Varicocele Repair
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Varicocele is a network of dilated veins in the scrotum which may compromise fertility. It is much like “varicose veins in the legs,” but is contained in the scrotum. Varicocele is present in about 15% [1] of the general population; and is therefore, common. However, varicocele is present in approximately 40% of men who are seen in infertility clinics [2]. Therefore, they are much more common in men who are unable to establish a pregnancy. Indeed, the presence of a varicocele is associated with suppressed semen parameters; which may contribute to decreased male fertility [3]. There are several theories why a varicocele may be detrimental to sperm production [4]. One theory is increased heat generated around the testicle due to engorged veins whenever a man stands. Indeed, when a thermometer is inserted into a testicle surrounded by a varicocele, the temperature is 1-2° warmer than a testicle not surrounded by dilated veins [5].
The diagnosis of varicocele is typically made by physical examination with the patient standing. In equivocal cases a Doppler stethoscope may be used in the office to further assess for presence of varicocele [6].
Varicocele repair, or varicocelectomy is typically performed surgically [7] or by embolization [8,9]. The state-of-the-art surgical approach is performed with an operating microscope [7], often referred to as, “microsurgical varicocelectomy.” The intra-operative microscope allows the surgeon to better visualize the structures of the spermatic cord compared to the non-microscopic approach. Better visualization allows ligation (tying off) of only the varicose veins with preservation of the other important structures in the spermatic cord; including, the testicular artery or arteries (there may be more than one), the vas deferens, and the lymphatics. Injury to these non-venous structures, causing intra-operative and post-operative complications, is significantly lower using the microscope compared to the non-microsurgical approach [10,11]. The surgery is performed under general anesthesia through a subinguinal 1-inch incision in the lower groin (bikini line) as an outpatient. Recovery time is 2-3 days, but heavy lifting (greater than 20lbs) is not recommended for about 7 days. The couple may resume intercourse whenever the patient is comfortable.
Embolization is performed by a radiologist [8,9]. This procedure involves inserting a needle in the neck or the groin and a catheter is placed into the main vein of the body (Inferior Vena Cava). Then, coils are dropped into the testicular vein to “plug up” the varicose vein. The benefit of embolization is that general anesthesia is not required. Usually, the patient receives an intravenous line (IV) and sedation (medicines to cause drowsiness). However, the success rates with surgery are often better [7-10].
There is approximately 75% chance of improvement in semen parameters and a 40% natural pregnancy rate following varicocele repair [7,10]. However, it may take up to one year for semen parameters to optimize. The patient will be followed every 3 months with a semen analysis or until pregnancy results. If the female partner is a candidate for natural pregnancy or intrauterine insemination (IUI), the varicocele repair may not only result in natural spontaneous pregnancy (the optimal result); but, may allow the couple to pursue IUI (which is significantly less costly) instead of, or at least prior to, pursuing invitro fertilization (IVF, or sometimes referred to as “test-tube baby”) [12].
[1] Kursh ED. What is the incidence of varicocele in a fertile population? Fertil Steril. 1987 Sep; 48(3):510-1.
[2] Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year study. Urology 1977 Nov; 10(5):446-9.
[3] Tulloch WS. Varicocele in subfertility. Results of treatment. Br Med J. 1955 Aug; 2(4935):356-8.
[4] Naughton CK, Nangia AK, Agarwal A. Pathophysiology of varicoceles in male infertility. Hum Reprod Update. 2001 Sept-Oct: 7(5):473-81.
[5] Goldstein M, Eid JF. Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. J Urol. 1989 Sept; 142 (3) 743-5.
[6] Greenberg SH, Lipshultz LI, Morganroth J, Wein AJ. The use of the Doppler stethoscope in the evaluation of varicoceles. J Urol. 1977 Mar; 117(3):296-8
[7] Thomas AJ, Geisinger MA. Current management of varicoceles. Urol Clin NA 1990 Nov; 17(4): 893-907.
[8 ]Gonzalez R, Narayan P, Formanek A, Amplatz K. Transvenous embolization of internal spermatic veins: nonoperative approach to treatment of varicocele. Urology 1981 Mar; 17(3): 246-8.
[9] Trombetta C, Liguori G, Bucci S, Ciciliato S, Belgrano E. Percutaneous treatment of varicocele. Urol Int 2003; 70(2): 113-8.
[10] Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994 Oct; 152(4): 1127-32.
[11] Testini M, Miniello S, Piccinni G, Di Venere B, Lissidini G, Esposito E. Microsurgical treatment of varicocele in outpatients using the subinguinal approach. Minerva Chir. 2001 Dec;56(6): 655-9.
[12] Cayan S, Erdemir F, Ozbey I Turek PJ, Kadioqlu A, Tellaloglu S. Can varicocelectomy significantly change the way couples use assisted reproductive technologies? J Urol. 2002 April; 167 (4) 1749-52.
