About 15% of all males have a varicocele. These varicoceles usually develop when a man goes through puberty and blood flow increases to the testes, predisposing to the risk of blood backing up toward the testicle because of reflux (back up) of blood toward the testes with enlargement of the scrotal veins that is referred to as a varicocele. Varicoceles have an adverse effect on sperm production, so they are found in 35% of infertile men, and repair of a varicocele can improve sperm production and increase the chances of fertility for those men.
Varicoceles result from reflux (back up) of blood from the body toward the testes. They are more common and tend to be more severe (larger veins) on the left side, where the veins are longer and more prone to have partial blockage and/or impaired valves in the veins. There are multiple sets of veins that drain the testes, some of which (veins along the vas deferens) drain deep in the pelvis and therefore do not result in reflux or cause varicoceles.
Very large varicoceles are able to be seen through the skin of the scrotum, looking like a sack of worms. Moderate sized varicoceles are detected by a doctor feeling the enlarged veins on physical examination. The veins will typically enlarge, so the doctor feels an impulse in the veins, if you stand up, take a deep breath, cough, or bear down. An ultrasound of the scrotum, which uses sound waves to create images of your internal organs and tissues, can identify the size of veins in the scrotum, although they are not routinely required to diagnose a varicocele. Enlarged veins are usually close to 3.0 mm in diameter on ultrasound.
A varicocele is a physical problem that is created by the reflux of veins in the internal spermatic (testicular) and/or external spermatic veins. Fixing a varicocele is done by blocking off the veins allowing the reflux of blood, allowing return of blood from the testes to occur through the vasal veins, as discussed above. Blocking off the veins can be done with surgery or radiographic intervention using X-rays, done by an interventional radiologist.
Most studies that compare different surgical and interventional approaches have shown that the microsurgical approach to varicocele repair at the low “subinguinal” level is the most effective and safest procedure to fix varicoceles without requiring any ionizing radiation of the patient. Using an operating microscope to assist during the procedure makes treatment more successful, since the scope allows the surgeon to identify and preserve normal structures such as the arteries carrying blood to the testes and the lymphatics that carry fluid away from the testes as well as to identify the very small veins that, if not tied off, can result in recurrence or persistence of a varicocele after attempting a repair.
Not surprisingly, microsurgical varicocelectomy has a very low chance of the complication of developing a hydrocele (that occurs if the lymphatics are tied off), or recurrence of varicocele (that occurs if small veins are missed during surgery, allowing persistence of reflux of blood and the varicocele. Microsurgical varicocelectomy is usually done as an outpatient procedure, so men come in, have the procedure done and go home the same day, under local or general anesthesia. Experienced microsurgeons typically find that patients have less than 1% risk of any complication, including bleeding, infection, recurrence of varicocele or hydrocele.
Varicoceles only occasionally cause dull pain, and most men with varicoceles are able to father children. So, do you have to treat varicoceles?
There is abundant evidence that varicoceles decrease sperm production, even if adequate sperm production for fertility persists in some men. The detrimental effect of varicoceles on fertility has been shown in several studies. A research study by the World Health Organization (WHO) on over 9,000 men showed a connection between varicoceles and decreased testicular volume, impaired sperm quality, and a decline in Leydig cell (the cells that manufacture the male hormone testosterone) function.
Some studies in animals and humans also suggest that varicoceles cause progressive testicular damage over time. There is evidence that surgically repairing varicoceles not only stops decline in testicular function, but often reverses it.
Finally, the highest level of medical evidence (systematic reviews of controlled studies) indicate that varicocelectomy improves pregnancy rates. Certainly other assisted reproductive treatments such as IVF (in vitro fertilization with single sperm injection – ICSI) can treat male infertility even if a varicocele is present. For selected men, varicocele repair can actually fix the fertility problem in the man, and allow couples to have multiple children naturally.
Take the first step towards better health and schedule a consultation with Dr. Schlegel today to discuss your specific concerns and explore personalized medical solutions.
New York Men’s Health Medical
Dr. Peter N. Schlegel
983 Park Ave, 1C
New York, NY 10028
(833) 746-5491
International: +1-646-661-5877
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