A varicocele occurs when veins in the spermatic cord (the structure containing neurovascular supply to the testicle) become tortuous and dilated, similar to what happens with varicose veins in the leg. In fact a scrotal varicocele is simply a varicose enlargement of the veins around the testicle.
Varicoceles have been recognized as a clinical disorder of the scrotum for almost four hundred years. In the late 19th century, Barfield first proposed a relationship between infertility and the presence of a varicocele. Shortly thereafter, other surgeons reported an association with an “arrest of sperm secretion” and subsequent restoration of fertility following varicocele repair. During the last fifty years, studies have focused on the specific effect on semen parameters. From these studies, a pattern of low sperm count, decreased percentage motility, decreased quality of forward movement and a predominance of abnormal sperm forms (abnormal morphology) was recognized.
Varicoceles appear in about 15% of the general male population, but their prevalence is higher in the subfertile population (40%). Furthermore, in patients with secondary infertility (previous pregnancies without difficulty, but currently unable to conceive) that number has been reported to rise to 75%.
Varicoceles are more common on the left side than on the right for anatomic reasons; however, a one-sided varicocele can still affect both testicles. Varicoceles may vary in size and can be classified into three groups: large, moderate, and small. Larger varicoceles tend to exert more of an effect, however, sometimes repair of even a small varicocele can exert an effect on sperm production.
Several theories have been proposed to explain the harmful effect of the varicocele on sperm quality, including possible effects of pressure, oxygen deprivation, heat injury, formation of reactive oxygen species (ROS) or toxins. Historically, the effect of elevated intrascrotal temperature caused by the inability of the varicose veins to prevent retrograde blood flow was the most popular and accounts for a lot of the myths about boxers versus briefs or wearing ice packs. Today, more attention is being given to ROS.
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. The varicocele is detected by a physician when performing a physical examination. Scrotal ultrasound with color-flow Doppler before and after performing Valsalva (bearing down) can often, more clearly identify and or confirm the presence of a varicocele.
Although there are several surgical approaches for the correction of a scrotal varicocele, I prefer the sub-inguinal (groin) microsurgical approach. The operation can usually be performed through a 1 inch long opening. Generally, I use optical magnification with an operating microscope to ensure precise identification of all contributory veins and lymphatics and I use an intra-operative Doppler to ensure identification and preservation of the testicular artery. The surgery is typically performed on an outpatient basis. The operative time is about forty-five to sixty minutes per side. All external sutures are absorbable and do not have to be removed. Generally patients are up and about after 2-3 days.
Other options included a laparoscopic approach as well as embolization through a percutaneous transvenous route.
The resultant improvement in semen quality has been reported to occur in 70% to 80% of patients, with pregnancy rates as high as 40%. The 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 risks of varicocele repair are remarkably low (less than 1% incidence of bleeding infection, hydrocoele formation or other issues) and successful surgery will often increase the incidence of eventual pregnancy in the infertile couple. Even more, the surgery can often provide a lasting improvement in semen parameters allowing subsequent pregnancies in the future.
