Varicoceles

FAQs for Varicoceles

What is a varicocele?

Simply put, a varicocele is a varicose vein in the scrotum. Much like the appearance of varicose veins in legs, the varicocele can be best seen or felt when standing. In the standing position, men with varicoceles may note fullness around and/or above the testicles. This fullness should disappear when lying down. This is called “reflux” when blood travels the wrong way (backwards) through a vein. The vein responsible in the case of a varicocele is called the testicular vein.

How common are varicoceles?

Fifteen percent of men have varicoceles. Interestingly, varicoceles are identified in 40% of men with fertility problems and 80% of men who have had a child or children and are having trouble conceiving another one. Based on these statistics, a few conclusions can be drawn:

Do varicoceles occur more commonly on one side?

Yes. Eighty-five percent of varicoceles are on the left side. Of the remaining 15%, the vast majority are on both sides.

Why are varicoceles important?

Varicoceles are the most common cause of male fertility problems.

How did I get a varicocele?

The most commonly accepted theory is that men with varicoceles lack a valve to prevent blood from traveling backwards through the testicular vein when they stand up. This reflux of blood results in a varicocele. The theory is that they are more likely to occur on the left because of the way the left testicular vein joins the kidney vein (right angle).

How is a varicocele diagnosed?

Physical examination. The physical exam is performed in a warm room to avoid the “cold shower” effect on the scrotum. The examination must be performed lying down and standing up. A varicocele which does not decompress when lying down is concerning. It could mean that there is a mass blocking the vein in the abdomen. This is rare but very important to recognize.

A varicocele can be seen on an ultrasound too. This test is useful for men with very tight scrotums or for obese men. In both cases, a physical examination can be difficult. An ultrasound purely to look for a varicocele when a good examination does not show a varicocele is not necessary. A varicocele that is not identified on a good examination but seen on ultrasound is called a subclinical varicocele and there is little evidence that repair of a subclinical varicocele is beneficial.

Are all varicoceles the same size?

No. Varicoceles can be so small that they are barely recognizable on examination or so large that they can be seen from across the room. They are graded from 1-3 with 3 being the largest.

How do varicoceles damage sperm and decrease semen quality?

There are many theories. The most commonly accepted theory is that the varicocele raises the scrotal temperature. This has been shown in scientific studies. The average scrotal temperature is approximately 94 degrees F but it is higher in men with varicoceles. We know that other causes of increased intrascrotal temperature, such as hot tub use and excessive laptop use, are associated with decreased semen quality. This also explains why a man who has a varicocele on the left side only can have decreased semen quality. Varicoceles have also been associated with DNA damage and increased reactive oxygen species (free radicals) in sperm and semen, respectively.

Why does a varicocele increase the scrotal temperature?

Normally, a plexus of veins called the pampiniform plexus acts as a heat sump for blood entering the scrotum. Before the blood at body temperature (98.6 degrees F) enters the scrotum, some heat is transferred from the testicular artery to the pampiniform plexus which should draw the heated blood away from the scrotum. With a varicocele, there is congestion in the pampiniform plexus and the exchange of heat doesn’t work. For those with a technical background, the pampiniform plexus acts as a counter-current exchanger.

How can a varicocele be fixed?

Unlike varicose veins in the legs, the veins are not “stripped” from the scrotum. This would be technically impossible and would result in injury to the blood supply of the testicle. Instead, varicocele procedures involve blocking the flow of blood in the veins so that they cannot reflux. This can be done from outside the veins (surgery) or from inside the veins (embolization). The testicle then drains itself through other channels which generally do not reflux.

What are the options for repair?

There are five options:

Retroperitoneal varicocelectomy: This is of historical interest only. It is “maximally invasive” and certainly no more effective than other options.

Inguinal varicocelectomy: The veins in the spermatic cord (the cord that contains the structures going between the abdomen and the testicle) are tied off. The advantage of this approach is that there are only a few veins and so it is easier for the surgeon. The disadvantage is that it requires opening of the muscle/fascial layer of the abdominal wall. Because of this, it is more painful than a subinguinal approach.

Subinguinal varicocelectomy: The veins in the spermatic cord are tied off just a little bit below where they are tied off with the inguinal approach. In this location, the spermatic cord has already left the abdominal wall muscles and is in the superficial tissues. This approach is associated with less pain. The disadvantage is that the surgeon must tie off as many as 15 veins. This is best done with an operating microscope. Using an operating microscope with either the inguinal approach or the subinguinal approach maximizes the effectiveness of the surgery and minimizes the risks. In most men, this procedure can be performed through an incision approximately one inch in length.

Laparoscopic varicocelectomy: This involves accessing the spermatic cord in the abdomen and clipping the veins at that level. The abdomen is filled with gas to allow visualization. This approach is not generally performed anymore since the subinguinal approach is actually less invasive and less risky.

Embolization: With this technique, an interventional radiologist accesses a vein in the neck (sometimes in the groin) and channels a catheter through the superior vena cava, alongside the heart, through the inferior vena cava, into the left renal vein and into the testicular vein. The radiologist then injects something (boiling contrast media, alcohol, metal coils) into the vein to prevent reflux.

Which technique is best?

There is no one best technique. Most patients favor either the subinguinal varicocelectomy or embolization because they are minimally invasive. The subinguinal approach is best performed by an experienced microsurgeon. Embolization is difficult to perform on the right side because the right testicular vein is hard to enter. Sometimes, if a man has a hernia and a varicocele, an inguinal approach is most appropriate since the abdominal wall musculature has to be opened anyway to repair the hernia. Most published series report a success rate (i.e. the varicocele goes away) of 95% with surgery and approximately 90% with embolization.

What is the success of varicocele repair?

The surgery is generally quite successful at eliminating the refluxing varicocele. Most published series report a success rate (i.e. the varicocele goes away) of 95%. Most series and meta-analyses show that about 70% of men will have a significant improvement in semen parameters after a varicocele repair. Pregnancy data vary widely from series to series (from no better than control to 80 %!). Most large series of repairs of clinically significant varicoceles report pregnancy rates of approximately 33%.

The pregnancy rates seem to be similar to those seen with intrauterine insemination (IUI). How should we choose between varicocele repair and IUI?

This is a common situation many couples face and the answer is complicated. Important factors include the age of the female partner, the presence of a female infertility problem, comfort with the risk for multiple births, desire for more children in subsequent years and timing. This is an excellent question to ask your fertility specialist.

Does varicocele repair make IUI more likely to be successful?

There is only one paper that addresses this. In a small study, Daitch et al (J Urol. 2001 May; 165(5): 1510-3) found that couples that underwent IUI after a varicocele repair were 10 times more likely to have a live birth than couples that underwent IUI with an uncorrected varicocele.

What if I had a varicocele repair and it came back?

In this instance, it is well recognized that if the first procedure was surgery, embolization is most likely to result in eradication of the varicocele. Conversely, if the first procedure was embolization, surgery is most likely to result in eradication of the varicocele.

Should a varicocele be fixed?

The answer is: it depends. It depends on many factors including the precise semen abnormalities, the presence of a female fertility problem, comfort level with other options etc. These issues should be discussed thoroughly with your fertility specialist.

What are the other options?

Many couples in which the man has a varicocele and they are having trouble conceiving have treatment options. These include: medical treatments, varicocele repair, intrauterine insemination, insemination with donor sperm, in-vitro fertilization and adoption. These options should be discussed thoroughly with your fertility specialist.

Are there potential complications from a varicocele repair?

Surgical complications are very rare, particularly with a subinguinal microsurgical approach. These complications are similar to other surgical procedures and include bleeding, infection and pain. Damage to the testicular artery is theoretically possible but the likelihood is minimized by using an operating microscope, identifying and preserving the testicular artery. Hydroceles (fluid around the testicle) can occur if the lymphatics are tied off. These structures can be identified and preserved with the operating microscope. You should always talk to your surgeon about the risks involved prior to undergoing a surgery.

Risks of embolization include injury to the vein that is accessed in the neck or the groin, heart arrhythmias during the procedure, injury to the abdominal and chest veins traversed during the procedure and migration of the substance used to block off the testicular vein.

Are varicoceles repaired for any other reason than fertility problems?

Yes. In children, asymmetric growth of the testicles is a reason to repair a varicocele. Occasionally, varicoceles will be repaired because of discomfort or for cosmetic reasons.

Can a varicocele cause physical harm other than decreasing semen quality?

Recently, there has been much talk about a concept commonly known as “Andropause” or “Male Menopause.” It is well known that testosterone levels tend to decline with age. Some investigators believe that a varicocele can speed up this decline in testosterone levels. Since testosterone is produced primarily by the testicles, this is theoretically possible. This is an experimental notion at this time.