A. A varicocele is a dilation of the pampiniform plexus - the veins that drain blood from the testicle. Due to anatomical differences, varicoceles are more common on the left side although they may also occur on both sides simultaneously. As the varicose veins dilate, the valves within the veins become incompetent and no longer function. This allows blood flow to reverse within the veins which causes abnormal blood flow around the testicle. It is this change in blood flow which leads to poor testicular function by causing overheating of the testicle.

A. A varicocele is found in approximately 15% of all men. In men presenting for an infertility evaluation, varicoceles are found in approximately 40% of patients. Although a varicocele is the most common surgically correctable factor leading to impaired testicular function, not all men will necessarily require repair.

Q. How is a varicocele diagnosed?

A. Most varicoceles are asymptomatic although occasionally a man will complain of scrotal pain, discomfort or pressure. A varicocele can be diagnosed by physical examination when a man is examined by a properly trained physician. Varicoceles vary in size - some large varicoceles are actually visible beneath the surface of the scrotal skin. Smaller varicoceles may be discovered with the patient standing and performing deep breathing maneuvers which will accentuate the varicocele. In certain cases where the varicocele is less obvious, an ultrasound of the scrotum may be obtained in order to confirm its presence.

Q. How does a varicocele affect semen quality?

A. The most common theory to explain how a varicocele affects semen quality has to do with overheating of the testicle. It is felt that the dilated veins allow warm blood from the abdominal cavity to flow around the testicle. This causes overheating of the testicle which then impairs its function. Commonly, a low sperm count, low motility, and abnormally shaped sperm (stress pattern) are found in men with varicoceles. A varicocele surrounding 1 testicle may affect the testicle on the opposite side of the body. A varicocele may also lead to testicular atrophy (impaired growth) and thus the testicle on the side of a varicocele may be smaller than its contralateral mate.

Q. How is a varicocele repaired?

A. There are 3 methods of varicocele repair:

1. Standard surgery
2. Radiographic embolization
3. Laparascopic repair

All of these procedures are performed on an outpatient and accomplish the same goal - interrupt blood flow in the abnormal veins. Radiographic repair of a varicocele is performed by an interventional radiologist - a physician specializing in x-rays. For this procedure, a small tube (catheter) is inserted into a large vein in the groin. Under x-ray guidance this catheter is then manipulated through larger blood vessels until the abnormally dilated veins can be identified. Once localized, these veins are then embolized (blocked) by placing small medical devices (coils, balloons, scarring agents) within the veins. Risks of this procedure include allergic reaction to the x-ray dye, migration of balloons or coils, bleeding/infection at the skin puncture site, and the inability of the procedure to be performed successfully.

The other 2 methods of varicocele repair are performed by a urologist. Both approaches, i.e. standard surgery and laparascopic surgery, tie off the abnormally dilated blood vessels. Laparoscopy involves inserting a small telescope, and several other instruments, into the abdomen. Each incision measures between 5mm and 10mm. (¼ - ½ inch) The veins are then visualized inside the abdomen and either clipped or tied. Although recovery from this surgical procedure may be slightly shorter than standard surgery, the potential risks are higher. Since telescopes and surgical instruments are inserted into the abdomen, the chance for bowel, bladder and major blood vessel injury exist.

Standard varicocele repair is performed through a small (1 inch) incision in the groin - no surgery is performed on the scrotum. The spermatic cord containing the dilated veins is then brought into the operative field and the abnormal veins are either tied off or clipped. The highest success rates and lowest complication rates are reported using a technique called the "microsurgical varicocele repair". This technique utilizes an operating microscope so that individual structures within the complex of vessels can be identified. Additional use of a doppler ultrasound probe (microphone) can help identify and differentiate the testicular artery from the dilated varicose veins. The operating microscope allows the surgeon to tie off veins which can not be seen with the naked eye. Utilizing these modern techniques, success rates should approach 95% and risks of testicular atrophy, recurrence of the varicocele, and hydrocele (accumulation of fluid around the testicle) should be < 1%.

A. In general, surgical success rates using the microscopic varicocele repair should approach 95%. The first semen sample after a varicocele repair is not usually obtained for 3 - 4 months following surgery. Approximately 60% of patients will note improvement in some aspect of the semen analysis (count, motility, or morphology). Pregnancy rates following varicocele repair may be as high as 65% if the there are no female factors and the female partner is young. Most pregnancies are reported within the first year following varicocele repair. If no improvement is noted after 8 months, then alternative methods of achieving a pregnancy are discussed.

A study by Madgar in 1995 (Fertility & Sterility) compared a group of patients who underwent immediate varicocele repair versus a group of patients who waited 1 year before undergoing varicocele repair. Both groups had a minimum of 12 months of infertility and were followed for 3 years after entering the study.

In the group who waited 1 year before undergoing varicocele repair, only 10% established pregnancies during this time. After undergoing varicocele repair, the pregnancy rates in this same group of patients improved to 66.6% within 2 years of surgery. Thus, a total of 76.6% of these patients achieved pregnancies.

In the group of men who underwent immediate varicocele repair, pregnancy rates after 1 year were 60%. After completion of the study at 3 years, 76% had achieved pregnancies.