John J. Bauer, M.D.
The term varicocele (var-ick-o-seel) refers to abnormally dilated veins of the testis. The veins of the testis are intended to cool the blood being delivered to the testis so that the temperature of the testis remains approximately 2 degrees cooler than body temperature. This is thought to be the ideal temperature for normal sperm production. When the veins are dilated, the blood that is delivered to the testis is warm and is associated with impaired sperm production.
Approximately 15 percent of men have varicoceles. Approximately 35 percent of men with infertility have varicoceles. The varicocele may or may not cause discomfort, however, they almost always result in abnormalities in sperm concentration and motility (swimming ability).
The primary indications for repairing a varicocele are (1) pain, (2) infertility, and (3) abnormal testicular growth.
The repair is intended to relieve pain in men who are symptomatic. In men with infertility, improvements in sperm concentration and motility can be expected. In adolescents with varicoceles that have resulted in a small, soft testis, some catch-up growth can be expected. In adults, the repair will not result in an increase in testicular size, but should halt the progression of impairments in sperm production.
The improvements in sperm concentration and motility may not be realized until 3 to 6 months after varicocele repair. For this reason, couples are recommended to proceed with varicocele repair if (i) the varicocele is thought to be the cause of the poor semen quality, (ii) the couple is prepared to wait 6 to 12 months for a pregnancy to occur, and (iii) the wife is not of advanced reproductive age such that a delay of 6 months will compromise the couple's chance at achieving a pregnancy.
A varicoceole is a varicose vein of the testicle similar to varicose veins of the leg. They are dilated or enlarged veins, which drain the testicle. The varicoceole is usually present on the left side only. Occasionally, it is present bilaterally and, rarely, it is present on the right side only.
It is thought that most varicoceles begin in early to late puberty and progressively enlarge with time at a variable rate. That is to say, in the milder forms it may take 10-20 years before the varicoceles becomes clinically important, whereas, in the more severe form it may only take a few years to become clinically significant.
There is circumstantial evidence that a varicoceole causes infertility in the male. Approximately 16% of the adolescent and adult population will have a varicoceole, whereas, approximately 40% of the males seen for infertility will have a varicoceole. Not all males who have a varicoceole will be infertile. This is probably because one does not know where the testicle "started" nor how severe the varicoceole is affecting the fertility. In other words, if the sperm counts begin very high and the varicoceole is not having much of an affect on the testicle, then it may take 10--20 years before infertility develops and, by this time, many men have completed their family and it no longer becomes a factor. On the other hand, if the individual has a relatively low count to start with or the varicoceole is having a deleterious affect on the testicle to a greater degree, it may only be a few years before infertility, develops. Unfortunately, there is no accurate way to determine who will become infertile, when they will become infertile, or if repair of the varicoceole will restore fertility.
If one biopsies the testicle of adolescents at the time of their varicocle repairs, approximately 40% will have evidence of damage to the testicle. Since it is difficult or impossible to obtain accurate sperm counts on adolescents, this is not a practical way to tell if there is a clinical problem developing. Additionally, the size of the varicoceole is not necessarily a reflection of the sperm counts or fertility potential.
The diagnosis is made by examining the patient in the standing position and feeling for the dilated veins in the scrotum,. The testicles should be measured for size as the varicoceole frequently causes a slowing of growth of the affected testicle making it smaller than the "normal" right side.
Those patients who should have their varicoceole repaired are: (1) those with an abnormal semen analysis, (2) those with bilateral varicoceles, (3) those with atrophy or a smaller testicle on the affected side, and (4) those who develop symptoms of testicular ache or pain because of the varicoceole.
Some experts advocate a GnRH stimulation test to help determine who should have surgery, but most experts feel that this is too unreliable to distinguish who should and who should not have surgery.
The surgery is usually done through a groin incision or by laparoscopic surgery under general anesthesia as an outpatient. If there is testicular atrophy, this will usually cease and the testicular size will increase to the same size as the normal opposite side.
As with any surgery, there are complications that may occur. The major problems with this surgery are the usual problems with any surgery; namely, bleeding and infections, which occur in a small number of patients. Potential problems which are particular to this surgery include failure to fix the varicoceole necessitating a re-do operation, testicular atrophy or further shrinking of the testicle, failure to restore fertility, and the production of a hydroceole, which is an accumulation of fluid around the testicle which may or may not need subsequent repair. If the surgery is originally intended to be done laparoscopically, there is the additional potential problem of injury to the bowels or other internal organs necessitating an emergency open operation but this is a rare complication. In general, this surgery goes welt with few complications.
The major unanswered question in adolescents is, does it really prevent infertility? Unfortunately, no one knows the answer. It would appear that if the varicoceole is seemingly causing testicular atrophy and therefore, damage, and/or if the semen analysis is abnormal, that it would be prudent to repair the varicoceole. We know that in adults who have their varicoceole repaired that their semen quality improves about 60-65% of the time and fertility is restored about 40-45% of the time. Whether those who do not have an improvement is because they have had too much damage to testicles is speculative at this time.