Microsurgical Varicocele Repair

Dr. Karen Boyle performs many microsurgical varicocele repairs. A varicocele is the term used to describe abnormally dilated veins of the testis, located in the scrotum. This can cause pain, as well as adversely affect testosterone and sperm production.

Expert Varicocele Treatment in Maryland

Dr. Boyle is a leading expert in microsurgery, performing countless successful surgeries every year. She has a special expertise in genital surgery.

Learn more about Dr. Karen Boyle.

Varicocele: What is it?

Varicocele is a term used to describe abnormally dilated veins of the testis located in the scrotum. The term “varicosity” is familiar to those who have seen varicose veins of the leg. Veins are vascular structures that carry blood away from an organ; arteries are the vessels that supply oxygen-rich blood to organs.

Veins normally have one-way valves present with in their lumen to prevent back flow of blood. When these valves are incompetent, blood can pool. This is what happens with varicose veins of the legs upon standing. A varicocele is the same phenomenon, but in the scrotum. These varicose veins can often be seen with the naked eye and look like “a bag of worms.” More commonly, however, a varicocele is only detected upon examination by a physician.

Varicoceles: Causes

The exact cause of varicoceles and the method by which they damage the testis is unknown. The most popular theory is that varicoceles are caused by absent or abnormal valves in the veins of the scrotum. Since the reduced drainage of blood from the scrotum can affect the temperature of the testis, the testis may be adversely affected in terms of both sperm production and testosterone production.

Varicoceles: Symptoms

Varicoceles present in one of three ways:

  1. Most commonly, a doctor finds a completely asymptomatic varicocele in a man being evaluated for infertility.
  2. A young, asymptomatic man finds a mass in the scrotum either on his own or during a routine exam and is concerned about future fertility.
  3. A man experiences pain in the scrotum.

Varicocele Pain

Varicocele is a potential cause of scrotal pain that may be either a dull pain or an extreme pain. The typical varicocele is asymptomatic; however, occasional patients note an aching feeling in the scrotum associated with prolonged standing or activity and the aching pain is relieved by lying down supine (on one’s back) with the feet raised.

Varicoceles may cause more severe pain if the veins develop thrombophlebitis. The evaluation of patients with scrotal pain should include scrotal ultrasonography to rule out other pathology and cultures to rule out infection. If there is no other identifiable cause of the pain, and the pain qualities are consistent with a varicocele, then surgical repair of the varicocele may be considered. However, there is no guarantee that varicocele repair will eradicate the pain.

Varicocele Repair: Am I a Candidate?

Management of the young man with an incidental finding of an asymptomatic varicocele is somewhat controversial. There is strong evidence to suggest that repairing a varicocele improves testicular function and may prevent any further testicular damage over time. Thus, the first step in the evaluation of this patient is to assess testicular function directly by semen analysis or indirectly by measuring testis volume. Repair of the varicocele is indicated if there is any evidence of testicular damage.

The controversial aspect in managing these patients is if current testicular function appears normal. Since the patient is not currently trying to conceive, we cannot assure him that his fertility is actually intact just because he has a normal semen parameters or testis volume. There is some evidence to suggest that varicoceles exert a progressive deleterious effect over time that would imply that all varicoceles should be repaired if future fertility is being considered. However, there is equal evidence against a progressive effect of varicoceles upon the testis and the fact remains that the vast majority of men with varicoceles (80 percent) are able to conceive on their own without utilizing fertility services.

Thus, the controversy is whether to repair all varicoceles, repair only those varicoceles associated with signs of testicular damage or to observe patients with varicoceles over time with serial semen analyses.

Varicoceles and Infertility

Varicoceles are found during physical examination of roughly one-third of men being evaluated for failure to conceive. They are categorized by:

  • Size (large, medium and small)
  • Presence on one or both sides of the scrotum

It is important to know that varicoceles of all sizes may affect fertility and the chance of improvement is equivalent after repair. In addition, a varicocele on side of the scrotum has an effect upon both testes in regards to function and temperature. Varicoceles that are diagnosed by an imaging study, such as an ultrasonography, but cannot be felt by the physician, are not clinically significant.

Varicocele Repair in Infertile Couples

We may recommend varicocele repair when a couple is having difficulty conceiving when:

  • There is objective evidence of a male factor (such as abnormal semen analysis)
  • The wife’s fertility status is intact
  • There are no other obvious causes for male infertility, such as obstruction or genetic abnormality

Varicocele Repair: What to Expect

Varicocele repair can be performed surgically or non-surgically. There is no ideal method or absolutes in making this decision.

Nonsurgical Varicocele Repair

The nonsurgical repair is a minimally invasive technique performed by an interventional radiologist on an outpatient basis. The success rate varies significantly dependent upon the experience of the radiologist, the anatomy of the patient and the presence of varicoceles on both sides.

A nonsurgical approach is utilized primarily in patients with:

  • A previously failed surgical repair
  • Pain as the main indication
  • Body features that increase the risk of surgery such as morbid obesity

Microsurgical Varicocelectomy

Microsurgical varicocelectomy is an outpatient procedure performed under general anesthesia through a small incision in the lower groin. This procedure has the greatest chance of repair with the least morbidity and lowest cost.

Varicocele Repair: Complications

Potential complications from varicocele repair include:

  • Persistent/recurrent varicocele
  • Bruising
  • Infection
  • Testicular tenderness

A hydrocele, collection of water around the testis, occurs in an extremely small number of men. For those patients undergoing the nonsurgical repair, there is the added risk of reaction to the contrast agent used in the procedure. Finally, there is an extremely low risk of loss of the testicle. Insurance typically covers microsurgical varicocelectomy.

Varicocele Repair: The Effect on Fertility

A study of 540 infertile men with clinical palpable varicocele who underwent microsurgical varicocelectomy and were followed more than one and two years postoperatively for alterations in semen quality and conception, respectively, found that:

  • A greater than 50 percent increase in total motile sperm count was observed in 271 patients (50 percent).
  • An overall spontaneous pregnancy rate of 36.6 percent was achieved after varicocelectomy with a mean time to conception of seven months (range one to 19).
  • Of preoperative IVF and ICSI candidates, 31 percent became IUI candidates.
  • Of IUI candidates, 42 percent gained the potential for spontaneous pregnancy.

Varicocelectomy has significant potential not only to obviate the need for assisted reproductive technology, but also to downstage or shift the level of assisted reproductive technology needed to bypass male factor infertility. [Cayan S, Turek PJ. J Urol. 2002 Apr;167(4):1749-52]

This means that repairing a clinically significant varicocele can significantly improve semen parameters and allow for natural conception or lessen the need of reproductive assistance. In addition, microsurgical varicocele repair can result in an improvement in testosterone production.

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