Hello Again!
This is a subject that I have been avoiding for years. I am not a urologist, but in 40% of the couples I treat, male factor fertility is at least part of the problem.

While I have my opinion, established through 18 years in the business, this morning I went through much of the research on varicocele repair and reconfirmed that this topic is as controversial as it gets. Most urologists say varicocele repair is a must-do, and others say it’s a procedure that will not help.

A varicocele is a dilated vein, or a whole collection of dilated veins in the testicle. No different than varicose veins in a leg. The problem? The theoretical problems are:
1) The temperature of the testicle needs to be lower than normal body temperature to function properly, and some say the big veins keep the temperature too high.
2) Veins take blood away from organs. Some feel that if the veins are enlarged and congested, they cannot properly take the blood away from the testicle, and this leads to a buildup of waste products and toxins that impair proper sperm development.

Just a few thoughts of my own:

In my experience, I have not had men improve their sperm counts after varicocele repair. To be fair, I do not have a log tracking the counts of these men. In addition, maybe some of them become fertile and leave my practice pregnant without telling me. I don’t know about this one. My patients are very good about communicating with me, and while I should at have heard of at least a few of such cases, I have heard of only one. I see tons of men who show me their sperm reports pre and post varicocele repair with no change in the counts, motility or morphology.

So what do care if mister has a varicocele repair? Well, why have a procedure that may not be necessary? A bigger issue for me is the waiting. Urologists who perform the surgery tell you you need to wait 6-12 months to see a change in the count, sometimes even longer. Hello? Are any of these wives approaching 40? Waiting 6-12 months can do in whatever chances you currently have with iui or IVF, even if the sperm gets better.

I also see some men who know that the procedure may not do much, but volunteer for the knife in order to show support and help contribute to a problem that effects the partnership as a whole. This is to be commended, but not always necessary. Surgery is not to be taken lightly, as there is a complication rate associated with any surgical procedure. And if the count is less than 5 million to start, I recommend freezing sperm. There are cases of sperm counts becoming lower, even going to zero, after the surgery.

What if the doctor does not feel a varicocele, but sees a small one on ultrasound? This to me is really pushing it. If he can’t see it, something only visible via ultrasound can’t be making much of a difference.

Another question is, what constitutes an improvement in sperm quality? Is a count that goes from 2 million to 4 million a success?

A good rule of thumb in medicine is that if something is controversial, it means it does not help most people.

Now there are urologists out there who swear but the varicocele, and say it’s not controversial. They should at least present to you the counter argument so you can make an informed decision.

Hearing an opinion form a gyn/infertility specialist is not as powerful as hearing an opinion from a urologist. Therefore I can summarize the philosophy of a famous urologist who used to work with me. He had 2 main points. One, evidence for improved fertility after varicocele repair is lacking. A little study here and there showing improvement does not make up for the larger studies showing no benefit. Two, men’s sperm counts change without varicocele repair. This is especially true with very low counts because just playing the law of averages; a low count may be higher when tested in 6-12 months later, even without surgery.

Thanks again and please read disclaimer 5/17/06.

Dr. Licciardi

References:

  • Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short R, Benoff S, Thomas A. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril 2007; 88:639-48.
  • Kim H, Goldstein M. Adult Varicocele. Curr Opin Urol 2008; 18:608-12.
  • Smit M, Romijn JC, Wildhagen MF, Veldhoven JLM, Webert RFA, Dohle GR. Decreased sperm DNA fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. Journal Urol 2010; 183:270-4.
  • Inci K, Hascicek M, Kara O, Dikmen AV, Gurgan T, Ergen A. Sperm retrieval and intracytoplasmic sperm injection in men with nonobstructive azoospermia, and treated and untreated varicocele. Journal Urol 2009; 182:1500-5.