Overview

A varicocele is dilated veins in the pampiniform plexus (veins that drain the testicle). They are most commonly found on the left, but can be seen on both sides. We believe they are more common on the left due to anatomical differences.

Varicoceles can also run in families and are similar to varicose veins commonly seen in the legs. There are many theories as to why varicoceles cause infertility in some men. The most commonly accepted theory is increased scrotal temperature. The testicles optimally produce testosterone and sperm at a temperature that is slightly lower than our internal body temperature of 98.6 degrees Fahrenheit.

The purpose of the scrotum is to allow the testicles to reside outside of the body where the temperature is cooler. Varicoceles can increase the pooling of warm blood around the testicle which can raise the scrotal temperature, thus potentially impairing fertility.

Evaluation

Approximately 20% of men in the general population have a varicocele, but most men will not need to undergo varicocele repair (varicocelectomy).

A proper evaluation is of paramount importance to determine if the man is a good candidate for repair. Men with sub-clinical varicoceles (small varicoceles only detectable by scrotal ultrasound) do NOT need to be repaired.

Candidates for repair should have a noticeable varicocele that is obvious on clinical exam. The best candidates for repair typically have palpable varicocele, abnormal semen testing, discrepancy in the size of the testicles, and a female partner without significant fertility issues. Large varicoceles can also cause dull or achy pain in the testicle and repair may improve this discomfort in properly selected men.

Management Options

- Embolization

Interventional radiologists commonly perform the embolization approach. They are able to access the varicocele using the major veins in the body with a small needle stick in the neck or groin.

Pros for this approach: minimal anesthesia and potentially less postoperative pain.

Cons for this approach: exposure to a small amount of radiation, slightly higher recurrence rates, and difficulty accessing the right side.

- Surgery

There are also several valid surgical approaches including laparoscopic, retroperitoneal, macroscopic (no operating microscope), and microsurgical.

Most male fertility specialists perform a microsurgical varicoceletomy using an operating microscope.

Pros for this approach include: very low recurrence rates, no risk of injury to the bowel, sparing the testicular artery, and minimal risk of hydrocele formation (fluid sack surrounding testicle).

Cons for this approach include: requires general anesthesia, small groin incision, and risk of injury to testicular artery/testicular atrophy.

During the microsurgical approach, a small incision is made on one side or both sides. The spermatic cord (contains the varicocele and blood supply to the testicle) is delivered through that incision and the varicocele is identified. A high powered operating room microscope is used to help identify the varicocele and testicular artery. The varicocele veins are then tied off with permanent stitches and the testicular artery is spared. The cord is then lowered back into the incision and the incision is then closed with absorbable stitches.

Additionally, this is NOT a vein stripping procedure so the dilated veins will still be present in the scrotum and typically remain visible after the procedure has been performed. The purpose of this operation is to limit the blood that is pooling around the testicle and lower the temperature inside the scrotum. The overall objective of the procedure is to cease any additional decline in semen parameters and improve semen analysis parameters.

- Outcomes

It is very important to note that varicoceletomy (repair of varicocele) does NOT result in immediate improvement in semen parameters. It typically takes 72 days to complete a sperm cycle. Therefore, most men typically will not see improvements in semen parameters until at least 3 months after surgery. It can take up to 1 year or more for some men to see maximal improvement.

Therefore, if the female has a significant fertility issue which is not correctable and/or time is of the essence, these couples may not be good candidates for varicoceletomy. These couples may be better suited for immediate assisted reproductive technology (ART), such as insemination (IUI) or in vitro fertilization (IVF).

While some of the studies examining varicoceletomy show mixed results, the majority of research shows significantly improved semen parameters and pregnancy rates in appropriately selected couples.

Post-operative instructions:

- Microsurgical Varicoceletomy:
  • Alternate ice packs to groin for 24 hours after surgery.
  • Ok to remove the top dressing and scrotal support the following day at noon and then shower. No tub baths as stitches in the skin are absorbable.
  • Please allow the steri-strips to fall off on their own.
  • No heavy lifting (greater than 10lbs) for the next 48 hrs. After that it is ok to ease back into activity. Common sense rules apply: if it hurts, don’t do it.
  • Wear supportive briefs until follow up appointment.
  • Swelling, mild bruising, and discomfort are very normal.
  • Most men require narcotic pain tablets for 48-72 hours.
  • The varicocele will normally be larger in the immediate postoperative period due to inflammation.
  • A healing ridge (firmness at the incision site) is very normal for several weeks after surgery.
  • Please call the office if you do not have a follow up appointment scheduled. We generally like to see you back in the office approximately two weeks after the procedure.
  • We will resume semen testing at 3 months after surgery and then every 3 months for the next year. Remember, improvements in semen parameters generally take time and cannot be guaranteed.
  • It is important that couples begin trying for a natural pregnancy with timed intercourse as soon as the patient feels up to it. Couples do NOT need to wait to see improvements in semen parameters before trying for a pregnancy.

Patient Resources:

CONTACT US

Request to be contacted for an appointment

Click Here