I had a bilateral varicocele operation for low sperm count. My sperm count is now 36 million per milliliter. After hormone testing done last month, I have been advised to take Proviron 50mg once a day. Are hormone treatments for men effective? How reliable is the prolactin test for men? (Mine was 21.57 ng/ml.) Does it matter if the blood sample for the test is taken just after a semen specimen collection? I read somewhere that prolactin goes up during semen release. Is a CT scan to rule out pituitary tumor necessary?

B.G.

Hormone abnormalities are a rare cause of male fertility problems. Testing for the hormones FSH (produced by the pituitary) and testosterone (produced by the testicles) can indicate whether there is insufficient pituitary activity or testicular failure. If the FSH is low or normal, testosterone is low, and the testicle is smaller than normal and very soft, hormonal stimulation with either clomiphene tables or injections of a combination of hCG and FSH (Follistim or Gonal-F) may be of benefit. However, giving testosterone or an anabolic steroid such as Proviron is more likely to suppress adequate testicular sperm formation than help. Testosterone administration either by shots, patches or pills will not improve the production of sperm.

Prolactin is another pituitary hormone. Its role in men is not entirely clear. Significant prolactin elevations -- levels over 100ng/ml -- may indicate a small pituitary tumor called a microadenoma. In women, prolactin microadenoma may be associated with irregular menses and galactorrhea (milky breast discharge). In men, the most common consequence is impotence, not abnormal sperm production.

More and more attention is being given to the role of phytoestrogens (plant estrogens) or natural estrogens (estradiol). High estrogen levels are found in a small percentage of men with markedly abnormal sperm counts. The basis for this elevation is unclear. Liver disease such as cirrhosis or excessive marijuana use may be the culprit in some cases. The use of a medication called an aromatase inhibitor has been shown to block the production of estrogen and may benefit this group of men.

Varicoceles are frequently diagnosed when fertility problems are present; they may be the most overdiagnosed fertility problem. We know that many fertile men are found to have varicocele on physical exam, and these men have no difficulty impregnating their wives. So do all varicoceles require surgical repair? Certainly not. If the varicocele is not readily obvious on physical exam and requires an ultrasound to diagnose, I usually recommend my patients consider other options to achieve a pregnancy.

After surgery, about 60 percent of men with moderate to large varicoceles will see a benefit in sperm count and motility. While your question suggests that your sperm count has improved since your surgery, you made no mention as to the effect of the surgery on the percentage of normal-appearing sperm (morphology) or the percentage of moving sperm (motility). These factors are incredibly important to successful impregnation.