services - Varicocele Repair
Varicoceles are dysfunctional dilated veins which normally provide drainage to the testicle. Varicoceles are the most common identified factor contributing to male infertility. Excellent treatment options are available that have been shown throughout the surgical literature to benefit fertility in many instances.
What Are Varicoceles?
Varicoceles are dysfunctional dilated veins which would normally provide drainage of the testicle. Varicoceles are akin to varicose veins in the leg, only located in the spermatic cord instead. Varicoceles are common, 15% of the general population will have a varicocele if examined by an expert. However, not everyone with a varicocele will have infertility. Varicoceles are still the most common identifiable cause of male infertility. Approximately 30-40% of men presenting with infertility trying to conceive their first child will have a varicocele. This number increases to 80% of men that have previously been successful in achieving a pregnancy and now present with infertility for a subsequent pregnancy. Thus, varicoceles are thought to exert a cumulative negative effect over time on both fertility and testosterone production.
What is the impact of Varicoceles on Fertility?
Varicoceles have been shown to result in lower pregnancy rates among couples and increased miscarriage rates. They are also associated with impaired testosterone production and abnormalities in sperm production. Some of these abnormalities include reduced sperm counts, reduced sperm motility, and abnormal sperm shape. Varicoceles have also been associated with increased DNA fragmentation. Increased DNA fragmentation within sperm can be thought of as nicks or damage to the DNA strands or associated binding molecules. This DNA fragmentation is present in normal conditions and in fertile men; however, mounting evidence in the literature is describing associations between abnormally elevated levels DNA fragmentation and reduced fertilization and pregnancy rates, and increased miscarriage rates. However, better designed studies are still needed to delineate the impact of DNA fragmentation, and effective treatment strategies.
What is the treatment of Varicoceles?
Fortunately, treatment of varicoceles is effective. Two approaches exist, a surgical approach and an interventional radiology approach. The gold standard is considered to be the subinguinal microsurgical varicocele repair. This technique involves a small incision in the groin, above the scrotum. Using a highly powered operating microscope the abnormal veins are identified and tied off, leaving only the arteries, vas deferens (tube carrying the sperm), and lymphatic vessels necessary for normal functioning. Varicocele recurrence rates have been described to be extremely low at approximately 1% using the microsurgical technique. This technique is typically performed as a day procedure, meaning that the patient will arrive, receive the procedure and leave in the same day.
Embolization of varicoceles by interventional radiologists is another effective technique. Here, a small incision is made to access the patient’s venous system. Using X-rays and an IV contrast agent to visualize the vessels, specialized intravascular catheters are used to aid the radiologist to the veins contributing to the varicocele. An agent is then released to plug the veins achieving a similar functional result as above. The recurrence rates are slightly greater than using the microsurgical approach; however, this technique is used by many and is also an excellent option for patients.
What is the impact of Varicocele repair on fertility?
Following repair, men’s testosterone increases, improve spontaneous pregnancy rates, decrease miscarriage rates, increase live birth rates among men with low sperm counts, increase the success rate of surgically retrieving sperm as well as the clinical pregnancy rates in men that have no sperm identifiable at baseline, increases clinical pregnancy rates of intra-uterine insemination (IUI) among men with low sperm counts and improves the sperm counts, motility, and shape or morphology of a man’s sperm. Varicocele repairs have also been shown to improve sperm numbers that may lessen the extent of assisted reproductive techniques that is required for some couples, if assisted reproduction is required due to male factor infertility.
Several publications have grouped these studies together (i.e. called a Meta-analysis) and have reported the effect of varicocele repair. These studies report that varicoceles:
- Increase pregnancy rates in men
- Increase sperm concentration by an average of 12 million sperm per ml
- Increase sperm motility by 10.86%
- Improved morphology of sperm
- Decreased miscarriage rate and increased pregnancy rate (Randomized trial not meta-analysis)
- Improved sperm DNA fragmentation
- Improved live birth rates for men with low counts
- Improved pregnancy rates and sperm retrieval rates for men with no sperm in the ejaculate (azoospermia)
- Improved ICSI clinical pregnancy rates, live birth rates and decreased miscarriage rates
In summary, varicocele repairs have many potential benefits. It’s important for couples presenting with infertility and a varicocele to discuss their particular scenario with their reproductive care team to determine if varicocele repair is of benefit for them.
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