Background: Varicoceles are dilated veins of the spermatic cord (the attachment of the testis to the body which travels into the groin) that drain blood from the testicle. The network of veins draining the testicle includes three main sources (the internal spermatic vein, the external spermatic veins (also called cremasteric veins), and the veins of the vas deferens. Any of these veins can become enlarged or dilated and this can pose a problem for men. Varicoceles happen due to problems with valves in the veins or possibly genetic reasons are graded 1 (small) to 3 (large). The issue with varicoceles as discussed, is that testicular damage, infertility, and low testosterone may occur due to increased heat, and low oxygenation. Diagnosis is discussed and includes physical exam and possible ultrasound as well as blood hormonal levels. Fixing a clinically significant varicocele is known to improve chances of spontaneous (natural) pregnancy approximately 2.5 times.
Varicoceles are most commonly eliminated in selected patients with a surgery called varicocelectomy. They occur more often on the left side, but can occur on both sides in 30 to 80% of men. Right-side only varicocele raises other concerns, and this also must be managed by your urologist. The reasons for performing a varicocelectomy according to the American Urological Association Best Practice Policy include when all of the following are met:
Palpable varicocele, infertile couple (with normal female fertility), and sperm abnormalities
Additionally low testosterone, testicular atrophy (testicle shrinkage especially in adolescent or young men), or less commonly dull aching pain in the testicle can be reasons to perform varcicoelectomy. In the case of non-obstructive azoospermia (no sperm in ejaculate), varicocele repair may be helpful but may be dependent on the exact testicular issue (maturation arrest and hypospermatogenesis better than Sertoli cell-only). Even if assisted reproductive technology is required, varicocelectomy may improve outcomes for both intra-uterine insemination and motile sperm for ICSI.
Varicocelectomy has been performed since the late 1800’s, but not to worry- the technique has been significantly refined since then. The optimal technique, currently used today, includes microsurgery (using the operating microscope) which is able to precisely preserve the main artery (internal spermatic artery) and lymphatic channels (leads to less hydrocele formation postoperatively).
The procedure: Varicocelectomy is a surgical procedure to pinch off dilated veins (again, the blood vessels that drain the testicle), blocking them permanently. This can be done on one or both testicles depending on how dilated the vessels are (usually greater than 2.7mm diameter is considered to be abnormal). Smaller veins may be obstructed using electro-cautery. With normal anatomy, there are other veins that carry the necessary blood away from the testicle so this does not cause any issue after surgery. The approach (incision) to access these veins is best performed through the groin (inguinal), or low groin (subinguinal, below the external inguinal ring so there is no incision of this region as with inguinal approach). Subinguinal approach is our preferred technique since it has been shown to have the best outcomes, least side effects, and to minimize postoperative discomfort. Either approach avoids damage to any nerves (ilioinguinal nerve) or the vas deferens. Arteries are avoided using the micro-Doppler (a small ultrasound device to detect arterial pulse). Once the spermatic cord is exposed, internal spermatic large veins (as well as cremasteric and gubernacular veins) are tied off. At the end of the varicocelectomy, the spermatic cord has only testicular and cremasteric arteries, lymphatics, and vas deferens with its vessels.
The outcomes: Microsurgical varicocelectomy has been shown to have the best outcomes and least side effects. Alternatively, embolization or blockage of the internal spermatic vein can be done radiologically, but success rates are less than surgical outcomes, radiation exposure may affect sperm production, and long-term follow-up data is not available. Complications from surgery that can occur include hydrocele formation, testicular shrinkage (atrophy), recurrent pain, and infection but these rates are very low with the microsurgical approach.
In many cases, additional testicular damage is stopped and many men experience improved semen parameters, increased Leydig cell function, and subsequently increased testosterone especially if your testosterone was low before the surgery. Microsurgical varicocelectomy is a safe procedure with excellent outcomes. Overcoming the varicocele may increase your chances of becoming a father.
For additional information about the initial evaluation and microsurgical varicocelectomy, please visit the Center for Male Health and Reproduction site. You may also contact us with any additional questions and our physician team will respond.
–Matthew Wosnitzer, M.D.
June 1, 2014