What is a varicocele? The testicles are housed in the scrotum, a skin-covered sac that houses the two testicles as well as blood vessels that deliver blood to these glands, nerves, and lymphatics. An abnormality of the plexus of veins (the pampiniform plexus) that carry blood away from the testicles can result in their distention, proliferation and enlargement within the scrotum. We refer to this as the development of varicosities similar to varicose veins that can occur in the leg.
How does a varicocele cause male infertility? The increased scrotal blood flow often raises the temperature in the scrotum by 1-2 degrees. This in turn sometimes results in decreased sperm production and functionality as well as testicular shrinkage (atrophy), leading to male infertility. However, the existence of a varicocele by no means inevitably compromises sperm production and functionality.
Who develops a varicocele and how common is the condition? About 15 percent of men have varicoceles. These generally form during puberty and are more commonly found on the left side than on the right side of the scrotum. Rarely are both sides of the scrotum affected. Most males are diagnosed between the ages of 15 and 25 years of age. There are no established risk factors for developing a varicocele, and the exact cause is unclear.
How does a varicocele present and how can it be diagnosed? The presence of a varicocele does not invariably mean that it is the cause of male infertility. In fact many males who have varicoceles do not have any fertility problem at all. Also, in many cases the detection of a varicocele is an “incidental finding and is not the cause of coexisting male infertility. You see, contrary to popular belief, varicoceles seldom reduce sperm count. In fact, in many cases of low-sperm count, treatment of the varicocele rarely results an improvement in sperm production. It is important to recognize that the majority of men who have varicoceles, do not have evidence of sperm dysfunction.
Most varicoceles are not even symptomatic. In fact, most are never detected. Those that are symptomatic present with scrotal enlargement, scrotal and/or lower abdominal pain, and infertility. The condition is often diagnosed by physical examination where, to the touch, a varicocele feels like a “bag of worms”. However ultrasound examination of the scrotum offers a more definitive diagnostic capability.
When a varicocele causes sperm dysfunction, this most commonly manifests with a normal or even raised sperm count. However, there is usually markedly reduced motility and sperm progression, but a high percentage of sperm are found to be “immature” Collectively this is referred to as a “stress pattern”. In many such cases the Sperm Chromatin Structure Assay (SCSA) will show an increase in the DNA Fragmentation Index (DFI). These are the cases where treatment of the varicocele will often improve sperm function, along with improving the likelihood of a viable pregnancy occurring naturally or following IVF with intracytoplasmic sperm injection (ICSI).
Treatment: There are two approaches to treating varicoceles:
- Traditional treatment of a varicocele is through ligation (under general anesthesia) of one or both spermatic veins that carry blood from the pampiniform venous plexus (“varicocelectomy”). While surgery is in most cases curative, post-surgical recurrence is not uncommon.
- Another approach is interventional radiological obliteration of one or both the spermatic veins. This approach involves passing a balloon catheter via a groin blood vessel, under radiological view, into the spermatic vein and inflating the balloon in that position. This causes the spermatic vein to permanently occlude. Sometime later, the catheter is withdrawn and the vein remains occluded causing the varicocele to collapse and the pampiniform plexus to shrink or disappear. This radiological approach is often more effective, far less costly, less traumatic and less likely to, result in a recurrence than is spermatic vein, surgical ligation. It is also conducted under local anesthesia and as an out-patient procedure. In my opinion this approach has become the preferred method for treating varicoceles.
Regardless of whether surgical or interventional radiological treatment is contemplated, it is in my opinion, advisable for the patient to take a male fertility blend that is rich in antioxidants (I recommend a product called Proceptin, which requires online purchase). This will sometimes result in an improvement in the DFI within 3-6 months.. It should be taken for at least 12 weeks whereupon the SCSA should be repeated.
It is important to bear in mind that both surgical and radiological treatment will only improve sperm function in about 35% of men who have varicocele. Understandably, it is tempting to attribute a cause and effect relationship to fertility problem and a varicocele. However, the existence of a varicocele is often coincidental (unrelated) to the underlying cause of the infertility.
Under what circumstances will treatment be unlikely to succeed? The following, in my opinion, represent situations where treatment of a varicocele (whether surgical or radiologic) is unlikely to resolve the male infertility issue.
- When the man has an elevated blood FSH level (greater than 12MIU/ml)
- In cases where there is a persistently low sperm count (<20million/ml).
- When the DFI is below 30%. In such cases ICSI is the best approach.