Varicocele is among the most common causes of male infertility. It is also one of the most controversial issues in the field of Andrology, especially regarding why, when and to whom varicocelectomy should be applied. Many experts believe that the surgical repair of varicocele should be applied only in a meticulously selected group of infertile men, although there are no generally accepted criteria. Up to now, the only confirmed prognostic factor for achievement of pregnancy after varicocelectomy is the age of the female partner. Given the wide application of intra – cytoplasmic sperm injection (ICSI) during the last few years, the modern research approaches should compare the benefits of varicocelectomy and ICSI, taking under consideration both the efficacy and the cost-effectiveness of the methods.
About 25% of all infertility is caused by a sperm defect and 40-50% of infertility cases have a sperm defect as the main cause, or a contributing cause. This is referred to as male factor infertility.
A varicocele is an abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord. It is somewhat like a varicose vein of the scrotum. A varicocele could possibly affect sperm by increasing testicular temperature – at least that is one theory.
Varicocele repair is done to improve male fertility. It can usually be done surgically on an outpatient basis using local or general anesthetic. A small incision is made in the abdomen close to where the testicles originally descended through the abdominal wall. The veins that produce the varicocele are identified and cut to eliminate blood flow to the varicocele.
Several studies have shown that varicocele surgery can improve sperm counts or low motility but randomized and controlled trials do not consistently show improved pregnancy rates (see below). There could be a difference between getting a higher sperm count, and getting the female partner pregnant.
In other words, if a couple will need inseminations with male partner’s sperm, or possibly in vitro fertilization anyway, why waste time, money, etc. on surgery for a varicocele. These treatment options depend on the degree of abnormality in the semen and other factors involved in the individual couple’s case.
For example, if the count is under about 5 million per cc, or the motility below about 30%, it is unlikely that the semen quality will improve enough after varicocele repair to result in pregnancy without inseminations or IVF. These couples should consider seeing an infertility specialist for a discussion of their options.
Couples with a male partner’s sperm count of less than about 5 million per cc, or the motility below about 30% will most likely need IVF with ICSI in order to conceive. In our opinion, varicocele surgery is probably not a viable option for men with such low numbers.
Men with counts that are just slightly low (15-20 million) may be more reasonable candidates for varicocele surgery. Many couples with sperm parameters in this range will conceive on their own, as well. However, the female should also be evaluated prior to the surgery – if her tubes are blocked or she has anovulation (no ovulation), or an ovarian reserve problem, surgery on the male is not indicated.
The best type of study to prove whether a medical “treatment” is effective is a controlled randomized trial. The treatment is done on some patients and not done on others, and the patients that are treated are randomly selected. That is supposed to eliminate bias in the study. Then we compare the outcomes in the 2 groups to see if there is any difference.
There are 6 controlled randomized published trials of varicocele surgery vs. no surgery:
3 studies had lower pregnancy rates with surgery 3 studies had higher pregnancy rates with surgery
Meta analysis of these 6 studies (a statistical technique that combines results from multiple studies) showed no significant effect of surgery on pregnancy rates.
The jury is still out on how effective varicocele surgery is as a treatment of male infertility. The waters are still murky.
Couples considering varicocele surgery should see a well trained urologist as well as an infertility specialist for education about all of their options before proceeding.Some couples (with a young female partner) will decide to proceed with the varicocele surgery and see what happens. It is not a big surgery and recovery is pretty easy. If they don’t get pregnant within 6-12 months after the surgery, the other treatment options such as insemination and/or IVF and ICSI are available.
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