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Controversial Fertility Topics

Varicocele Surgery - Do I Need It?

Variocele

Approximately 40-50% of the time the difficulty with conceiving is due to a male factor and a varicocele has been implicated as one of those causes. A varicocele is an abnormal tortuosity and dilation of veins of the pampiniform plexus of the spermatic cord in the scrotum, and is commonly called "varicose veins of the testicle". The most common theory of how a varicocele can affect sperm quality is by raising the temperature in the testicle from the increased blood flow. Normally, temperature in the scrotum is 2 degrees centigrade (celsius) less than the rest of the body. Increased temperature in the scrotum is the most popular theory as to the cause of decreased sperm parameters, although, there are others. Sperm motility and sperm numbers are commonly affected, and less so, morphology.

Varicoceles are common and are found in 10% of normal men. They are more common in the left testicle but can involve both sides. With one out of every six couples having difficulty with conceiving and 50% of those due to the male, it is sometimes difficult to decide, especially if the male has a varicocele, is it the cause of the male infertility or just coincidence?

Variocele Diagnosis and Surgical Treatment

The diagnosis is often made by a urology specialist on a routine examination or if the male has decreased sperm parameters and is sent to the urologist for evaluation. Urologists often diagnose and commonly recommend surgical repair of the varicocele in men with abnormal SA. The problem is, surgically correcting a varicocele, known as a varicocelectomy, often does not improve the semen quality enough to change the therapy that will be required to result in pregnancy for the couple. A number of scientific studies have shown that varicocele surgery may improve sperm parameters (counts or motility), but randomized and controlled trials do not consistently show improved pregnancy rates. Therefore, because of these studies and Arizona Center for Fertility Studies experience in tracking pregnancy rates in infertile males who have had varicocele surgery, and have seen no statistical improvement in pregnancy rates, has not recommended varicocele surgery for the past 15+ years.

Statistically, in these couples, where there is a male factor as the cause of the infertility, the couple will need IUI or In-Vitro Fertilization (IVF) anyway, so Arizona Center for Fertility Studies asks, "why waste time and money on surgery for a varicocele"? To be fair, there is no way of knowing if the surgery "could" improve the sperm parameters enough to result in a pregnancy. Arizona Center for Fertility Studies believes that the couple needs to be given the pros and cons, as well as the unbiased results in the literature of varicocele surgery vs. no varicocele surgery, before they make their decision.

For couples that cannot or do not want to do infertility treatments when a male factor is found to be the reason for their difficulty with conception, there are some criteria to consider before making the decision to have varicocele surgery. If the count is under about 5 -10 million per cc, or the sperm motility is 30% or less, it is unlikely that the semen quality will improve enough after a varicocele repair to result in pregnancy without IUI or In-Vitro Fertilization (IVF). Men with sperm parameters that are just slightly low (15-20 million and motility at 50%) and the female work-up is normal, may be more reasonable candidates for varicocele surgery. However, most couples with sperm parameters in this range will probably conceive on their own without surgery. There are as many studies in the literature showing varicocele surgery makes no difference in pregnancy outcome as there are that shows it does. In younger couples, or where the surgery may be covered by insurance and the infertility treatments are not, the male may decide to have the surgery and "see what happens". Generally done under general anesthesia, the procedure is relatively easy, quick and associated with few complications. If the couple is not successful in 6-9 months then either IUI or In-Vitro Fertilization (IVF) can be discussed.

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