the results do not take too long to come out.

2.  His LH level is 20.9 (range 1.7-8.6).  Initially his prolactin levels were very high and he was asked to retake the test because they contributed the high levels to stress.  In fact he took the blood test again in the morning and it was then in the normal range.  His TSH is 0.4 (Range 0.3 - 4.2) so that is quite low.  He has not been told to take blood tests for Estrogen Levels for some reason.

3.  We will definitely consider the varicocele replacement surgery once results for karyotyping come out.  If it is confirmed that he has a deletion of the Y chromosome then it would be pointless for him to go through the surgery since retrieval rate of sperm is very low.  However, if it is confirmed that he has klinefelter's (extra X chromosome) or that he has no genetic disorders whatsoevery we would have to go for the varicocele repair surgery.  I have read that varicoceles could affect the function of the Leydig Cell which would therefore disrupt the production of sperm.  

4.  I do believe in alternative medicine but I would need to seek professional help in view of the fact that some herbal supplements may have an impact on FSH Level and I certainly don't want those to go any higher.  He has been taking multivitamins and Vitamin C with Zinc and therefore I hope he is getting enough zinc intake and of course I also try to include zinc rich foods in his diet.  

Someone has also recommended acupuncture recently and he decided to go for it since at this stage we have nothing to lose.  Tomorrow he will be going for repeat blood tests for FSH, LH, Prolactine and Testosterone and we will see whether there is any improvement.

I am just hoping that all this hard work pays off because we are both so depressed.  We are simply existing and not living.  
Thanks a lot for your help.
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Avatar universal
Hello,
    I am sure you are  on the right track, hope for the best and do not get depressed.
You may not have to worry about FSH, LH and Prolactin being high, since as of now, combination of  these being high have been reported in clinical reports without any specific differential diagnosis being made out.Only FSH being high confirms some deficiency in the spermatogenesis functioning of the testis and the steps you are following appears to be in the right direction.Please keep us posted with your progress.

All the best,
Solace.  
Helpful - 0
Avatar universal
Thanks.  Today we went for the karyotyping blood test.  We were both advised to undergo this test just in case we opt to go down the ivf route.  My husband also took the blood tests for FSH, LH, Prolactin and Testosterone once again just to check whether acupuncture has done any miracles for us.  We should be getting these by tomorrow but with regards to karyotyping, it will take another 6 weeks before we know the results because we also got tested for cystic fibrosis and my husband got also tested for the y microdeletion.  But it will be only after we get these blood test results that we will be in a position to decide whether we would be able to go for ivf or not.

Thanks a lot for your help and I will keep you posted on the progress.

Helpful - 0
Avatar universal
Hello,
          Thank you very much for the feedback. I will continue to keep my self updated with your inputs.

By the way, it may be a good idea to get his Free Testosterone, Estrogen and thyroid hormone levels tested in case you are going for any further blood test in future. Even though his TSH level is within range, it is very much towards low normal range. If in this case, his T3/T4 levels are found very high, in the presence of other symptoms, he may come under a borderline case of hyper thyroid. I am also interested to know if the raised LH level may have anything to do with an associated reduced estrogen level or free T.

Also, if his prolactin level keeps showing high values, it may be important to control it using medications, since as per the following link, the control of prolactin is found beneficial :

http://www.drmalpani.com/book/chapter5b.html

Since his varicocele is only on the left side,the intriguing  question here is  what has prevented his right testicle to produce at least some sperms, (even if they were defective), which makes one feel that there has to be a common cause that is affecting the health of both testicles - like childhood mumps, genetic causes, or some hormone related problems.

Regards,
Solace
  
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Avatar universal
My biggest fear is that the common cause that is affecting the health of both testicles is some form of genetic disorder such as Y microdeletion which will minimize greatly our chances of ever having children of our own.  I think my husband falls under the primary hypogonadism category which is caused by mumps or genetic disorders. Hormonal problems are more part of the secondary hypogonadism which is also caused by Kallman's Syndrome, Aids/HIV, medications, etc.  Like you I had my doubts whether his varicocele could be the cause of his azoospermia because it is on the left hand side but I have read some articles that varicoceles may be the cause of azoospermia and that they are mostly situated on the left hand side.

We have received results for his fsh,lh, prolactin and testosterone levels and they are still very high following acupuncture.  But they have greatly reduced since two weeks ago.  His FSH is now 46 (having gone down from 86).  Since acupuncture works on a long term basis we have to wait for probably another month to get a clear result as to whether his FSH has gone down from the original level (i.e. 29).  What is weird is that even though his LH is very high at the moment (at 34), his testosterone level is higher than when his LH was 20.  We will wait for another month until his body settles from acupuncture and we will see where his results are at.

He did undergo tests for TSH and readings were as follows:
FT4 - 18.5 (range 12.0-22.0)
FT3 - 4.9 (range 3.9-6.7)
TSH - 0.4 (0.3-4.2)

So basically these were quite good except for his TSH which is quite low.  He has recently lost over 13kg when he started exercising and he is about 170cm tall and now weighs 65.8kg so I think he is a bit underweight and he has lost way too much weight considering that he was only doing about 20mins treadmill everyday.

Thanks a lot for the link and for your continuous support and advice.
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