Varicoceles are the most common cause of male infertility, accounting for up to 40 percent of cases. Varicoceles are thought to cause defects in the sperm by raising the temperature in the other testes. Studies have also shown subtle hormonal abnormalities. Varicocele repair will halt any further damage to testicular hormone function and, in a large percentage of men, result in improved sperm production.
Found in nearly 15 percent of all men, varicoceles do not always lead to fertility problems. Not all varicoceles require treatment, but it is recommended when fertility is affected.
Varicoceles are a dilation of the veins that drain the testis. A varicocele may occur on one or both sides of the testicles, but it most often forms on the left side. A varicocele develops because of defective, one-way valves that normally let blood flow away from the testicle. The resulting reverse flow of blood stretches and enlarges the tiny veins around the testicle to form a varicocele.
Varicoceles typically develop after puberty, although many are not detected until a man has been evaluated for fertility problems.
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, they will expand when the patient bears down, as the blood reverses flow back towards the testicle.
Most experts agree that only varicoceles detected by physical exam are clinically significant. Therefore, further testing, such as scrotal ultrasound, is usually not necessary except under certain circumstances. If tests are needed, these may include semen fluid analysis, sperm morphology assessment (the structure of the sperm) and hormone testing.
The goals of varicocele repair are to relieve pain in symptomatic cases and to improve semen quality, testicular function and pregnancy rates in couples with infertility associated with a man’s varicocele.
Varicocele repair results in a significant improvement in semen quality in 60 percent 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 options include radiologic and surgical approaches:
- Radiologic ablation to block off the veins. This is performed with a radiologist who injects either small coils or pure alcohol into the veins, thus causing them to become non-functional. While this procedure is less invasive than surgery, it is also less effective, has a higher cost, and has a higher rate of recurrence of the varicocele.
- Surgical ligation to tie off the dilated veins. This surgery, typically performed on an outpatient basis, consists of making a small incision just below the groin. While most men prefer general anesthesia, the procedure may be performed under local anesthesia with intravenous sedation. Most men are able to go back to work within three to four days and resume full activity within seven to 10 days.
- Open surgery to find and preserve the tiny artery that brings blood to the testes. Magnification allows identification and preservation of the testicular arteries and lymphatics, reducing the risk of complications after surgery. Microsurgery contributes to higher success rates and fewer complications.
- Laparoscopic minimally invasive surgery can also be used to repair varicoceles successfully, although this approach tends to be more expensive and no less invasive than the microsurgical approach.
Microsurgical removal of a varicocele offers a safe and effective approach to varicocele repair with preservation of testicular function, improvements in semen quality and improvements in conception rates in a significant number of men.
Correction of varicoceles will lead to an improvement in semen quality in about two-thirds of patients, with most studies reporting unassisted pregnancy rates ranging from 30 percent to 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 after repair, as compared to a 10 percent baseline pregnancy rate for uncorrected varicoceles. Because the sperm production cycle is nearly 90 days long (70 days to produce sperm and 15-20 days of transit through the ductal system), semen results are checked for improvement at three and six months. In infertile men with low serum testosterone levels, microsurgical removal of the varicocele has been shown to improve serum testosterone levels.
In an abundance of caution, care and concern for our patients, staff and community, we are delaying fertility treatment starts until we have a greater sense of the degree of COVID-19 transmission in our region. We will closely follow ASRM and CDC recommendations as they become available.