Varicocele & Infertility

What is a varicocele and how common is it?

Varicocele is a term used to describe abnormally dilated veins (called the Pampiniform Plexus of veins) in the scrotum (the sac that holds the testes).Varicocele usually is much more common on the left side than on the right side. Sometimes it occurs on both sides.

About 15% of all adult men have a varicocele. About 20% of adolescents have varicoceles, so a fraction of them are likely to resolve spontaneously.

Why does varicocele occur?

Every vein has a valve (door) that prevents blood from flowing backward, but sometimes the valve fails. This causes blood to flow back due to gravity, collecting in, and damaging the vein and causing swelling.Though doctors do not understand the exact cause but smoking increases the risk, possibly alcohol does, and certain type of cancers (testicular) may cause varicoceles. Rarely, a mass or abnormal growth in the abdomen can put pressure on the veins, causing a varicocele. But in the majority a varicocele has no apparent cause.

How is a varicocele diagnosed?

When your doctor examines you in the standing posture, a varicocele can be found on physical exam. The reason for examination in standing posture is because it disappears while lying down.You don’t always need an ultrasound to diagnose a varicocele. A varicocele not felt physically but seen on USG (ultrasonography) scan is not important and is called a subclinical varicocele.

An ultrasound of the scrotum is needed only to confirm the physical findings with the help of colour flow. You will also need a semen analysis to check your sperm quality.

Effects of varicocele :

In most men, a varicocele is just a structural finding and is of no clinical significance. Sometimes, a varicocele can lead to decreased fertility or scrotal pain. Around 50% of men with varicoceles have a reduced sperm count and/or sperm motility (sperm activity), reducing their reproductive potential. Less than 5% of men with varicocele have pain in the scrotal sac due to the varicocele.

Varicoceles do not cause any major health problems.

How do varicoceles cause infertility?

Varicoceles are sometimes, but not always, a factor in infertility but how they cause it is not clear. There are mixed views on effect of treatment of varicocele on fertility in literature. The testis functions optimally at around 3 degrees below body temperature, thus this warmer blood accumulated in the varicocele can affect its ability to make sperm and testosterone.

Do I need Treatment ?

Any varicocele that is not causing any problem does not require treatment. But rarely they can be associated with dangerous conditions like, a unilateral varicocele on the right side may be associated with a mass or other abnormality in the abdomen that might be causing it. If you have a varicocele and a low sperm count or other problems with sperms, only then you would need treatment. The indications for treatment in varicoceles are:

• The varicocele is causing you pain or swelling.
• Couple has unexplained infertility, and the male has a varicocele.

What are the treatment options?

The treatment is surgical and usually two approaches are used, these are laparoscopy and open surgery. An incision is made in the groin and the spermatic cord is checked. The veins are examined and ligated. Highest success rate is reported with this method with minimal complication rates including intra-abdominal injuries.A third approach is varicocele embolization where small coils are introduced through a vein in the groin area and are used to block the veins in the abdomen feeding the varicocele.

What are the complications of varicocele repair?

Serious complications are rare.

• Potential complications from varicocele repair include persistent/recurrent varicocele (10-15%), bruising, infection and testicular tenderness and blood clots in legs along with some anaesthesia related risk.
• Caution to be practiced while doing non-surgical repair as there is an added risk of contrast sensitivity.
• Loss of the testicle is a remotest possibility.

Will treatment help me?

Around 75% of men see improvement in their semen analyses and about 40% can achieve a spontaneous pregnancy.
If performed in skilled hands, a microsurgical Varicocelectomy can increase spontaneous pregnancy rates and if ART is still needed, it may increase the success rates.
But it will not cure infertility in all men.

What next, if surgery does not help?

In some situations, a couple may have better results with assisted fertilization techniques, such as intrauterine insemination (IUI) and in vitro fertilization (IVF/ICSI).