Citation Nr: 22014223 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 15-23 250 DATE: March 11, 2022 REMANDED Entitlement to service connection for low testosterone, to include as secondary to service-connected chronic left inguinal pain status post left varicocele surgery and chronic symptomatic varicocele, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from October 1995 to April 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in October 2018 when it was remanded for additional development, to include providing the Veteran a VA examination to determine the nature and etiology of his low testosterone. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In a January 2020 decision, the Board denied service connection for low testosterone. The Veteran appealed the Board's January 2020 decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a July 2021 Court Memorandum Decision, the Court vacated the Board's January 2020 decision, and remanded the matter to the Board for further action. 1. Entitlement to service connection for low testosterone, to include as secondary to service-connected chronic left inguinal pain, status post left varicocele surgery and chronic symptomatic varicocele is remanded. As highlighted by the Court in the July 2021 Memorandum Decision, a September 2019 VA examination was inadequate as the examiner provided no rationale as to whether the Veteran's low testosterone, referred to as hypogonadism, was a manifestation of primary hypogonadism. It was noted that when the Veteran was diagnosed with low testosterone in 2009, testing at the time did not include serum luteinizing hormone (LH) laboratory results that would enable differentiation of the cause of the low testosterone. Because the Veteran's LH was not tested contemporaneously with his follicle-stimulating hormone (FS) in 2009, the examiner could not accurately identify the Veteran's condition as either primary or secondary hypogonadism. The inability to accurately identify the Veteran's condition as primary or secondary hypogonadism is significant because the examiner's opinion rests on the assumption that the Veteran's low testosterone likely resulted from methadone use rather than a service-connected disability because the reviewed literature listed chronic opiate use as a common cause of secondary hypogonadism. Therefore, it was instructed that remand was requested to obtain an adequate medical examination. The Board also notes an October 2009 VA treatment record in which it was noted that low testosterone was documented in April and May 2009. The differential includes secondary (opiate effect, hemochromatosis, pituitary tumor (not present on MRI per patient report)) versus primary hypogonadism. Although methadone likely contributing to lower testosterone, one would not expect an undetectable total testosterone as seen in April 2009. Low normal IGF-1 and low normal FSH may point toward a central/pituitary issue, but major abnormality not detected on MRI. The diagnosis was questionable primary versus secondary hypogonadism. The Board finds the October 2009 VA treatment record supports the finding in the July 2021 Court Memorandum Decision that there remains a lack of clarity as to the nature of the Veteran's low testosterone, that is, whether it is primary or secondary in nature, rendering the etiology of such in doubt. Hence, the Board finds that this matter must be remanded again for a VA examination and opinion as to the etiology of the Veteran's low testosterone. If additional testing is necessary, such should be performed in collaboration with the examination. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of the Veteran's low testosterone. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Whether it is at least as likely as not that the Veteran's low testosterone, referred to as hypogonadism had its onset, or the underlying disease process began, in service, or is otherwise related to service? (b) Whether it is at least as likely as not that the Veteran's low testosterone, referred to as hypogonadism, is caused by his service-connected chronic left inguinal pain status post left varicocele surgery? (c) Whether it is at least as likely as not that the Veteran's low testosterone, referred to as hypogonadism, was aggravated by his service-connected chronic left inguinal pain status post left varicocele surgery? A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. The examiner is specifically asked to review the September 2019 VA examination and opinion, as well as the July 2021 Court Memorandum Decision, in the formulation of the opinion and rationale provided. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Marley, 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.