Varicocele

A varicocele is the most commonly identifiable lesion seen in men with male infertility that can be surgically corrected. A varicocele is when the veins that drain your testicle become enlarged and engorged. It is very similar to the varicose veins that some people have on the back of their legs. A varicocele is a very common finding. While it is present in 15% of all men in the community at large, it is found in 40% of men who present with infertility. Dr. Kuang’s top priority is to “empower you with education” about your reproductive choices.

What is a varicocele?

Dr. Kuang recently co-authored an online summary of Varicoceles to help other doctors.

Click here to see this published article on the Internet.

A varicocele is the most commonly identifiable lesion seen in men with male infertility that can be surgically corrected. A varicocele is when the veins that drain your testicle become enlarged and engorged. It is very similar to the varicose veins that some people have on the back of their legs. A varicocele is a very common finding. While it is present in 15% of all men in the community at large, it is found in 40% of men who present with infertility.

I have a varicocele. What are the options for establishing a pregnancy for my partner and me?

Depending on your sperm count, your options are to have a surgical varicocele repair, a percutaneous embolization, medications, intrauterine inseminations or in vitro fertilization. Some of these options can be offered in combination. For example, some men pursue varicocele repair in addition to intrauterine inseminations. Alternatively, the most severe cases may require IVF. Dr. Kuang along with your partner’s reproductive doctors will help you navigate this menu of choices to find the combination that best resonates with your needs.

Types of Surgical Varicocele Repair

Treatment options for a varicocele include an open microsurgical, laparoscopic or a percutaneous approach. Open surgery is performed through a small 1.5 inch incision just below your beltline. With the use of a microscope, the dilated veins are found and delicately tied off with very fine suture to stop them from being engorged with warm blood that makes the testicle a “sweat shop” for sperm production. A laparoscopic or minimally invasive surgery can also be performed. Tiny keyhole incisions are made to identify the vein(s) farther along its course within your abdomen where they are tied off or occluded with clips. A percutaneous approach involves a small needle puncture into the major leg vein (“femoral vein”). Small plastic catheters are guided through the main vein in your abdomen (“inferior vena cava”) around and down to the vein(s) that cause the varicocele. These plastic catheters are used to deploy metal coils and chemical agents that occlude the veins. This is just a brief overview. Dr. Kuang looks forward to talking to you about all of your options after taking into special consideration the needs of you and your partner as well as your reproductive timetable.

How is an open surgical varicocele repair performed?

Under general anesthesia, a small 1.5 inch incision is made below the beltline on the side of the varicocele. An operating microscope is used to identify all the veins that are responsible for the varicocele. Additionally the microscope and a special Doppler instrument (a fancy machine that uses sound waves to detect blood flow) are used to detect the testicular artery (which supplies the blood to the testicle) and lymphatic channels. This is done to minimize any chance of any complication. At this point, all the veins are then tied off so that they no longer contribute to the varicocele. The operation is done on an outpatient basis and is completed in less than an hour. Patients are able to return home that same day once they recover from the anesthesia. Success rates for the elimination of the varicocele are close to 95%, and the complication rate is 1%.

The spermatic cord that carries the veins from the testicle is identified.

Individual veins are then tied off with surgical threads while working under a microscope.

How Successful is a Varicocele Repair?

Overall, 2/3 of men will see an improvement in their sperm number and motility, and more than 40% of these couples will be able to establish a pregnancy. Currently, our understanding of sperm is still rather crude and restricted to very basic tests such as counting sperm and seeing how well they move. At this point, we do not have any proven ways to really assess sperm for their genetic potential or their fertilization capacity.

With this said, some men actually do improve when we dare to look past what we can and cannot measure in the andrology laboratory. A recent study actually looked at couples undergoing inseminations when the man had a varicocele. The varicoceles were repaired in one group and not in the other. Even though there was not any significant difference in what they could measure in the semen, the couples who had a varicocele repair doubled their pregnancy rates and increased their live birth rate 8-fold. The bottom line is that varicocele repair may be a treatment modality that may help you improve your reproductive capacity as a couple. It is important that you be counseled appropriately as to the risks and benefits inherent to each treatment modality. This will allow you to make the most informed decision possible.

Another important consideration is time. At SFCM, we never overlook the fact that the man is only half of the equation. The woman’s reproductive needs and timetable are critical in formulating a treatment plan. A measurable improvement in semen parameters after a varicocele repair may take 6-9 months. For couples where the woman’s reproductive window is narrowing, this may not be the best option. This is why Dr. Kuang feels that it is imperative that the woman is being seen in parallel to the man so that the couple can make the best decision possible.

Why do varicoceles occur?

In your legs, the veins have valves that prevent blood from pooling due to gravity along the veins that run superficially under your skin. When the valves are not working properly, blood will gather in these superficial leg veins making them large and prominent which are called varicose veins. For cosmetic reasons, some people have these veins surgically “stripped” to remedy the situation.

Similarly in your scrotum, if the veins that drain your testicle are defective, then blood will pool in these veins making them large and readily visible through the skin in some cases. These varicoceles can prevent a man’s testicles from functioning at full capacity.

Varicoceles happen mostly just on the left side. Why? Also can they occur on both sides?

Most varicoceles occur on the left since the left vein is longer and travels along a different course within the body as compared to the right vein. These anatomical differences cause the left side to be more prone to varicoceles.When there is only one varicocele, it is on the left side 85% of the time. A varicocele on both sides of the scrotum is found in only about 20% of the men. While the exact mechanism is unclear, it has been found that a varicocele on one side can actually affect sperm production on the other side that does not have a varicocele.

How do you diagnose a varicocele?

Most varicoceles can be diagnosed with a gentle and careful examination of the scrotum. Some varicoceles can actually be seen by the naked eye through the skin of the scrotum creating a tubular appearance that resembles a “bag of worms”. Others will actually be more “sponge-like” where there is a fullness or plumpness to the skin above the testicle. These findings often disappear or are greatly reduced when a standing man is asked to lie down.

In certain cases, a scrotal ultrasound has been found to help confirm the presence of a varicocele. The ultrasound does not harm your testicles and can be performed in the comfort of an office setting. The ultrasound allows us to actually look at the flow of blood and see to what degree the veins from the testicle become dilated and engorged.

Ultrasound will show an abundance of veins above the testicle…

that fill with blood and “light up like fireworks” when you stand up or increase your abdominal pressure by bearing down.

Why do varicoceles hurt a man’s fertility potential?

A varicocele is the single most common identifiable cause of male factor infertility. Its adverse effect on sperm function and a man’s reproductive capacity is well documented in the medical literature. The predominant explanation for infertility is that the engorged veins allow for warm blood to pool near the testicle. Since sperm production within the testicle is felt to be temperature-sensitive, the pooled blood increases the scrotal temperature which makes the testicle a “sweat shop” for sperm production. Under such harsh conditions, sperm numbers can go down, the sperm motility (“how well they move”) can be hindered and the sperm morphology (“how they look”) can also be impaired.

Your testicle works very hard as a factory for sperm production. It is said that more than a thousand sperm are made with every beat of a man’s heart. It is such a challenging task that the factory must operate at a specific temperature range which is cooler than the rest of your body.

The large and dilated veins of a varicocele are filled with warm blood that increases the temperature at which the factory must function. In essence, the varicocele converts the factory into a “sweatshop.” Under these hostile conditions, the testicular factory functions suboptimally, and this can lead to a significant decrease in quality and quantity of sperm produced. The exact mechanism by which this occurs remains unknown. In some men, if the testicles are subjected to these grueling conditions for too long, then the factory can begin to shut down, and the testicles can actually start to shrink.

Alternative theories that include the harmful exposure to adrenal toxins, reactive oxygen species and altered testosterone levels have been postulated. Much work remains to be done to further substantiate these other theories.

My friend has a varicocele and four children. How does that work?

Varicoceles do not work like a light switch. If you have a varicocele, one’s sperm do not just disappear all of a sudden. They have a gradual adverse effect on sperm production over a long period of time. Men with varicoceles may pass through three phases. The first is where the sperm parameters may be slightly diminished but not enough to affect fertility (this would be the case for the man with a varicocele and children). The second is where the sperm production is impaired but can be recovered with a varicocele repair. The final phase is where the sperm production is impaired but unrecoverable. Modern medicine currently cannot predict where each man is within this fertility timeline for varicoceles or how long each man will spend in each phase. Our hope is that we can take care of the problem before the man passes into the final unrecoverable phase.

Is this something that I really need a male fertility specialist for?

This is a great question. In this day and age of In Vitro Fertilization, some couples elect to pursue conception through Assisted Reproductive Technology without having the man or his varicocele seen by a male fertility specialist. In the vast majority of cases, there are no negative consequences as a result of this. On the flip side, infertility is associated with certain conditions such as testicular cancer and certain types of varicoceles can be associated with kidney cancer. The incidence is extremely low so the odds of something bad being there is extremely small; however, if you end up being the one person who does have something, you might have wished you had been seen by someone who is trained to pick up such pathologies that can impact your personal health and longevity.

The other important consideration is that you and your partner deserve to know all of your options to make the healthiest decision possible. Dr. Kuang’s top priority is to “empower you with education” about your reproductive choices. He will give you all the up-to-date information that is out there to help make this challenging journey as smooth and safe as possible.

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