Varicocele Repair

What is a Varicocele?

Varicocele is a dilation (enlargement) of the internal spermatic veins that drain the testicle. It is a similar condition to varicose veins that people get in their legs. It is a very common condition present in 15% of the general male population, and 40% of men evaluated for infertility.

[photo: varicocele1; Caption: Varicocele can cause one testicle to be smaller than the other.]

A varicocele develops because of defective valves that normally allow for blood to flow back from the testicle to the abdomen. When the one-way valves don’t trap the blood, gravity pulls the blood down to the testicle. Testicular injury occurs due to abnormal back flow of blood from the abdomen into the scrotum, and this creates an inhospitable environment for sperm development.

The significance of this condition has been known for a thousand years. In the first century, Greek physician Celcius originally described the Varicocele like this: “The veins are swollen and twisted over the testicle, which becomes smaller than its fellow in as much as its nutrition has become defective.”

Varicoceles can occur in either the right or left testicle, but are more common on the left side, probably because the left spermatic vein is longer than the right one.

Does having a varicocele mean that a man is infertile?

Not necessarily. Some men with major varicoceles may show little evidence of testicular injury, while others with small or “subclinical” (detected only by radiological tests) varicocele may be infertile. The effects of a varicocele on sperm quality and quantity are thus difficult to define and predict. Analysis of the sperm in men with a varicocele frequently shows an increase in tapered abnormal sperm forms and decreased motility (ability to move spontaneously and actively.)

Diagnosing a Varicocele

A thorough examination and some tests may be necessary to help determine if varicocele treatment is necessary. Techniques that may be necessary include:

  • Physical examination. The diagnosis of a varicocele can usually be made on physical examination of the scrotum while you are standing. A very large varicocele feels like a “bag of worms” and disappears or becomes significantly reduced when you lie down.
  • Observation. Occasionally a varicocele is so prominent that it can be seen through the skin. Often the testicle on the side of the varicocele is smaller than the other side.
  • Ancillary Tests. Testing with a Doppler stethoscope and an technetium isotope study may aid Los Angeles Fertility Specialist Dr. Werthman in making his diagnosis.
  • Scrotal Ultrasound. An accurately-performed ultrasound, in which the size of the veins and abnormal blood flow can be seen and measured, can be a very accurate means of confirming the presence of a varicocele.

When is Varicocele treatment recommended?

If you have a varicocele in one or both testicles, Dr. Werthman may recommend varicocele repair under very specific circumstances, including:

  • When you and your partner are infertile (failed to conceive after a year or more of unprotected, frequent sexual intercourse), your tested semen shows abnormal parameters, and you have a varicocele present on physical examination;
  • When a varicocele is causing you testicular pain or discomfort; or
  • When there is a significant discrepancy between the size of the two testicles.

Surgical Repair of the Varicocele is likely to improve fertility

If you have a varicocele and are dealing with infertility, the best course of treatment is usually to repair the varicocele as a first step. Semen improvement is expected in up to 70% of men and pregnancy in up to 60% of couples within the first two years after successful repair*.

Even in men with worst-case scenarios who were not candidates for In Vitro Fertilization because they had no sperm in the ejaculate, or they had sperm that were not moving, varicocele repair restored sperm or motility in 55-69% of patients. 20% of these men were able to father children after varicocele repair without any other assistance.

The surgical procedure that Dr. Werthman uses in the treatment of a varicocele is a Microsurgical Inguinal Varicocele Repair. In this procedure, the varicose veins in the scrotum are identified using a surgical microscope. The veins are tied off to prevent the backflow of blood from recurring. Extra care is taken to protect the testicular artery and the lymph system which are extremely delicate structures. This procedure has the greatest success rate in repairing the varicocele, the best chance of preventing recurrence, and the lowest rate of complications.

*Study by Madagar et al. Fertility & Sterility, vol.63, no., 1995

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