Microsurgical Varicocelectomy

What is a Varicocele? 

Varicocele is a term used to describe abnormally dilated veins of the testis located in the scrotum. The term varicosity is familiar to those who have seen varicose veins of the leg.  Veins are vascular structures that carry blood away from an organ and arteries are the vessels which supply oxygen rich blood to organs.  Veins normally have one-way valves present with in their lumen to prevent back flow of blood.  When these valves are incompetent, blood can pool, as what happens with varicose veins of the legs upon standing.  A varicocele is the same phenomenom in the scrotum, and these varicose veins can often be seen with the naked eye and look like “a bag of worms.”  More commonly, however, a varicocele is only detected upon examination by a physician. 

The exact cause of varicoceles and the method by which they damage the testis is unknown.  The most popular theories is that varicoceles are caused by absent or abnormal valves in the veins of the scrotum.  Since the reduced drainage of blood from the scrotum can affect the temperature of the testis, the tesis may be adversely affected from both a sperm production standpoint as well as testosterone production. 

How Does a Man Present with a Varicocele?

There are three clinical scenarios related to varicoceles:

1. The most common, is finding a completely asymptomatic varicocele in a man being evaluated for infertility,
   
2. Young asymptomatic men who find a mass in the scrotum either on their own or during routine exam and are concerned about future fertility and
   
3. A man with pain in the scrotum.

What kind of pain does a varicocele sometimes cause?

Varicocele is a potential cause of scrotal pain that is either dull like in quality or extreme. The typical varicocele is asymptomatic, however occasional patients note an aching feeling in the scrotum associated with prolonged standing or activity and the aching pain is relieved by lying down supine (on one’s back) with the feet raised.

Varicoceles may cause more severe pain if the veins develop thrombophlebitis. The evaluation of patients with scrotal pain should include scrotal ultrasonography to rule out other pathology and cultures to rule out infection. Repair of the varicocele may be considered when there is no other identifiable cause of the pain and the pain qualities are consistent with a varicocele, however there can be no guarantee that varicocele repair will eradicate the pain.

When Should a Varicocele Be Repaired?

Management of the young man with an incidental finding of an asymptomatic varicocele is somewhat controversial. There is strong evidence to suggest that repairing a varicocele improves testicular function and may prevent any further testicular damage over time. Thus, the first step in the evaluation of this patient is to assess testicular function directly by semen analysis or indirectly by measuring testis volume. Repair of the varicocele is indicated if there is any evidence of testicular damage.
The controversial aspect in the management of these patients is if current testicular function appears normal. The issues related to this controversy include the fact that since the patient is not currently trying to conceive we cannot assure him that his fertility is actually intact just because he has a normal semen parameters or testis volume. There is some evidence to suggest that varicoceles exert a progressive deleterious effect over time that would imply that all varicoceles should be repaired if future fertility is being considered. However, there is equal evidence against a progressive effect of varicoceles upon the testis and the fact remains that the vast majority of men with varicoceles (80%) are able to conceive on their own without utilizing fertility services. Thus, the controversy is whether to repair all varicoceles, repair only those varicoceles associated with signs of testicular damage or to observe patients with varicoceles over time with serial semen analyses.

Varicocele and Fertility

Varicoceles are found on physical examination of roughly one third of men being evaluated for failure to conceive. They are categorized by size (large, medium and small) and by their presence on one or both sides of the scrotum. It is important to know that varicoceles of all sizes may affect fertility and the chance of improvement is equivalent after repair. In addition, a varicocele on side of the scrotum has an effect upon both testes in regards to function and temperature. Varicoceles that cannot be felt by the physician but are diagnosed by imaging studies, such as ultrasonography, are not clinically significant.
Repair of a varicocele in the male partner of an infertile couple is indicated when:

1. There is objective evidence of a male factor (i.e. abnormal semen analysis),
2. The wife’s fertility status is intact and
3. There are no other obvious causes for male infertility (i.e. obstruction or genetic abnormality).

         
How is a Varicocele Repaired?

Varicocele repair can be performed surgically or non-surgically. There is no ideal method or absolutes in making this decision. The non-surgical repair is a minimally invasive technique performed by an interventional radiologist on an outpatient basis. The success rate varies significantly dependent upon the experience of the radiologist, the anatomy of the patient and the presence of varicoceles on both sides.
Microsurgical varicocelectomy is an outpatient procedure performed under general anesthesia through a small incision in the lower groin.  This procedure has the greatest chance of repair with the least morbidity and lowest cost. Non-surgical approach is utilized primarily in patients with a previously failed surgical repair, pain as the main indication and body features that increase the risk of surgery such as morbid obesity.
Potential complications from varicocele repair include persistent/recurrent varicocele, bruising, infection and testicular tenderness. A hydrocele, collection of water around the testis, occurs in an extremely small number of men. For those patients undergoing the non-surgical repair, there is the added risk of reaction to the contrast agent used in the procedure. Finally, there is an extremely low risk of loss of the testicle.  Insurance typically covers microsurgical varicocelectomy.

How Does Repairing a Varicocele Positively Affect Fertility?
         
In 540 infertile men with a clinical palpable varicocele who underwent microsurgical varicocelectomy and were followed more than 1 and 2 years postoperatively for alterations in semen quality and conception, respectively:

1. A greater than 50% increase in total motile sperm count, was observed in 271 patients (50%).
2. An overall spontaneous pregnancy rate of 36.6% was achieved after varicocelectomy with a mean time to conception of 7 months (range 1 to 19).
3. Of preoperative In-Vitro Fertilization/Intra Cytoplasmic Sperm Injection (IVF and ICSI) candidates, 31% became Intrauterine Insemination (IUI) candidates
4. Of all IUI candidates 42% gained the potential for spontaneous pregnancy.
5. Microsurgical Varicocelectomy has significant potential not only to obviate the need for assisted reproductive technology, but also to down stage or shift the level of assisted reproductive technology needed to bypass male factor infertility.

                                      Cayan S, Turek PJ.  J Urol. 2002 Apr;167(4):1749-52

This means that repairing a clinically significant varicocele can significantly improve semen parameters and allow for natural conception or lessen the need of reproductive assistance.  In addition, microsurgical varicocele repair can result in an improvement in testosterone production.