A varicocele is an abnormal dilation of varicose veins that drain the testicle, and it can be associated with a progressive decline in testicular sperm and testosterone production. Varicoceles are the most common identifiable cause of male infertility world wide. Although varicoceles are present in 15% of the normal male population, they are found in up to 40% of patients with male infertility. For infertile men with a prior history of normal fertility (called secondary infertility), a varicocele is the cause in up to 70% of cases. Male infertility has been found to be the major cause of a couple’s inability to conceive. There are many reasons for male infertility including: deficiencies in sperm production; blockage of the sperm conducting system; sperm antibodies; injury to the testicle with resultant loss of size and function; hormonal problems; poor descent of one or both testes; and finally, the presence of a varicocele.
In order to understand what a varicocele is, one must be aware of some basic anatomy and physiology. The testicles are paired male genital organs that contain not only sperm, but also cells that produce and nourish the sperm (Sertoli cells), as well as cells that produce the male hormone testosterone (Leydig cells). The testes are located in a sac called the scrotum. The epididymis is a small, tubular structure attached to the testicle which is a reservoir where the sperm mature and are stored. The vas deferens connects to the epididymis and connects is the tube through which sperm travel during ejaculation. The vas deferens is a part of a larger tissue bundle called the spermatic cord that also contains blood vessels, nerves, and lymphatics coming from the testicle. The veins of the spermatic cord are known as the pampiniform plexus, and that drain blood from the testes, epididymis, and vas deferens. The pampiniform plexus of veins may become tortuous and dilated (like varicose veins in the leg). Indeed, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus around the spermatic cord above testicle. The other two veins that drain the testicles (cremasteric and deferential) are rarely involved in the varicocele process.
Varicoceles are more common on the left than on the right for multiple anatomic reasons, e.g., primarily because of the angle at which the left testicular vein exits from the renal vein compared to the right. Varicoceles may vary in size and can be graded into three groups: small, moderate, and large.
- Grade I: Identified only while bearing down
- Grade II: Identified by feel without bearing down
- Grade III: Easily identified by inspection alone
It is important to remember, however, that the size of the varicocele is not related to the degree of changes in the sperm. In addition, up to 40% of many infertile males will have bilateral varicoceles. More importantly, a one-sided varicocele can often have an effect on the opposite testicle!
Several theories have been proposed to explain the harmful effect of the varicocele on sperm quality. These include the possible effects of pressure, oxygen deprivation, heat injury, or retrograde flow of toxins. However, despite considerable research, none of these theories has been unquestionably proven. The belief that elevated heat caused by impaired circulation appears to be the most reproducible defect. Indeed, creation of a varicocele in an experimental animal can lead to poor sperm function with elevated intratesticular temperature supports this concept. Regardless of the mechanism, a varicocele is indisputably a significant factor in decreasing testicular function and changing the worsening semen quality in a large percentage of men seen for infertility.
Because of its potential role in causing significant testicular damage, it is important to identify the varicocele on physical examination. The reasons for surgical correction include pain, impairment of testicular function, or loss of testicular size. The mere presence of a varicocele does not mean that surgical correction is necessary.
Usually, the varicocele is asymptomatic, and the patient is seen primarily for evaluation of a possible male factor in an infertile marriage. However, he may sometimes complain of pain or heaviness in the scrotum. Careful physical examination remains the primary method of varicocele detection. It is important to examine the patient in the standing position, having him perform the Valsalva maneuver (i.e., take a deep breath and bear down) to magnify a small varicocele. When small varices varicoceles are difficult to diagnose, more objective means can be used such as high-resolution color-flow Doppler ultrasonography.
Reasons for Surgical Correction
- The presence of significant testicular pain.
- Impairment of testicular function, as evidenced by decreased semen quality.
- Loss of testicular size (atrophy).
Once a varicocele is diagnosed, reasons for surgical correction include: testicular discomfort or pain unrelieved by routine symptomatic treatment, testicular atrophy (loss of testicular size), or the possible contribution to male infertility. In addition, varicoceles may be a cause of progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.
Common Surgical Approaches for Varicocele Repair
- Transinguinal (groin) approach
- Retroperitoneal (abdominal) approach
- Infrainguinal approach.
There are three commonly used surgical approaches for the correction of a scrotal varicocele. Under routine conditions, we prefer the transinguinal (groin) approach, utilizing optical magnification (with an operating microscope) to ensure precise identification all contributory veins and the testicular arteries.
All abnormal veins are permanently tied off to prevent continued abnormal blood flow. The retroperitoneal or infrapubic approach is used in patients who have already had an attempted varicocele or hernia repair, where considerable scarring in the groin may be encountered. Also, the percutaneous transvenous route may be performed by an interventional radiologist. However, because of potentially greater risks, we reserve this approach for recurrent varicoceles. The laparoscopic route also has potential major risks and has little benefit over the transinguinal approach.
With our preferred transinguinal (groin) approach, a 1.5 – 2 inch inguinal (hernia-type) incision is used. The patient returns home the same day with a prescription for pain medication, and frequently can return to work within several days. Two weeks of recovery and avoidance of strenuous activity is recommended.
The side effects following varicocele repair are remarkably low. There is a less than 1% risk of hydrocele (fluid around the testicle), 1% risk of hematoma or superficial wound infection, and small risk of recurrent varicocele.
Although the mechanisms whereby varicoceles cause impairment in sperm production and semen quality remain theoretical, the statistical association between varicocele and male infertility is unquestionable. Furthermore, improvement in semen quality after varicocele correction has been repeatedly demonstrated.
The resultant improvement in semen quality occurs in close to 70% of patients, and the pregnancy rate is as high as 40%. Correction of varicoceles has been shown to improve sperm motility, density, and shape (morphology), but also specific functional sperm defects including oxidative damage (ROS) and breaks in DNA. Studies have also shown the return of motile sperm after varicocele repair in patients who have complete absence of sperm on semen analysis (azoospermia). Varicocele treatment improves pregnancy and live birth rates among couples undergoing intrauterine insemination (IUI) and in vitro fertilitization (IVF) with intracytoplasmic sperm injection (ICSI) for male factor infertility. The chance of miscarriage has also been reported to be decreased if varicoceles are treated before assisted reproduction.
On average, pregnancy occurs 6–9 months following surgery. The first semen analysis is obtained at 3–4 months, because spermatogenesis (the formation of sperm) takes about 3 months for mature sperm to develop.
The scrotal varicocele remains the most correctable factor when treating poor semen quality. Therefore, when present in the infertile male who demonstrates abnormalities of semen quality, surgical correction should be strongly considered. The side effects following varicocele repair are remarkably, and successful surgery will often increase the chance for eventual pregnancy in the infertile couple.