Varicocele and Male Fertility and Infertility
Varicocele is the presence of enlarged or dilated veins in the blood vessels of the scrotum. Normally the scrotal veins have valves that regulate the blood flow. However, in some cases, the valves are absent or defective and the blood does not circulate out of the testicles efficiently. This results in swelling of the veins above and behind the testicles. 85% of varicoceles develop in the left testicle.
Varicocele and Infertility
It is estimated that varicoceles are present in about 20% of the normal fertile male population and up to 40% of an infertile population. It is clear, then, that the finding of a varicocele is not necessarily abnormal. At the present time, there is no way to determine whether a varicocele in an individual is the cause of infertility problems.
Scientists believe that at least some varicoceles are associated with infertility because they are found more commonly in infertile men. It is uncertain how varicoceles may cause infertility. Some evidence points to the increased temperature of the blood raising the temperature of the testes, which then damages the sperm. Heat can damage or destroy sperm. The increased temperature may also impede production of new, healthy sperm. Another theory is that in men with varicoceles, the testicular fluid which carries sperm has an increased concentration of chemicals which can damage sperm. The chemicals are called reactive oxygen species or ROS.
A varicocele may be detected on a physical exam. It is describes as looking or feeling like a “bag of worms”. It is more obviously seen or felt when a man is standing then when he is lying down. Sometimes, a varicocele may become more apparent when a man “bears down” to try to increase the intra-abdominal pressure.
The American Urological Association states that only varicoceles that can be felt have been documented to be associated with infertility. Not everyone agrees with that position. Scrotal ultrasound can be used to diagnose a smaller, less obvious varicocele. Echo color Doppler is a type of ultrasound that can measure blood flow in the veins of the scrotum.
Most varicoceles can be corrected through a surgical procedure called varicocelectomy ( surgically “tying off” the affected veins). The following methods are used.
This procedure is performed under general anesthesia (the patient is asleep). In this procedure, a 2 to 3 inch incision is made in the groin or lower abdomen, the affected veins are identified and the surgeon cuts the veins and ties them off. This surgery can usually be performed on an outpatient basis. Full recovery takes about 6 weeks.
Laparoscopy is a technique in which a fiber optic telescope is inserted through the belly button into the abdominal cavity through a small incision. The surgeon can view what is happening by connecting a video camera to the laparoscope and watching a monitor. Once the varicocele has been located, the surgeon will introduce special instruments through small incisions near the pubic hair line to tie off the dilated veins. Most men can resume normal activities in a few two days.
An alternative to tying off the veins is blocking the blood flow to the veins.
Since embolization is a non-surgical procedure, it does not require general anesthesia but often the patient will be sedated. A small catheter is inserted into the veins just beneath the varicocele. A special dye is used to highlight the varicocele on x-ray and to visually guide the catheter. This is known as venography. Tiny coils are then advanced through the catheter to block the blood flow to the dilated veins. Most men can resume normal activities in a few two days.
There is no evidence to suggest that any of these procedures work better than any other. However, the risks and recovery times are different.
There are two endpoints that are discussed after a varicocele repair: improvement in sperm counts and pregnancy. Unfortunately, many of the studies looking at varicocele repair have been poorly done. Consequently, there are mixed results as to whether more couples achieve pregnancy. There have been two well designed and well performed studies looking at varicocele repair. One study showed an improvement in pregnancy rates and one study did not.
Varicocele and In Vitro Fertilization – IVF and Intracytoplasmic Sperm Injection -ICSI
For couples in whom the men who have mild to moderately low numbers of moving sperm , intrauterine insemination (placing the sperm in the uterus) at the time of ovulation can be performed with reasonable success. For couples with any severity of sperm problems, in vitro Fertilization – IVF with intracytoplasmic sperm injection -ICSI is a highly effective method to achieve fertilization. Pregnancy rates are no longer dependent on the number of sperm but rather on female factors such as her age and response to fertility drugs.