Varicocele

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.

However, despite considerable research, none of these theories has been unquestionably proven. Elevated heat caused by impaired circulation appears to be the most reproducible defect. In an experimental animal, the creation of a varicocele leads to poor sperm function with elevated intratesticular temperature. Regardless of the mechanism, a varicocele is indisputably a significant factor in decreasing testicular function and worsening semen quality in a large percentage of men seen for infertility.

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!

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 varicoceles are difficult to diagnose, more objective means can be used such as high-resolution color-flow Doppler ultrasonography.

Under routine conditions, we prefer the transinguinal (groin) approach, utilizing optical magnification (with an operating microscope) to ensure precise identification of 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 a small risk of recurrent varicocele.

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 a 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 fertilization (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.