Varicocele is an enlargement of veins within the scrotum, specifically the pampiniform plexus, which typically drain blood from the testicles. This condition can affect male reproductive health.
Varicocele and its Impact on Fertility
Varicoceles are present in approximately 15% of the general male population, but their prevalence increases significantly to 17% to 41% among men experiencing infertility. This condition is often considered a leading cause of male-factor infertility.
One of the primary theories explaining this impact involves elevated scrotal temperature due to blood pooling in the enlarged veins. The testes require a cooler temperature than the rest of the body for healthy sperm production, and this increased heat can impair sperm formation and function. Additionally, varicoceles may lead to increased oxidative stress, which generates reactive oxygen species that can damage sperm cells and their DNA integrity. Hormonal imbalances and altered testicular blood flow are also thought to contribute to the negative effects on sperm production and quality. These mechanisms collectively can result in lower sperm count, reduced sperm motility, and abnormal sperm shape.
Varicocele Surgery Procedures
Several procedures are available to treat varicoceles, aiming to block the enlarged veins and redirect blood flow. Open surgery, or varicocelectomy, involves a small incision, typically in the groin or lower abdomen, allowing direct access to the affected veins. Microsurgical varicocelectomy is a refined open technique performed with an operating microscope, enabling precise identification and ligation of the veins while minimizing damage to surrounding tissues.
Laparoscopic varicocelectomy is a minimally invasive surgical option where a surgeon makes several small incisions in the abdomen. A camera and specialized instruments are inserted to visualize and clip or tie off the veins. Another non-surgical alternative is percutaneous embolization, performed by an interventional radiologist. During embolization, a catheter is inserted into a vein, guided to the varicocele, and then small coils or a liquid substance are released to block the blood flow. This outpatient procedure typically requires only a local anesthetic.
Does Surgery Improve Fertility Outcomes?
Evidence suggests that varicocele repair can lead to improvements in various semen parameters. Studies show significant increases in sperm concentration, total sperm count, and progressive sperm motility after treatment. Some research also indicates a positive effect on sperm morphology and a reduction in sperm DNA fragmentation. These improvements in semen quality can often be observed within three to six months following the procedure, as sperm take approximately 90 days to mature.
Regarding natural conception rates, several studies have reported positive outcomes after varicocele repair. One randomized controlled trial found that the natural pregnancy rate was 32.9% in the treated group compared to 13.9% in the observation group over a 12-month period. Another study noted that 32% to 41% of infertile patients achieved spontaneous pregnancy after varicocelectomy. Overall, pregnancy rates after surgical varicocelectomy have been reported to be as high as 40% to 50% in certain populations.
While improvements in semen parameters and natural pregnancy rates are frequently observed, the direct link to live birth rates can be more complex and is a topic of ongoing research. Some sources note that while semen quality often improves, fertility rates may remain relatively low in some cases. However, the American Urological Association and American Society of Reproductive Medicine recommend offering varicocele treatment to infertile men with palpable varicoceles and semen abnormalities. This recommendation is supported by meta-analyses showing benefits in sperm parameters and spontaneous pregnancy rates.
Selecting Candidates for Surgery
Careful selection of candidates maximizes the potential for fertility improvement following varicocele surgery. Treatment is generally considered for men with a clinically palpable varicocele, meaning it can be felt during a physical examination. The varicocele should also be associated with abnormal semen analysis results, such as low sperm count, reduced motility, or abnormal morphology.
Another important criterion is documented infertility in the couple, typically for at least one year. It is also important that the female partner either has normal fertility or a treatable cause of infertility. Varicocele repair is generally not indicated for men with normal semen quality or those with subclinical varicoceles, which are only detectable by imaging but not by physical exam, as treatment has not consistently shown benefit in these cases. For adolescents with varicoceles, especially those with reduced testicular size or pain, surgery may be considered to prevent future fertility issues, though long-term data on fertility outcomes in this group is still developing.