Citation Nr: 20003471 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 15-23 250 DATE: January 16, 2020 ORDER Entitlement to service connection for low testosterone, including as secondary to left varicocele surgery with pain, is denied. FINDING OF FACT The preponderance of the evidence is against finding the Veteran’s low testosterone began during active service, or is otherwise related, or secondary, to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for low testosterone, to include as secondary to left varicocele surgery with pain, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1995 to April 1997. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a January 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The appeal was previously before the Board in October 2018 and was subsequently remanded for further development. The requested development has been completed and the claim is before the Board for adjudication. 1. Entitlement to service connection for low testosterone, including as secondary to left varicocele surgery with pain. In this previously remanded case, the Veteran contends he is entitled to service connection for low testosterone to include as secondary to left varicocele surgery with pain. In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b), Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the present of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although lay persons are considered competent to provide opinions on some medical issues, some medical issues fall outside of the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Here, the Board notes the Veteran claimed entitlement to service connection for erectile dysfunction (ED) in August 2008 and was denied in a May 2009 rating decision. The Veteran was afforded a VA examination in April 2009. The examiner opined the condition is less likely than not related to left varicocele and its treatment. The examiner also stated low testosterone is the reason for his ED. However, the examiner failed to opine as to the etiology of his low testosterone and whether his left varicocele condition could result in low testosterone and thus his ED. The Veteran was also diagnosed with low testosterone at a September 2018 VA examination and no etiological opinion was provided. Subsequently, the claim was remanded by the Board in an October 2018 decision in order for the Veteran to obtain an additional examination and etiological opinion. As per the previous Board remand, with regard to the first element of service connection, a current disability, Veteran’s April 2009 VA examination states he has “extremely low testosterone.” As it pertains to the second element, an in-service event or injury, the Veteran has documented in-service treatment of varicocele and other urological conditions. Further, he is currently service-connected for pain associated with treatment of his varicocele condition and symptoms. Therefore, the Board concedes the first two elements of service connection are satisfied. The question before the Board is whether the Veteran’s diagnosed low testosterone is related to service or secondary to his service-connected varicocele condition. The Veteran was provided an examination in this regard in September 2019. The examiner opined the condition is less likely than not (less than 50 percent probability) incurred in, caused by, aggravated, or proximately due to or the result of the Veteran’s in-service injury, event, or current service-connected condition. The Veteran contends his low testosterone is the result of the surgery he underwent in 2006 to repair a varicocele. The examiner provided the rationale that, after a thorough review of the literature, it is less likely than not that the Veteran’s condition is the result of his surgery. He states the decrease in testosterone can be broken down into two simple categories, primary and secondary hypogonadism. The examiner, in his opinion, quotes “UpToDate,” an electronic clinical resource tool for physicians. Hypogonadism in a male refers to a decrease in either or both of the two major functions of the testes: sperm production and/or testosterone production. These abnormalities can result from disease of the testes (primary hypogonadism) or disease of the pituitary or hypothalamus (secondary hypogonadism). The distinction between these disorders is made by measurement of the serum concentrations of luteinizing hormone (LH) and follicle-stimulating hormone (FSH): The patient has primary hypogonadism if his serum testosterone concentration and/or sperm count are low and/or his serum LH and FSH concentrations are high. The patient has secondary hypogonadism if his serum testosterone concentration and/or the sperm count are low and/or his serum LH and FSH concentrations are inappropriately normal or low, which would be inappropriate if gonadotroph cell function were normal. (Snyder, Matsumoto, Geffner, Marting, 2018). The examiner discusses how the Veteran had his FSH, but not LH, measured in 2009, which appeared to be an inadvertent mistake. The examiner states the Veteran’s FSH was found to be low thus giving the consideration to be secondary hypogonadism. He goes on to clarify that UpToDate authors have said there are multiple causes for secondary hypogonadism and in the case of the Veteran, chronic opiate use, more specifically, methadone, has been linked to lower testosterone levels. He quotes, “When opiates are administered chronically, especially when they are administered continuously for relief of chronic pain, they often cause pronounced secondary hypogonadism. (Abs. Verhelst, Maeyaert, et al, 2000).” Further, he quotes, “In men being treated for opiod dependence, methadone, but not buprenorphine, is associated with low serum testosterone concentrations and sexual dysfunction. (Biliesner Albrecht, Schwager, et al, 2005).” More as to the Veteran’s specific contentions, the examiner states that without any further testing done to differentiate the cause of his low testosterone, and the fact that no research can be found to indicate ilioinguinal nerve dysfunction as a cause of low testosterone, the cause of the Veteran’s hypogonadism is likely to be his methadone use and NOT [emphasis original] the adverse outcome of his varicocele surgery. Lastly, the examiner states that while trauma to the testicles can cause low testosterone, there is no documentation of testicular trauma during surgery or other evidence the Veteran suffered trauma while on active duty. Unfortunately, therefore, the Board finds that it has no alternative but to find that the preponderance of the evidence is against a finding that the Veteran’s low testosterone began during active service, or is otherwise related, or secondary, to an in-service injury or disease. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher J. DeBoer, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.