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FERTILITY ALERT: New Research Shows Varicocele Repair to Improve Semen Quantity, Quality and Pregnancy Rates

By Dr. Philip Werthman
Center for Male Reproductive Medicine and Vasectomy Reversal

Varicocele, the most common condition associated with male factor infertility, has been a controversial topic for more than a generation. The controversies stem from a discrepancy in published articles as to whether repair of a clinical varicocele improves sperm quality and ultimately enhances pregnancy rates. Urologists have known for years that fixing this pathological condition benefits many patients in terms of fertility but also in regard to androgen function. Some of our reproductive endocrinology colleagues frown upon varicocele repair and point to the studies that show no benefit to this surgery. They have a bit of a different perspective than urologists since they ultimately see the surgical failures because the success stories conceive naturally and never need to pursue IVF treatments.

The second issue amongst urologists is which type of varicocele repair provides best results given there are six different ways to fix a varicocele (Inguinal, Retroperitoneal, Sub-inguinal, Laparoscopic, Microsurgical, and Non-Surgical Embolization). A large meta-analysis study/ review article published in the May 2012 Journal of Urology examined the impact of three different types of surgical repair on sperm counts, motility, and pregnancy rates.[1]

The study reviewed 94 articles and found 14 randomized controlled trials and interventional trials that were free of significant bias. They compared high retroperitoneal ligation, inguinal, and sub-inguinal repair that were performed either microsurgically or with magnification. The authors concluded that all techniques of varicocelectomy improved semen parameters in men with subfertility and abnormal semen analyses. The microsurgical inguinal repair afforded the highest pregnancy rates and most significant increase in sperm parameters over the other techniques.

Varicocele is known to cause of sperm DNA fragmentation, leading to infertility and a significantly increased miscarriage rate. Werthman et al discovered that microsurgical inguinal varicocele repair decreases DNA fragmentation in 90% of men who had high levels of sperm DNA fragmentation as measured by the Sperm Chromatin Structure Assay.[2] Several cost effectiveness studies showed varicocele repair to be significantly more economical than IVF and not surprisingly, varicocele repair prior to IVF improves IVF success rates most likely by improving sperm quality and reducing the number of cycles needed to conceive.[3] The cost to have a baby after varicocele repair was 4 times lower than by IVF for similar live birth rate.[4]

In this author’s opinion, microsurgical inguinal varicocele repair is the gold standard procedure for the treatment of varicoceles because it affords the greatest improvement in sperm parameters, highest pregnancy rates, lowest failure and recurrence rate, and fewest complications of all the available procedures. The recurrence rate is less than 5% and post operative hydrocele formation approaches zero because of the ability to preserve the lymphatic channels with the microsurgical approach. I have  found the subinguinal approach more difficult and longer to perform than the inguinal approach because the venous channels are smaller and more numerous (as are the arterial branches) closer to the testicle. There is no increased morbidity or prolonged recovery from opening the inguinal ring. There is little place for laparoscopic repair of varicocele because the increased risks of an intra-abdominal procedure are not acceptable or warranted given the alternatives. High ligation provided the poorest results of the multiple surgical techniques and should be relegated to history.

Varicocele repair continues to be a mainstay in the armamentarium for the treatment of male infertility in those patients with a clinically detectable varicocele. Evidence demonstrating the effectiveness of varicocelectomy in regards to improving semen parameters and pregnancy rates, reducing oxidative stress and sperm DNA fragmentation levels, and cost effectiveness data all point to the conclusion that clinically detected varicoceles should be repaired in men with subfertility provided there are no other female-related factors that would preclude repair or make other treatments more appropriate.

[1]Schauer I, Madersbacher S, Jost R, et al: The Impact of Varicocelectomy on Sperm Parameters: A Meta-Analysis. JUrol 187:5, 1540 (May 2012).

[2] Werthman P, Wixon, R, Kasperson, K, Evanson D: Significant decrease in sperm deoxyribonucleic acid fragmentation after varicocelectomy. Fert Steril 87:7, 2007

[3] Penson DF, Paltiel AD, Krumholz HM, Palter S. The cost-effectiveness of treatment for varicocele related infertility. J Urol. 2002 Dec;168(6):2490-4.

[4] Schlegel PN: Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis. Urology 49:83-90, 1997.