Varicoceles are an enlargement or dilation of the veins in the spermatic cord that drain blood from the testicle. Varicoceles are present in about 15% of all men but in about 40% of men that present with impaired fertility.
Although varicoceles may cause dull pain or impaired semen parameters, many men live entirely unaffected by the vein enlargement. It is important to note however, that uncorrected varicoceles may have a progressive negative effect on sperm counts. Although the exact mechanism is unclear, the increase in testicular temperature or toxins due to pooling blood is thought to disrupt sperm production. A varicocele on one side can increase the temperature of the entire scrotum by about 1.5 degrees Celsius, and repair of varicoceles has been shown to reduce scrotal temperature by about 1.5 degrees Celsius.
The vein dilation can be caused by a lack or malfunction of valves normally present in veins or from external compression by other structures. Varicoceles are more commonly found on the left side due to the right-angle orientation of the left testicular vein as it returns blood to the body and due to compression from a nearby artery, but about 25% of cases have varicoceles on both sides. Unilateral right varicoceles require further evaluation of structures around the vein insertion in the back with imaging to rule out masses.
Diagnosis and grading are based on size during physical examination though a scrotal ultrasound with veins larger than 3mm or reversal of blood flow on Valsalva can be diagnostic in the setting of difficult physical examination. Significant research supports repair of clinically palpable varicoceles for fertility benefits in men with semen abnormalities while limited research supports repair of subclinical varicoceles.
Varicoceles are repaired by surgically by blocking the flow of blood through the testicular veins. This is typically achieved by tying these vessels off through an incision in the groin though percutaneous approaches through the main vein of the body are also possible. Most evidence supports the sub-inguinal approach with the aid of an operating microscope because reduces complications, eases recovery, and only entails a 2cm incision in the lower groin.
When to ask a Urologist about Microsurgical Varicocelectomy
You should speak to a Urologist about microsurgical varicocelectomy if you have trouble getting pregnant or if you are having scrotal discomfort and have been told that you have an enlargement of the veins in the scrotum.
Typically covered by most insurances (although coinsurance and deductibles may apply). Coverage will be verified prior to proceeding. If you do not have insurance, our office will be able to give you an out-of-pocket cost estimate.
For men with decreased sperm parameters and palpable varicocele on examination, compilation of multiple trials supports an average increase of 7 million total sperm and increase of 9% in sperm motility following microsurgical varicocele repair. Strict morphology improves by 1.5% on average. About one half of men have a greater than 50% improvement in total motile sperm count. Men with larger varicoceles tend to have larger improvements following repair. Improvements in semen parameters are typically seen between 3- and 6-months following varicocele repair.
Spontaneous pregnancy rates are higher on average in couples following varicocele repair relative to controls (26.8% vs 16.5%). A Cochrane review of randomized trials indicated that repair of a clinical varicocele approximately doubled the likelihood of a spontaneous pregnancy.
In couples undergoing intrauterine insemination, men with repaired varicoceles had higher pregnancy and live birth rates per cycle than controls (11.8% vs 6.3% and 11.8% vs 1.6%, respectively).
In couples undergoing in vitro fertilization, men with repaired varicoceles had high pregnancy and live birth rates per cycle than controls (60% vs 45% and 46.2% vs 31.4%, respectively).
Varicocele repair can change the reproductive method available to couples. For couples initially requiring intrauterine insemination, 28-65% had sufficient sperm for spontaneous pregnancy postoperatively. For couples initially requiring in vitro fertilization based on sperm count, 22-58% had sufficient sperm counts for intrauterine insemination, and about 10% spontaneous pregnancy postoperatively.
Sperm parameters do not always improve with varicocele repair and, in some rare instances, may decrease. There is evidence that sperm quality improves even in instances without increasing sperm quantity. In men who still required in vitro fertilization due to persistent low sperm counts following varicocele repair, the pregnancy and live birth rates were about 1.7 times higher following repair compared to controls.
Possible Side Effects
Significant risks with this procedure are extremely infrequent. The procedure is performed under a specialized operating microscope with the use of a doppler ultrasound probe in order to identify and preserve the artery to the testicle. There is a small risk (<1%) of damage to the testicular artery possibly resulting in testicular pain, testicular atrophy, or the need to remove the testicle.
Alternatives to varicocelectomy include varicocele embolization, a procedure where an instrument is inserted into the main vein in the body and material is deployed in the testicular vein to try to seal it. Additionally, couples may opt to continue to achieve a natural pregnancy without treatment or proceed directly with in vitro fertilization.
What to do to Prepare for Surgery
You will receive detailed instructions from the surgical schedulers regarding any necessary testing or appointments prior to surgery. In general, you should temporarily stop blood-thinning medications prior to surgery (when to stop depends on the type of blood thinner). Prescription blood-thinning medications should be stopped following clearance from the doctors that prescribed them though other medications that thin the blood including fish oil and pain relievers such as ibuprofen should be stopped as well.
On the day before surgery, you will receive a phone call alerting you to the time that you should arrive, and you should wash the surgical area with an antibacterial soap.
You should not eat or drink anything after midnight on the day of surgery, but you may take approved home medications in the morning before surgery with a small sip of water.
What to Expect after Surgery
Patients are sent home following the procedure. There can be tenderness, bruising and swelling in the scrotal and groin area that dissipates over 1-2 weeks. The first follow-up semen analysis is typically obtained around three months after surgery.