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Varicocele is a dilation (enlargement) of the internal spermatic veins that drain the testicle (picture below). It is a similar condition to varicose veins that people get in their legs. It is a very common condition present in 15% of the general male population and 40% of men evaluated for infertility. A varicocele develops because of defective valves that normally allow for blood to flow back from the testicle to the abdomen. When the one-way valves don’t trap the blood, gravity is pulls the blood down to the testicle. Testicular injury occurs due to abnormal back flow of blood from the abdomen into the scrotum and this creates an inhgospitable environment for sperm development. The significance of this condition has been known for a thousand years. The first century Greek physician Celcius originally described the varicocele: “The veins are swollen and twisted over the testicle, which becomes smaller than its fellow in as much as its nutrition has become defective”.

Numerous theories postulate how a varicocele can affect fertility:

Left-sided varicoceles are found in 60% of men with this problem and a right-sided varicocele is seen in 20%. The problem involves both sides in about 20% of men with this condition. A unilateral varicocele may affect both testicles. The most probable explanation for the more frequent development of a varicocele on the left side alone is because the left spermatic vein is longer than the right. The left vein enters the left renal vein at a right angle near a site of compression by the mesenteric artery while the right spermatic vein drains at a softer angle into the vena cava. These anatomical factors (and the aid of gravity) promote backflow of blood in the left spermatic vein, resulting in pooling of blood and increased temperature and congestion in the testicle.

Some men with major varicoceles may show little evidence of testicular injury; while others with small or “subclinical” (detected only by radiological tests) varicocele may be infertile. The effects of a varicocele on sperm quality and quantity are thus difficult to define and predict. The so-called “stress pattern” frequently found in men with a varicocele consists of an increase in tapered abnormal sperm forms and decreased motility (low motility, abnormal morphology).

The diagnosis of a varicocele can usually be made on physical examination of the scrotum while the patient is standing. A very large varicocele feels like a “bag of worms” and disappears or becomes significantly reduced when the patient lies down. The patient is asked to bear down and frequently the backflow of blood can be felt in these veins. Occasionally a varicocele may be so prominent that it can be seen through the skin. Often the testicle on the side of the varicocele is smaller than the other side. Ancillary tests such as the Doppler stethoscope and technetium isotope study may aid in the diagnosis. The scrotal ultrasound has been found to be an accurate way of confirming the presence of a varicocele. The size of the veins and abnormal blood flow can be seen and measured using the ultrasound therefore, it is usually more accurate in detecting varicoceles than physical exam. The ultrasound test is very “user dependent” meaning that the skill of the radiologist in performing the exam and the maneuvers he has the patient do during the ultrasound help improve the accuracy of the study. The ultrasound should be performed while the patient is lying down and also standing up. The patient then must bear down to increase the intra-abdominal pressure so the radiologist may detect reversal of blood flow through the varicose veins. The radiologist must also measure the size of the veins on both the right and left sides in order for the 0065am to be considered thorough. The diagnosis of varicocele is based on 3 criteria, any of which confirms an abnormality is present. 1. Size of the veins at rest greater than 2.7-3.0 mm. 2. Increase in size of the veins when the patient stands up or bears down. 3. Abnormal blood flow detected in the vein when the patient bears down (reversal of flow).

Repair of the varicocele is indicated when the couple has documented infertility with normal or potentially normal female partner but a male with one or more abnormal semen parameters and the presence of a varicocele on physical exam. Repair should also be performed when a varicocele causes testicular pain or discomfort or there is a significant discrepancy between the size of the two testicles.

Treatment options to aid with fertility include surgical varicocele repair, angiographic embolization, intrauterine insemination, in-vitro fertilization and medical therapy with clomid. Surgical repair offers the best results. Semen improvement is expected in up to 70% of men and pregnancy in up to 60% of couples within the first two years after successful repair (study by Madagar et al. Fertility & Sterility, vol.63, no., 1995). Even in men with worst case scenarios who were not candidates for In Vitro Fertilization because they had no sperm in the ejaculate or they have sperm that are not moving, varicocele repair restored sperm or motility in 55-69% of patients. Twenty percent of these men were able to father children after varicocele repair without any other assistance.

It has been established the varicocele can cause sperm DNA fragmentation (damage) and increase free radical formation and thereby cause infertility. Werthman et al (see article) proved that varicocele repair lowered the level of sperm DNA fragmentation to normal levels in 90% of patients.

There are 5 different methods to repair a varicocele. Four are surgical in nature and the fifth is performed via radiological embolization. The gold standard surgical technique is called microsurgical inguinal varicocele repair. This approach has the greatest success in repairing the varicocele, preventing recurrence and has the lowest complication rate (see table below).

Techniques of Varicocele Repair

Click to view movie - Varicocele Repair

Depending on the individual circumstances and the severity of the sperm abnormalities, multiple approaches to this problem can be taken. Surgical correction, intrauterine insemination and Clomid therapy can be used simultaneously to achieve a pregnancy. A recent study published in the Journal of Urology in May 2001 showed that varicocele repair improves intrauterine insemination success rates by almost double in men who have varicoceles. The most severe cases of male infertility may require in-vitro fertilization. The varicocele remains the most treatable cause of poor semen parameters and male infertility.