Varicocele Repair - Varicocle Treatment for Male Infertility

A varicocele is a scrotal abnormality defined by elongated, dilated and tortuous veins that drain the testicle (Figure 1). Varicoceles are common, observed in 15% of the general male population, and are presumably an evolutionary consequence of men's upright posture. Most varicoceles (>80%) occur on the left side and the remainder on both sides. They are generally acquired during puberty. Several theories have been proposed to explain their occurrence, including poorly functioning valves and increased resistance to blood flow where the varicocele veins drain, creating a "dam-like" effect and increasing venous pressure. They do not cause cancer and are not life threatening, but are simply an anatomic consequence of being human.

FIGURE 1. VARICOCELE (V) IS THE BLUE SET OF VEINS THAT DRAIN BLOOD FROM THE TESTIS TO THE BODY.

Most varicoceles are asymptomatic. However, they can be uncomfortable and cause scrotal pain. This pain is generally mild to moderate, occurs with long periods of sitting, standing or activity and is relieved by lying down. Although it can be uncomfortable before bedtime (after a long day of activity), it generally does not occur upon awakening after a night's rest. The pain is dull, congestive ‚"tooth ache" like and generally doesn't refer elsewhere. It is not associated with urination issues or erectile dysfunction; however, it is associated with male infertility. Lastly, when large, a varicocele can cause a clumpy "bag of worms" feel in the scrotum and can be bothersome for this reason as well.

Approximately 35% of men in Dr. Turek's practice who are evaluated for infertility will have a varicocele, a much higher rate than that found in the general population (15%). Over the last 50 years, this had led to the intensive study of the relationship between varicoceles and male infertility. The mechanism by which a varicocele on one side can affect the fertility of both testicles is not clearly understood. What is true is that the temperature of the scrotum is normally several degrees cooler than body temperature, which is important for normal sperm production and testis function. This temperature difference is carefully maintained by the normal anatomy of the scrotum. The dilated veins in a varicocele may decrease the effectiveness of this natural cooling mechanism and "overheat" the testis and reduce its ability to function. Exactly how heat affects sperm production is currently the subject of much study. However, a leading theory suggests that increased oxidative stress reduces the fertility of varicocele patients. In addition, there is recent data that shows that sperm DNA fragmentation rates, a measure of sperm quality, can be elevated in men with varicoceles and that varicocele repair can significantly lower these rates. In any case, the semen analysis in varicocele patients can show impaired sperm numbers, movement or both.

The "gold standard" way to diagnose varicoceles is by physical examination. With a patient in a standing position, palpation of the scrotum by a well-trained physician can reveal a varicocele. Exercise and prolonged standing may also demonstrate a varicocele. Difficulties palpating a varicocele arise when the scrotal wall is thick or contracted. In addition, benign fat, termed lipoma of the cord, can feel like a variocele. Unlike a varicocele, however, a lipoma will not go away when the patient lies down.

Varicoceles have been arbitrarily divided into 3 grades based upon physical examination findings (Table 1). Subclinical varicoceles are lesions not detected by routine examination suggested by radiologic or other imaging methods. These lesions are smaller than "clinical" varicoceles and, in Dr. Turek's view, the value of varicocele repair of these lesions is unknown. Grades I-III are considered "clinical" varicoceles, as they are found on physical examination alone. It is these lesions that are repaired for issues of discomfort or infertility.

The diagnosis of varicocele can also be made with venography, ultrasound, thermography, scintigraphy and CAT scan or magnetic resonance imaging. Venography is considered to be the best diagnostic test, but it is invasive, involving catheterization of large leg veins to access this system. Conveniently, venography can be combined with embolization using balloons or coils to treat varicoceles at the same time. Doppler ultrasound is less invasive than, and correlates well with, venography and relies on the detection of venous flow within the varicocele. This is the test that Dr. Turek prefers to have patients do if there is a question about whether or not a patient has varicoceles. Thermography, scintography and MRI or CAT scans are of limited clinical use for varicocele mostly because of increased cost, and lack of controlled studies surrounding their use.

The reasons to fix a varicocele include:

"WHEN I THINK HOW I TREAT VARICOCELES, I ALWAYS TRY TO REMEMBER THAT WE ARE TAKING A PERFECTLY HEALTHY MAN AND TRYING TO MAKE HIM EVEN HEALTHIER. THIS MEANS THAT THE COMPLICATION RATES HAVE TO BE REALLY LOW FOR IT TO BE WORTH IT." - DR. PAUL TUREK

The goal of varicocele treatment is to stop the backward flow of blood from the body to the scrotum, and therefore to "cool off" the testicles. To achieve this, veins leading from the testis to the body are tied off or interrupted as completely as possible. A single vein is left open (vasal vein) that is not subject to the same issues as the varicose veins and allows the blood to leave the testicle after surgery. There are several ways to treat varicoceles. Surgical or incisional methods are performed in the upper scrotum (subinguinal), groin area (inguinal) or lower abdomen (retroperitoneal). The procedure can also be performed with "telescope" surgery (laparoscopy) and also by an intereventional radiologist through a procedure called venography and embolization (Table 2).

In general, all approaches give similar results; their differences stem mainly from other issues. For example, the incisional approach has the lowest recurrence rate, because it is performed in the groin or scrotum, where all of the venous "action" is taking place. With the radiologic approach, there is a significant "technical" failure rate as it is sometimes difficult to manipulate catheters through the necessary veins to reach and interrupt the veins of interest. This is especially true for varicoceles on both sides. With laparoscopy, again the varicocele recurrence rate after the procedure is high, because all of the venous "action" occurs in the scrotum and laparoscopy is performed in the abdomen.

Complication rates must also be considered in any decision to have varicoceles treated. The overall complication rates range from 1% for the incisional approach to 4% for laparoscopy and 10% for radiologic methods (including technical failures) (see Table 3). The most significant complication with radiologic occlusion is the chance that the culprit veins cannot be accessed or interrupted (technical failure rate). Although the list of potential complications is long, remember that the chance of having a complication is really quite low.

How is Dr. Turek's varicocele procedure different from, or better than, another doctor's?

Dr. Turek is a fellowship-trained, internationally known, master microsurgeon and performs 100-150 varicocelectomies annually. He has operated on sultans and sailors, prime ministers and principals. He helped popularize the subinguinal microsurgical approach to varicocele repair in the 1990's and has trained over 50 urology residents, fellows, practicing urologists in this method since then. In addition, many varicocele patients he sees have failed the procedure elsewhere. Because of this experience, his complication rates are extremely low.

Dr. Turek's approach to varicocele treatment was chosen based on the need for any such procedure to meet the following criteria:

With these criteria, Dr. Turek began performing the microscopic subinguinal varicocelectomy, a form of incisional treatment for varicoceles that is performed in an hour or so on a come-and-go basis. Performed with a light general anesthetic along with local anesthesia, this procedure allows visual access to all possible routes of venous return to the testis and accomplishes this task through a small, minimally painful, upper scrotal incision. It avoids the need to open any muscular layers of the abdominal wall (commonly needed for the other incisional approaches) and dramatically shortens recovery time.

The procedure begins with a 2-3 cm skin incision near the junction of the groin and upper scrotum. The spermatic cord is exposed and inspected on either side for external cremasteric veins. If present, these veins are tied off with silk suture. The area around the testis is then inspected for the presence of any exiting veins and these are tied. The operating microscope is brought into the field and the investing layers of the spermatic cord opened.

Microsurgical dissection of the cord is then performed: the artery is visually identified by its pulsations (with the help of a small doppler ultrasound if necessary) and all surrounding veins are tied. Lymphatic vessels are noted and spared to prevent hydrocele formation. At the end, only the vasal veins remain intact to provide venous return from the testis.

The spermatic cord is then returned to its bed and the incision closed in two layers. Steri-strips and a bandage are placed. The patient receives pain pills and is advised to return to work as soon as 3 days after the procedure. It is best to return to work without the need to take narcotic pain pills, as they may cloud judgment. The patient is seen in the office 1-2 weeks later for a quick checkup and then formally assessed for pain or infertility at 3-4 months after the procedure.

Although scrotal pain can be complex, in well-selected patients who undergo varicocele repair for pain, approximately 80% will have complete resolution of the pain in Dr. Turek's hands. Fertility outcomes for varicocele treatment are even more complex, since fertility depends not only on the male partner but also the female partner. However, with Dr. Turek's procedure, pregnancy rates after varicocele treatment are generally double that (30-35% at 18 months) found if the varicocele were not treated (15%) at all. Approximately 65-70% of men will have a doubling of the total moving sperm count in the ejaculate (total motile count = sperm concentration x fraction moving x ejaculate volume) after their surgery. In addition, the average time to conceive after Dr. Turek's procedure is 7-8 months; indeed, among couples who will conceive after the procedure, 90% of couples will have done so within 1 year.

Compared to assisted reproduction, how good is
varicocele treatment for male infertility?

Dr. Turek has studied this issue at length and has written and published extensively on this topic. Since randomized, controlled trials have not been done yet to evaluate this issue, several other approaches have been taken to address this issue of how "good" varicocele treatment is compared to assisted reproduction. Research into the cost-benefit analysis of varicocele treatment and assisted reproduction (IVF-ICSI) as first-line treatment for varicocele related male infertility has found that the cost per delivery of a baby using IVF-ICSI is 3-4 times higher than that observed after varicocelectomy ($89, 091 vs. $26,268). In cost-benefit studies that compare varicocele treatment to no treatment, IUI and IVF, the cost per live birth is lowest without any treatment ($13,863), next lowest with varicocelectomy followed by IVF if varicocele repair does not result in a pregnancy ($44,562), even higher for IUI-IVF and no varicocele repair ($49,757), and highest for IVF treatment alone ($64,422). Interestingly, since varicocelectomy can "cure" the male infertility problem, but assisted reproduction does not, this study also analyzed the marginal cost for a second live delivery after an initial one. Remarkably, the cost of a second live delivery in the varicocelectomy-first group was equivalent to that for a first delivery ($52,152) but the cost in IUI-IVF group was $561,423. So, cost-benefit studies convincingly demonstrate the value of varicocelectomy instead of assisted reproduction.

Dr. Turek has confirmed the value of varicocele as suggested by cost-benefit studies by using more sophisticated decision analysis modeling. Decision models are constructed with predefined assumptions and serve as useful tools for estimating outcomes when multiple complex medical treatments are available. For his varicocele study, he assigned outcome probabilities based on his outcomes and published outcomes, and costs of interventions were calculated from his own cost data. Sensitivity analyses were applied to determine which elements were most important for varicocele treatment. Then, theoretical subjects were put into different levels of assisted reproduction (IUI vs. IVF-ICSI) based on their semen quality. Varicocelectomy was assigned an overall pregnancy rate of 36.6% and this value was varied with presenting semen quality. Overall, varicocele surgery was found to be more cost effective than IVF. Interestingly, there were some instances in which IUI was more cost-effective than varicocelectomy, depending on the presenting semen quality of the patient. Thus, the clinical characteristics that define the individual couple weigh heavily on whether assisted reproduction or varicocelectomy should be done.

Taking a different analytical approach, Dr. Turek has also examined the value of varicocelectomy from a "shift of care" perspective. The cost of IVF-ICSI is approximately $10,000-$12,000/attempted cycle; however, the cost of IUI is much less expensive at approximately $500-$1200/attempted cycle. What Dr. Turek demonstrated in his study was that roughly 50% of couples that would only be candidates for IVF or IVF-ICSI due to the effects of a varicocele or low semen quality could be "rescued" from the need to undergo assisted reproduction and actually conceive naturally (or with only IUI) after varicocelectomy. In essence, it appears to make good economic sense to repair varicoceles if ART costs are prohibitively expensive for couples.

What should I think about before and after the procedure,
in terms of planning and recovery?

The following is an outline of what to expect and do before and after the procedure:

This visit is important for you to meet and feel comfortable with Dr. Turek, to figure out whether you are a good candidate for a varicocele repair, and to assess if the procedure is right for you. At this visit:

Please call Dr. Turek's nurse Paula at 415-392-3200 to schedule an appointment to see Dr. Turek in 1-2 weeks for a quick postoperative check if you are in town.

Regarding diet, start with clear liquids or something light and then progress to your normal diet.

Shower daily. In 48 hours, remove the outer, clear dressing and gauze just prior to showering. Steri-strips will remain and will curl up and fall off in 7-10 days.

Take your prescribed pain medicine, usually Vicodin, for moderate discomfort. Always take the Vicodin with food in your stomach, so that you do not get nauseated. You can take Tylenol or Ibuprofen for mild discomfort.

If you have any further questions please call the surgery center at 415-393-9600 or Paula at 415-392-3200. For evening/weekends please call 415-392-3200.