What are varicoceles and why do they matter in infertility

What is a Varicoceles?

A Varicocele is a fairly common condition in which veins inside the scrotum are dilated (wider than usual). Veins are blood vessels that carry blood back towards the heart and have tiny valves in them, to stop the blood going the wrong way. If the valves in the veins don’t work properly then blood will pool in them and the veins will swell up a bit (become dilated). The testicle has a number of veins that drain it and they are located in a structure called the spermatic cord.

Male reproductive Anatomy

Varicoceles occur in 15% of men in the general population and 40% of infertile men. Most of the time, varicoceles are found on the left side, but sometimes they occur on the right side or on both sides. If you are diagnosed with one, you may hear your urologist assign a grade:

  • Grade 3: If it can be seen by the doctor looking at it
  • Grade 2: If it can be felt but not seen
  • Grade 1: If it can only be detected when the man is asked to strain or tense up his abdominal muscles

The patient may notice that they have a varicocele when they check their testicles and sometimes varicoceles may cause a dull pain in the scrotum. However, usually they are painless, and it is important to bear in mind that if the testicles are sore this may not be due to a varicocele, even if one if present. If testicles are painful it is important that the man be seen and assessed by a doctor or referred to a urologist.

Varicocele and Semen Quality

Because of the extra blood in the veins, varicoceles can increase the temperature in the scrotum. This can be a problem for making sperm which are more efficiently produced in slightly cooler temperatures (which is why testes hang away from the warm body), and may lead to lower sperm counts, worse sperm movement (motility) and worse sperm appearances (morphology). More recently, studies suggest that varicoceles may lead to the production of molecules called reactive oxygen species that can damage sperms. This could make sperm less effective at fertilizing eggs and may also increase the chance of the man’s partner suffering a miscarriage, but work is still on-going in this area to better understand the way in which this happens.

Is there treatment?

Varicoceles are not dangerous for a man’s health, and if painless, only need to be treated if the semen analysis is poor and the man is finding it difficult to get their partner pregnant. There are two types of procedures that can be used to treat varicoceles: Embolisation of the testicular veins and surgical repair.

  • Embolisation: This involves passing tiny coils or foam into the testicular veins using a wire. The wire is removed at the end of the procedure and the coils or sponges then block the veins, causing the varicocele to shrivel up. This is a same day procedure done with local anesthetic, (you are awake when it is carried out) and has a high success rate with few serious complications. Most embolization procedures are done in a radiology (X-ray) department. Sometimes though for technical reasons, it may not be possible for it to be carried out and it is not perhaps as widely available around the world as surgery.
  • Surgical Repair: Different approaches can be used for treating varicoceles surgically. These include keyhole surgery (laparoscopy) or an open repair under magnification, preferably using an operating microscope to clearly see the tiny and delicate structures in the spermatic cord. Surgical approaches are done under general anesthetic (i.e. you are asleep when it is carried out) and involve identifying and dividing the testicular veins, whilst preserving the other important structures in the spermatic cord, such as the vas deferens and the testicular artery. The keyhole surgery approach is done by placing a camera into your tummy, whilst the microsurgical approach is carried out through a small cut in the groin. Surgical methods of treatment have a higher chance of getting rid of the varicocele than embolization, but the side effects can include damage to the testicular artery, which can cause shrinkage or loss of the testicle (this is very rare) or for fluid to accumulate around the testis (this is called a hydrocele). Long-term pain is a potential complication of any procedure on the scrotum and your urologist will be able to advise you on what treatment approach (if needed) they recommend that you have.

Subclinical Varicoceles

Sometimes, varicoceles are not able to be felt during an examination by the urologist but can be seen on an ultrasound scan. In this case, they do not need any treatment since they likely do not affect a man’s fertility. However, treating varicoceles that can be found by Urologists in men with infertility, may help to improve the quality of sperm in a man’s semen.

Post-treatment success for pregnancy

Following treatment, a repeat semen analysis will be done after about three months to see if the sperm quality has improved (because it takes about 3 months for the body to make new sperm). Some, but not all research suggests that treating varicoceles can help to improve pregnancy rates as well as improve the quality and quantity of sperm.

If you would like more information, please see you your family practitioner or general practitioner.