Varicoceles are a dilation of the veins that drain the testis. These are found in the spermatic cord and are called the pampiniform plexus. Varicoceles typically develop after puberty, although many are not detected until evaluation for fertility problems is undertaken.
Varicoceles are very common. In fact, they are the most common cause for male factor subfertility, accounting for up to 40 percent of cases. However, they are found in nearly 15 percent of all men, and do not always lead to fertility problems. Therefore, not all varicoceles require treatment. However, most doctors recommend treatment of varicoceles in the event of male factor subfertility. Although they do not represent a health risk, they can lead to deterioration of fertility over time.
Pathophysiology (Why varicoceles cause fertility problems)
Varicoceles are thought to cause problems with sperm’s formation by raising the temperature in the testes (both the affected and other testis). Repair of varicocele will halt any further damage to testicular hormone function and in a large percentage of men, result in improved spermatogenesis (sperm formation), as well as enhanced Leydig cell function. The potentially important role of urologists in preventing future infertility underscores the importance of using a procedure to repair the varicocele that minimizes the risk of complications and recurrence.
- Physical exam: Varicoceles are typically diagnosed by physical exam. They are most easily detected when the patient has been standing in a warm room for several minutes. Often, varicoceles will expand when the patient bears down or strains, as the blood reverses flow back toward the testicle. Most experts agree that only varicoceles detected by physical exam are clinically significant, which means they should be considered for treatment.
- Seminal fluid analysis: Varicoceles are usually associated with abnormalities in most of the seminal parameters rather than isolated abnormalities. However, they can also cause isolated defects in sperm count, motility, morphology, or function.
- Strict morphology: This utilizes well-defined parameters in order to assess sperm morphology (structure). The percentage of strictly normal forms has been shown to correlate with in vitro (in a dish) fertilization rates. Samples that demonstrate 14 percent or more strictly normal forms tend to have much better fertilization in vitro than those with 4 percent or less. However, there is debate as to whether these percentages correlate with in vivo (in the body) success. Several studies have demonstrated that varicocele repair will improve strict morphology in certain patients. Therefore, although preoperative testing for strict morphology is helpful, the result should not influence the decision to treat the varicocele.
- Ultrasound and doppler
: Ultrasound is a sensitive study that can identify varicoceles as small as 2-3 mm in diameter. However, ultrasound will also identify varicoceles that are not seen on physical exam alone. These are termed "subclinical." Because the original studies examining the effects of varix ligation on seminal parameters did not find a significant correlation between size of the varicocele and response, some believe that correcting subclinical varicoceles would lead to the same rate of improvement as the correction of clinical varicoceles. However, most reports have refuted this, demonstrating a lower response rate following repair of subclinical varicoceles, and even lower pregnancy rates.
Doppler studies are easily performed in the office and identify the reversal of blood flow during Valsalva maneuver. This study may also detect a subclinical varicocele, although it is also useful in men with tight scrotal skin, short spermatic cords, or to examine the right side in the presence of a palpable left varicocele.
The goals of varicocele repair are to relieve pain in symptomatic cases and to improve semen parameters, testicular function, and pregnancy rates in couples with male factor infertility associated with varicocele. Studies have shown that varicocele repair can improve all three of these parameters. Varicocele repair results in a significant improvement in semen analysis in 60 to 80 percent of men. Men with large varicoceles tend to have poorer preoperative semen quality than men with small varicoceles, but repair of large varicocele results in greater improvement than repair of small varicoceles.
Treatment consists of either radiologic ablation or surgical ligation. The surgery is typically performed on an outpatient basis and consists of a small incision just below the groin. Most men prefer general anesthesia, however the procedure may be performed under local with intravenous sedation. Time to recovery varies, but most men are able to go back to work within 3-4 days, and resume full activity within 7-10 days, other than heavy lifting, which should be avoided for 3 weeks.
The open surgical procedures can be performed with loupe or microscope magnification. The advantages of the microsurgical approach to varicocele repairs are reliable identification and preservation of the testicular artery or arteries, cremasteric artery or arteries, and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins. Use of a microscope enables a surgeon to find and preserve the tiny artery that brings blood to the testes. Magnification also allows identification and preservation of the lymphatics, eliminating the risk of hydrocele (bag of water forming around the testis) after surgery. Postoperatively, venous return is via the vasal veins, which drain into the internal pudendal system and usually have competent valves.
Laparoscopy, so commonly used in female infertility, can also be used in men to repair varicoceles successfully.
The most common complications from varicocelectomy are hydrocele, varicocele recurrence, and testicular artery injury. Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries so that the incidence of these complications can be reduced significantly. Microsurgical varicocelectomy provides a safe and effective approach to varicocele repair with preservation of testicular function, improvements in semen quality, and improvements in pregnancy rates in a significant number of men.
Correction of varicoceles will lead to an improvement in seminal parameters in approximately two-thirds of patients, with most studies reporting unassisted pregnancy rates ranging from 30-50 percent. In the only prospective randomized trial of varicocele repair, the surgery group demonstrated pregnancy rates of 44 percent after one year, and as high as 76 percent up to two years post-repair, as compared to a 10 percent baseline pregnancy rate for uncorrected varicoceles. Because the spermatogenic cycle is nearly 90 days long, we typically will check for improvement in the semen results at three and six months. In infertile men with low serum testosterone levels, microsurgical varicocelectomy has been shown to improve serum testosterone levels.
Varicoceles are identified in 35-40 percent of men with primary infertility and 81 percent of men with secondary infertility (men who were able to father a child in the past). Studies have shown that varicocele causes progressive duration-dependent injury to the seminiferous epithelium. Varicocele repair is thought to halt this duration-dependent process. The patient's seminal parameters are maximized, a significant percentage of couples will go on to achieve pregnancy without assisted techniques, and those that do proceed to ART may have improved sperm quality.