Dr. Brij B. Agarwal

MBBS, MS (Gold Medalist), Dip. Yoga (Gold Medalist), FIMSA
Consultant Laparoscopic & Gen. Surgeon

Varicocele and Infertility– Current  Guidelines

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Introduction

Varicocele is the most common correctable cause of infertility in adult males. Varicoceles are present in 15 percent of the normal male population and in approximately 40 percent of men presenting with infertility .

A varicocele is literally a collection of varicose veins surrounding one or both of the testicle/s, however it is more common on the left side.

The possible reason for the varicocele being more common on the left side are: -

1.  Left testicular vein joins left renal vein at right angle while right testicular vein joins the inferior vena cava.

2.  Left testicular vein is longer than right testicular as left testis is at lower level. Hence has to bear a larger column of blood and therefore more pressure.

3.   Loaded pelvic colon compresses left testicular vein causing back pressure.

4. Left renal vein may be sandwiched between abdominal aorta and trunk of superior mesenteric vessels

5.   Left testicular artery may arch over left renal vein and cause compression

6. Close association of left renal veins and left suprarenal veins may cause adrenaline renal from suprarenal vein causing left testicular vein spasm.

 

Fertility of an individual, which is difficult to assess, depends more on quality than the quantity of the spermatozoa. This is most faithfully reflected in the crossed penetration test which defines the quality of penetration of a control mucus

Exact mechanism by which varicocele causes abnormal sperm quantity as well as quality, is not known. Rise of temperature, connective tissue, hyperplasia with decreased arterial blood supply causing testicular hypotrophy / atrophy,altered germ cell apoptosis are likely causes .

 On testicular biopsy germ cells hypoplasia, thickened seminiferous tubule walls, interstitial hyperplasia and premature sloughing of spermatids is seen.

A varicocele feels like a warm tangle of worms in the scrotum. It can cause an aching discomfort which is relieved by wearing an athletic support, but is often symptomless

 

 

 

Detection of varicoceles

Evaluation of a patient with a varicocele should include a careful medical and reproductive history, a physical examination and at least two semen analyses. The physical examination should be performed with the patient in both the recumbent and upright positions. When a suspected varicocele is not clearly palpable, the scrotum should be examined while the patient performs a Valsalva maneuver in a standing position.

Palpable varicoceles have been documented to be associated with infertility   therefore, ancillary diagnostic measures, such as scrotal ultrasonography ,thermography, Doppler examination ,radionuclide scanning and spermatic venography, should not be used for the detection of subclinical varicoceles in patients without a palpable abnormality. Scrotal ultrasonography, however, may be indicated for clarification of an inconclusive physical examination of the scrotum. Spermatic venography may be useful to demonstrate the anatomic position of refluxing spermatic veins that recur or persist after varicocele repair.

 

Indications for treatment of a varicocele.

A.

When the male partner of a couple attempting to conceive has a varicocele, treatment of the varicocele should be considered when all of the following conditions are met:

 1) the varicocele is palpable on physical examination of the scrotum;

2) the couple has known infertility;

3) the female partner has normal fertility or a potentially treatable cause of infertility; and

4) the male partner has abnormal semen parameters or abnormal results from sperm function  tests..

B.

An adult male who is not currently attempting to achieve conception, but has a palpable

varicocele, abnormal semen analyses and a desire for future fertility, is also a candidate for varicocele repair.

C.

Young adult males with varicoceles, who have normal semen parameters, may be

at risk for progressive testicular dysfunction and should be offered monitoring with semen analyses every one to two years, in order to detect the earliest sign of reduced spermatogenesis.

D.

Adolescent males who have unilateral or bilateral varicoceles and objective evidence of reduced testicular size ipsilateral to the varicocele should also be considered candidates for varicocele repair . If objective evidence of reduced testis size is not present, adolescents with varicoceles should be followed with annual objective measurements of testis size and/or semen analyses in

order to detect the earliest sign of varicocele-related testicular injury. Varicocele repair should be offered at the first detection of testicular or semen abnormality.

 

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Treatment of varicoceles- for male factor infertility

Varicocele repair, intrauterine insemination (IUI) and in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) are options for the management of couples with male factor infertility associated with a varicocele.

The decision as to which method of management to use is influenced by many factors. Most importantly, varicocele repair has the potential to reverse a pathological condition and effect a permanent cure for infertility, as opposed to IUI or ART, which is required for each attempt at pregnancy.

 Other factors to be considered are the age of the female partner , the unknown long term health effects of IVF and ICSI on the offspring resulting from these techniques, and the possibly greater

cost effectiveness of varicocele treatment than of IVF with or without ICSI .

 Finally, failure to treat a varicocele may result in a progressive decline in semen parameters, further compromising a man’s chances for future fertility

Varicocele repair usually is not indicated as the primary treatment for couples when IVF is necessary for treatment of a female factor. Nevertheless, there are certain circumstances in which treatment of a varicocele should be considered before initiating ART even when there is a female factor present. Specifically, varicocele repair has been shown to restore at least low numbers of sperm to the ejaculate in some men with non-obstructive azoospermia due to either hypospermatogenesis or late maturation arrest . In these cases, varicocele repair may restore sperm to the ejaculate, thus making it possible to perform IVF/ICSI without testicular sperm

aspiration or extraction. Therefore,  varicocele repair may be offered to these men.

 

There are two approaches to varicocele repair

1.      Surgical

 - Open – Retroperitoneal , inguinal, subinguinal

 - Laparoscopic repair

2.      Percutaneous embolization of the internal spermatic vein

Surgical treatment is the gold standard of management & it eliminates over 90% of the varicoceles .

 

Complications

The potential complications of varicocele repair occur infrequently and are usually mild. All approaches to varicocele surgery are associated with a small risk of wound infection, hydrocele, persistence or recurrence of varicocele and, rarely, testicular atrophy. Potential complications from an inguinal incision for varicocele repair include scrotal numbness and prolonged pain.

Laparoscopic repair of the varicocele is a simple, short procedure which fortunately has hardly any of these complications.

 

Results of varicocele treatment

Varicocele treatment should be considered as a choice for appropriate infertile couples because:

1) varicocele repair has been proven to improve semen parameters in most men;

 2) varicocele treatment may possibly improve fertility; and

3) the risks of laparoscopic varicocele treatment are negligible.

 

Follow-up

Patients should be evaluated after varicocele treatment for persistence or recurrence of the varicocele. If the varicocele persists or recurs, internal spermatic venography may be performed to identify the site of persistent venous reflux. Either surgical ligation or percutaneous embolization of the refluxing veins may be used.

Semen analyses should be performed after varicocele treatment at about three-month intervals for at least one year or until pregnancy is achieved. IUI and ART should be considered for couples in which infertility persists after anatomically successful varicocele repair.

 

 

Note- This write is guided by  the AUA  report on Varicocele & infertility.