Varicocele & Male Infertility

couple-1030744_1920Approximately 15% of men have a varicocele – a dilation of veins in the scrotum surrounding a testis usually felt like a “bag or worms.”  Certainly not all men with a varicocele experience infertility, but a varicocele is discovered in 40% of infertile men.  The damaging effects of a varicocele on fertility results from the increase in temperature caused by the veins around the testis.  While the exact impact of varicoceles on male infertility is not proven, this article will summarize the recent “Report on Varicocele & Infertility: A Committee Opinion”.

Diagnosis

  1. The most important diagnostic method for a varicocele is physical examination. Other methods, such as ultrasound, should only be used if the examination is uncertain.
  2. Unless a varicocele is felt on examination, it should NOT be considered clinically significant.

Reasons to Treat

  1. The varicocele can be easily felt on examination.
  2. The couple has a known diagnosis of infertility.
  3. The female partner evaluation is normal or she has a readily treatable cause of her infertility AND her age is not an immediate concern.
  4. The male has persistent abnormalities on two or more parameters of the sperm analysis, namely density, motility and/or morphology.
  5. Adult male not immediately interested in fertility but has a desire for future fertility with abnormal sperm analysis and easily felt varicocele and/or pain. Earlier treatment may avoid future fertility problems.

Management Issues

  1. Post-operative improvements in sperm analysis may take 3-6 months.
  2. Varicocele surgery is not necessary if female infertility warrants IVF.
  3. If the male has azoospermia (no sperm in ejaculate), varicocele surgery possibly may allow subsequent sperm in the ejaculate to allow IVF-ICSI without testicular sperm retrieval.

Treatment Options

  1. Tying off the veins (ligation)
    1. Low ligation by small inguinal incision microscopically – preferred method.
    2. High ligation by abdominal incision or laparoscopy – higher rates of recurrence.
  2. Embolization
    1. Uses metal coils or agents to block the dilated veins.
    2. Requires interventional radiology but 20% chance unable to access veins.
    3. Similar recurrent to high ligation approach.

Results

  1. At least 90% successful removal of varicocele.
  2. Most studies demonstrate improved sperm parameters within 3-6 months.
  3. Most studies show improved fertility but studies are low quality.

Varicocele surgery is an appropriate treatment option when the couple experience infertility essentially limited to the male having abnormal sperm parameters, the varicocele is felt on physical examination, and the female’s age allows time for post-operative fertility attempts.

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