Varicocele

Practice Essentials

A varicocele is a dilatation of the pampiniform venous plexus and the internal spermatic vein. Varicocele is a well-recognized cause of decreased testicular function and occurs in approximately 15-20% of all males and in 40% of infertile males. Understanding the significance of this anatomic abnormality in the infertile patient requires a brief review of the history, background, and current concepts of functional anatomy, as well as the methods and results of surgical repair, when repair is indicated.^[1]

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History of the Procedure

In De Medicina, written during the first century AD, the Roman nobleman Cornelius Celsus credits the Greeks with the first description of a varicocele, and describes several forms of surgical intervention.^[2]

In the 16th century. Ambroïse Paré (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality and attributed it to melancholic blood. Barfield, a British surgeon, first proposed the relationship between infertility and varicocele in the late 19th century. Shortly thereafter, other surgeons reported the association of varicocele with an arrest of sperm secretion and the restoration of fertility following repair. Through the early 1900s, reports by other surgeons continued to describe the association of varicocele with infertility.

In the 1950s, after a report of fertility following varicocele repair in an individual known to be azoospermic (ie, without sperm), the idea of surgically correcting varicoceles as a clinical approach to certain kinds of male infertility gained support among American surgeons. Research continued, leading to many published studies that associated varicoceles with impaired semen quality.^[3]

In these studies, researchers documented a recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms; this became known as the stress pattern of semen. Although not synonymous or specific to varicocele, the term suggests early evidence of testicular damage. Urologists then began to assess male infertility through the study of sperm, which are evaluated for count, percentage of motile forms, forward movement or motility, and morphology (shape or form); the semen is also evaluated.

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Problem

A varicocele is a dilatation of the pampiniform venous plexus within the scrotum. Approximately 15-20% of the healthy fertile male population is estimated to have varicoceles; however, 40% of infertile men may have them. How a varicocele impairs sperm structure, function, and production is unknown, but researchers believe it interferes with testicular thermoregulation.

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Epidemiology

Frequency

Although varicoceles appear in approximately 20% of the general male population, they are much more common in the subfertile population (40%). In fact, scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality. Varicoceles are easy to identify and to surgically correct.

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Etiology

Varicoceles are much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors, including the following:

• The angle at which the left testicular vein enters the left renal vein
• The lack of effective antireflux valves at the juncture of the testicular vein and renal vein
• The increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker effect)

Also of importance is that a clinical left varicocele is often accompanied by a subclinical right varicocele. Up to 35-40% of men with a palpable left varicocele may actually have bilateral varicoceles that are discovered upon examination. A 2004 study by Gat et al suggested that up to 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing.^[4]

Varicoceles vary in size and can be classified into the following three groups:

• Large - Easily identified by inspection alone
• Moderate - Identified by palpation without bearing down (Valsalva maneuver)
• Small - Identified only by bearing down, which increases intra-abdominal pressure, thus impeding drainage and increasing varicocele size

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Pathophysiology

Varicoceles can have detrimental effects on sperm concentration, motility, and morphology, and can reduce sperm DNA integrity and other aspects of sperm function.^[5]  Several theories have been proposed to explain the harmful effect of varicoceles on sperm quality, including the possible effects of pressure, oxygen deprivation, heat injury, and toxins.

Despite considerable research, none of the theories has been proved unquestionably, although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. Supporting this hypothesis is the fact that a varicocele created in an experimental animal led to poor sperm function with elevated intratesticular temperature. Regardless of the mechanism of action, a varicocele is indisputably a significant factor in decreasing testicular function and in reducing semen quality in a large percentage of men who seek infertility treatment.

An unproven hypothesis holds that a varicocele may represent a progressive lesion that can have detrimental effects on testicular function.^[6] An untreated varicocele, especially when large, may cause long-term deterioration in sperm production and even testosterone production. If an infertile male has bilateral varicoceles, both are repaired to improve sperm quality.

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Presentation

A patient with a varicocele is usually asymptomatic and often seeks an evaluation for infertility after failed attempts at conception. From 2% to 10% of patients with varicocele complain of pain, which is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing.^[7]

Careful physical examination remains the primary method of varicocele detection. An obvious varicocele is often described as feeling like a bag of worms. Scrotal examination for varicocele should be a facet of the standard urologic physical examination because of the potential for varicoceles to cause significant testicular damage. The presence of a varicocele does not mean that surgical correction is a necessity.

Bogaert and colleagues analyzed the paternity rates of 361 men older than 30 years who had received early screening and diagnosis of varicocele (at age 12 to 17 years; mean age 15.3 years). Of the 158 men who had an active desire to have a child, 85% of those who had been managed with observation only had achieved paternity, compared with 78% of those treated with antegrade sclerotherapy for varicocele. The investigators concluded that early screening and treatment for varicocele had no impact on paternity in adulthood.^[8]

In men with a varicocele, the presence of an initially abnormal semen quality may be a risk factor for future deterioration of semen quality. In a prospective study of men with a mean follow-up of 5 years, among men with an abnormal semen analysis at presentation, the quality of semen degenerated in 28 subjects (87.5%); however, but among men with initially normal semen quality, only 6 patients (20%) had degenerated quality during follow-up.^[9]

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Indications

Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume < 20 mL, length < 4 cm), and addressing the possible contribution to unexplained male infertility. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.

A 2014 committee opinion of the American Society for Reproductive Medicine and the Society for Male Reproduction and Urology recommended considering treatment of varicocele in the male partner of a couple attempting to conceive when most or all of the following conditions are met^[10] :

• The varicocele is palpable on physical examination of the scrotum
• The couple has known infertility
• The female partner has normal fertility or ­a potentially treatable cause of infertility, and time to conception is not a concern
• The male partner has abnormal semen parameters

A man with a palpable varicocele who is not currently attempting to achieve conception is a candidate for varicocele repair if he has one or more of the following^[10] :

• Abnormal semen analysis results
• A desire for future fertility
• Pain related to the varicocele

Similarly, 2014 European Association of Urology guidelines in male infertility recommend considering varicocele repair in patients with the following^[11] :

• Clinical varicocele
• Oligospermia
• Infertility duration of ≥2 years
• Otherwise unexplained infertility in the couple.
• Varicocele treatment is recommended for adolescents with progressive failure of testicular development documented by serial clinical examination.

The guidelines recommend against varicocele treatment in infertile men who have normal semen analysis or in men with subclinical varicocele.^[11]

A scrotal varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable choice for appropriately selected individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility; in addition, the risks of varicocele repair are small.

A systematic review and meta-analysis found that in oligospermic and azoospermic patients with clinical varicocele, repair of the varicocele leads to improved live birth rates and pregnancy rates with in vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection (ICSI). In men with persistent azoospermia after varicocele repair who require testicular sperm extraction for IVF/ICSI, varicocele repair improves sperm retrieval rates.

Prognostic features

In a prospective study in 123 patients by Shabana et al, the following three preoperative findings were major predictors for a successful outcome of varicocelectomy^[12] :

• Grade II or III varicocele
• Sperm density >8 million/mL
• Sperm progressive motility >18%

Condorelli et al found that in patients with varicocele accompanied by dilation of the periprostatic venous plexus (DPVP), sperm progressive motility remained low after varicocele repair, whereas it improved significantly in patients without DPVP.  In addition, patients with DPVP were significantly more likely to have seminal fluid hyperviscosity, and their viscosity quantitative measurement remained significantly higher after varicocele repair, compared with patients without DPVP.^[12]

Varicoceles in adolescents

The results of treating varicoceles in adolescents are not as clear as the results of treating varicoceles in adults. Although varicoceles first become apparent in adolescence, their natural history and its timeline for the onset of detrimental effects on testicular function remain unclear. Varicoceles occur in approximately 10-15% of the fertile male population, but not all varicoceles impair sperm function, overall semen quality, or fertility.^{[13, 11, 14]}

Important determinations to be made regarding varicoceles in adolescents are whether (1) the varicocele is a progressive lesion and (2) early repair of the varicocele would prevent infertility.

In 1977, Lipshultz and Corriere suggested that varicoceles were associated with testicular atrophy that was progressive with age.^[15] They also observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities. However, Diamond et al from Harvard have challenged this concept.^[16]

In 1987, Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.^[17] Although Kass and Belman noted catch-up growth, they did not study semen parameters. Collecting a semen sample from an adolescent is not always easy; consequently, studying the effects of a varicocele and the benefits of treatment is difficult.

The indications for repairing varicoceles in adolescents include the following:

• Significant testicular asymmetry (>20%) demonstrated on serial examinations
• Testicular pain
• Abnormal semen analysis results

Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial. Young men with varicoceles but normal ipsilateral testicular volume should be offered follow-up monitoring with annual objective measurements of testicular volume, semen analyses, or both.

For complete discussion, see Varicocele in Adolescents.

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Relevant Anatomy

The testes are the paired male genital organs that contain sperm, cells that produce and nourish sperm (spermatogonia and Sertoli cells, respectively), and cells that produce testosterone (Leydig cells). The testes are located in a sac called the scrotum. The epididymis is a small tubular structure attached to the testes that serves as a storage reservoir wherein sperm mature.

Sperm travel through the vas deferens, which connects the epididymis to the prostate gland. The vas deferens is in the scrotum and is part of a larger tissue bundle called the spermatic cord. The spermatic cord contains the vas deferens, blood vessels, nerves, and lymphatic channels.

The pampiniform plexus is composed of the veins of the spermatic cord. These veins drain blood from the testes, epididymis, and vas deferens and eventually become the spermatic veins that drain into the main circulation of the kidneys. The pampiniform venous plexus may become tortuous and dilated, much like a varicose vein in the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus above and around the testicle. Two other veins, the cremasteric and the deferential, also drain blood from the testicles; however, they are rarely involved in the varicocele process.

The image below illustrates the basic anatomy.

View Image

A large varicocele is seen through the scrotal skin. In a patient with a varicocele, the dilated vessels of the pampiniform plexus are easily apprecia....

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Contraindications

Opinions vary regarding the value of repairing subclinical varicoceles in infertile men, but most experts do not recommend it. A 2014 committee opinion of the American Society for Reproductive Medicine and the Society for Male Reproduction and Urology advises that varicocele treatment is not indicated in patients with subclinical varicocele or in those with either normal semen quality or isolated teratozoospermia.^[10] :

In addition, discovery of a varicocele at the time of vasectomy or vasectomy reversal is a relative contraindication to immediate repair. A 6-month delayed repair is recommended to allow the development of collateral vessels in order to decrease the chance of vascular compromise to the testicle.

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Laboratory Studies

When the clinical examination findings are equivocal, high-resolution color-flow Doppler ultrasonography is the diagnostic method of choice. The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that imaging studies are not indicated for the standard evaluation unless the physical examination provides inconclusive findings.^[10]

If a patient has sudden onset of a varicocele, a single right-sided varicocele, or any varicocele that is not reducible in the supine position, consider possible retroperitoneal pathology (eg, renal cell carcinoma) as the cause of spermatic vein compression. Investigate further with appropriate ultrasonography or CT scanning before repairing the varicocele.

Although varicocele diagnosis may be assisted with numerous methods (eg, venography, radionuclide angiography, thermography, ultrasonography), the current standard of care is high-resolution color-flow Doppler ultrasonography. High-resolution real-time scrotal ultrasonography using a 7- to 10-MHz probe defines a varicocele as a hollow tubular structure that grows following a Valsalva maneuver.

Color-flow Doppler ultrasonography defines the anatomic and physiologic aspects of varicoceles by using real-time ultrasonography and pulsed Doppler in the same scan. The color of the signal identifies the blood flow and direction within the varicocele. The characteristic reverse flow of varicoceles is confirmed by prolonged flow augmentation within a colored flow area; the flow changes color (ie, reverses) on real-time imaging.

Although the exact size definition is controversial, most surgeons consider a varicocele to be a vein 3 mm in diameter or larger while the patient is at rest. McClure et al define a varicocele as the presence of 3 or more veins, with 1 having a minimum resting diameter of 3 mm or an increase in venous diameter with the Valsalva maneuver.^[18] Because other surgeons use 2-3 mm as a cutoff, comparing results of these ultrasound-based varicocelectomy studies is difficult.

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Imaging Studies

Ultrasonography, particularly Doppler ultrasonography, allows accurate diagnosis of varicoceles. Computed tomography can demonstrate varicoceles, but exposure to radiation is a disadvantage, and the diagnostic role of magnetic resonance imaging (MRI) has not been established. Venography is usually reserved for use in patients undergoing occlusive therapy, for mapping of the venous anatomy.

Tsili et al describe the use of 1.5 T diffusion tensor imaging (DTI) MRI as an adjunct tool for the diagnosis of varicocele. In their study, fractional anisotropy (FA) was significantly lower in the testes with varicocele in 16 infertile men, compared with 14 age-matched controls. A cut-off of FA 0.08 had 88% sensitivity, 93.5% specificity, 91.6% positive predictive value, and 90.6% negative predictive value for the diagnosis of varicocele.^[19]  Other pilot studies of diffusion-weighted imaging MRI have reported that decreased apparent diffusion coefficient (ADC) values in the testicles of patients with varicocele correlate with abnormal semen parameters.^{[20, 21]}

For complete discussion of this topic, see Varicocele Imaging.

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Medical Therapy

A varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. While some investigators are evaluating the role of antioxidants for the treatment of elevated levels of reactive oxygen species, this treatment approach is still experimental.

In elderly men, impairment of Leydig cell function by varicocele can compound the decrease in testosterone production that occurs with aging, resulting in hypogonadism. Testosterone replacement therapy is an option in these patients, who are unlikely to be concerrned with fertility. Nevertheless, while the possibility of avoiding surgery may appeal to these patients, with education about their options they may conclude that a one-time low-risk microsurgery is preferable to lifelong testosterone therapy with laboratory monitoring.^[22]

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Surgical Therapy

The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not in itself mean surgical correction is necessary.

The ultimate goals of varicocele repair should include occlusion of the offending varicosity, preservation of arterial flow to the testis, and minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.

Results from a prospective, randomized controlled trial from Saudi Arabia compared subinguinal microsurgical varicocele repair to observation.^[23] Inclusion criteria included infertility lasting 1 year or longer, demonstration of a palpable varicocele, and presence of at least one impaired semen parameter (sperm concentration < 20 million/mL, progressive motility < 50%, or normal morphology < 30%). A total of 145 participants had follow-up within 1 year; spontaneous pregnancy was achieved in 13.9% of controls compared with 32.9% of treated men (odds ratio, 3.04). In treated men, the mean of all semen parameters significantly improved in follow-up compared with baseline (p< 0.0001). This study provided an evidence-based endorsement of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality.

Surgical techniques for varicocele repair include retroperitoneal, laparoscopic, inguinal, and subinguinal. The microsurgical subinguinal approach is the gold standard.^[24] A meta-analysis found that although microsurgical varicocelectomy involves a longer operative time, it has a lower incidence of postoperative complications and recurrence than laparoscopic and open varicocelectomies and a shorter time to return to work, as well as a greater increase in postoperative sperm concentration, better improvement in postoperative sperm motility, and a higher pregnancy rate.^[25]

Microsurgical repair of varicocele may improve the patient's erectile and ejaculatory function, along with raising  testosterone levels. In a review by Najari et al of 17 patients with infertility and 13 with symptomatic varicocele associated with hypogonadism, most of whom had bilateral varicoceles and left grade III varicoceles, 15 patients (44%) reported improvement in their erectile function and 18 (53%) reported improvement in ejaculatory function. Serum testosterone levels rose 136.0 ±201.3 ng/dL.^[26]

In patients with a left clinical varicocele accompanied by a right subclinical varicocele, the choice of unilateral versus bilateral varicocelectomy has been controversial. However, studies have shown superior improvement in sperm parameters and spontaneous pregnancy rates with bilateral varicocelectomy in these patients.^{[27, 28]}

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Preoperative Details

Perform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort.

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Intraoperative Details

The three most common surgical approaches used to correct a scrotal varicocele are as follows:

• Inguinal (groin)
• Retroperitoneal (abdominal)
• Infrainguinal/subinguinal (below the groin)

With all three approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow. Avoidance of the vas deferens and the testicular artery during the surgery is critical. The inguinal approach is depicted below.

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Incision for an inguinal approach to varicocele repair.

The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided.

The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle that obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially among obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, which makes subinguinal ligation technically challenging.

The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. [VTI] 20-MHz microvascular Doppler) with the use of a topical vasodilator.

The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, and this approach may be accomplished laparoscopically. Although this approach to varicocele ablation remains popular among pediatric urologists, it has the following potential drawbacks:

• A high recurrence rate (nearly 15%), due to inguinal and retroperitoneal collateral veins
• Failure to ligate fine periarterial veins when the testicular artery is preserved
• Inability to preserve lymphatics
• Potential hydrocele formation when the artery and vein are ligated en bloc

Percutaneous embolization represents the least invasive means of varicocele repair. The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair.

Shibata et al reported that intraoperative indocyanine green angiography (ICGA), which is regularly used in microsurgical neurosurgery, can facilitate microsurgical subinguinal varicocelectomy by enabling the visualization and identification of the testicular arteries in the spermatic cord. After the exposure of the spermatic cord blood vessels, ICG was injected intravenously under a surgical microscope and the resulting infrared fluorescence allowed surgeons to safely and quickly ligate the spermatic veins.^[29]

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Postoperative Details

Patient instructions

See the list below:

• Varicocele surgery is usually performed in an outpatient setting (ie, day-surgery unit). Patients may return to normal nonstrenuous activities (eg, work) after 2 days.
• All outer dressings are removed 48 hours after surgery. The small strips of tape (Steri-Strips) are left in place for 7-10 days before removal.
• Inform patients that bathing or showering is permitted 48 hours after surgery.
• A normal, well-balanced diet can be resumed when patients return home. Advise patients to start with fluids and gradually return to solid foods.
• Prescribe pain medication and advise patients to take as directed. After 2 days, patients may take nonprescription acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil, Motrin) to relieve discomfort.
• Patients can engage in normal, nonstrenuous activity when they feel up to it. If activity causes discomfort, it should be discontinued. Patients can resume more strenuous activities (eg, weightlifting, jogging) after 2 weeks.
• Advise patients to refrain from intercourse for 1 week.

Common discomforts and symptoms that do not require medical attention

Patients may experience some postoperative discomfort. Complications are rare. Common discomforts or symptoms do not require a doctor's attention and may include the following:

• Minor bruising and slight discoloration may appear around the groin incisions but are self-limited.
• The sensation of hardness around and beneath the incision site resolves in approximately 3 weeks.
• The slight redness and tenderness around the incision from the normal healing process resolves in a few days.
• A very small amount of thin, clear, pinkish fluid drains from the incision for a few days after the procedure. Advise patients to keep the area clean and dry.
• A sore throat, headache, nausea, constipation, and general body ache occur because of the surgical procedure and anesthetic. Advise patients that these problems resolve within 24 hours.

Postoperative complications that require prompt medical attention

If wounds become infected (usually 3-5 d after surgery), antibiotics may be necessary. Infected wounds can become warm, swollen, red, and painful, with significant drainage from the incision site, and patients may develop fever.

Hematomas may form. Extreme discoloration around the abdominal incisions results from bleeding underneath the skin, which causes throbbing pain and bulging wounds.

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Follow-up

Check the patient's semen 3-4 months after surgery. Because spermatogenesis requires approximately 72 days, any effects from the varicocele repair on semen analysis results are delayed.

Patient instructions

See the list below:

• The patient returns to the clinical office for a wound evaluation in approximately 7-10 days.
• Schedule a follow-up examination for a wound check and varicocele examination for 8 weeks after surgery.
• Schedule a semen analysis and consultation for 4 months after surgery. At this time, the timing of subsequent appointments can be discussed.

For patient education information, see the Men's Health Center, as well as The Male Anatomy and Testicular Pain.

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Complications

The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%.

The long-term occurrence of hydroceles and varicocele recurrence was analyzed in a study comparing 67 patients who received lymphatic-sparing laparoscopic varicocelectomy with 30 patients who received a plain laparoscopic varicocelectomy. The risk of hydrocele formation was significantly less in lymphatic-sparing group (4.5% vs. 43.3%). In addition, none of the patients with hydrocele formation in the lymphatic-sparing group required a hydrocelectomy, compared with 31% in the plain laparoscopic group.^[30]

The varicocele recurrence rate was higher in the lymphatic-sparing group (6% vs 3.3%) but when the artery was not preserved, the rate in the lymphatic-sparing group fell to 1.3%. The success and complication rates of lymphatic-sparing, non–artery preserving, laparoscopic varicocelectomy were comparable with those of subinguinal microsurgical varicocelectomy.^[30]

Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases.

In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form.

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Outcome and Prognosis

Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery.

While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates (1995) confirmed that varicocelectomy is an effective treatment for male subfertility. Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy.^[31]

Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates.^[31]

In addition, Vasquez-Levin et al (1997) demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria.^[32]

Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates.^[33] The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis.

The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed.^[34]

The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe.

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Future and Controversies

In 1992, researchers introduced a new micromanipulation technique known as intracytoplasmic sperm injection (ICSI). With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization and, eventually, a pregnancy. With the success of this technique, some researchers question the need for varicocele repair.

Conversely, a cost-analysis study by Schlegel shows the significant cost advantage of varicocele repair over ICSI.^[35] In addition, varicocele repair has the potential for improving the male factor, rather than using unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries some risk for the female who donates surgically removed eggs.

Another current topic focuses on the benefit of varicocele repair in men who are azoospermic or severely oligospermic. Although numerous studies indicate that varicocele repair can improve spermatogenesis in up to one third of azoospermic men, the initiation of spontaneous pregnancy is highly unusual in this population. The remaining two thirds eventually require testicular sperm extraction and IVF-ICSI, even after varicocele repair. Couples must therefore be counseled realistically regarding the benefit of varicocelectomy in this setting.

Other concerns focus on the benefit of varicocele repair in infertile men with poor semen quality who have only ultrasound evidence of a varicocele. While opinions differ about the value of repairing subclinical varicoceles in infertile men, most experts do not recommend it.

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