Playing Poker with Varicoceles

He was a sweet sixteen when he came to see me with his parents, both doctors. Before he said a single word, his Father blurted out: “Our son has a clinical varicocele and we’ve <a href="
I asked a few questions and examined him. Yup, definitely a big ol’ grade III lesion, left side only, straight outta the textbook. But it wasn’t hurting him and the testicle on that side was pretty much the same size as its mate. So neither of the currently accepted indications for treatment, including pain and a smaller testicle on the side of the varicocele, was met. Hence, the parental confusion about what to do with this bag of veins.

The Softer Side

Similar to playing poker, it’s really a “crystal ball” decision to fix varicoceles in asymptomatic teens. Trying to peer into the future could help to avoid the woulda-coulda-shoulda’s when it comes to your kid’s health. What happens in adulthood if he doesn’t have it repaired? What is the most likely consequence of leaving it alone? What are the real risks of varicocele treatment? Most of the office visit was a frank discussion of the facts surrounding clinical varicoceles:

  • They are a disorder unique to humans (we stood up way back when) and begin at puberty. They don’t change much throughout adulthood.
  • 15% of teens will get them, almost always on the left side.
  • Most men with varicoceles have no pain or other symptoms
  • Most men with varicoceles have normal fertility. Among my fertile patients having vasectomies for contraception, 15% have varicoceles. Didn’t stop them!
  • When they are painful, varicocele repair eliminates the pain in 90% of cases.
  • Varicoceles are the most common correctable cause of male infertility: 40% of men unable to have their first child will have one.
  • Varicocele repair definitely improves semen quality and can often improve fertility, both naturally and with IVF.
  • Fixing varicoceles in adult men can improve testosterone levels. Nothing is known about how it affects testosterone levels in teens.
  • Surgery for varicoceles is day surgery that is best done microscopically and takes about an hour. Normal activity can be resumed in 3-4 days.
  • The complication rate for subinguinal varicocele repair is <1% in experienced hands (bleeding, infection).

Royal Flush

I laid these issues out to the family to help them make a decision. The son was easy-peasy either way, as befits his age. The parents’ biggest concern was whether varicocele repair would protect their son’s future fertility. I told them that the definitive study, in which teens with varicoceles are followed serially into adulthood with periodic semen analysis checks to see if declines are imminent, has simply not been done. It’s a Holy Grail study.
But I did have some red hot new evidence for them on the issue of future fertility among teens with varicoceles. A former fellow of mine from Turkey just published a provocative study on adolescent varicoceles. Among 408 teens 12 to 19 years old with clinical varicoceles, they examined downstream paternity rates and time to conception years later among those with repaired varicoceles and those whose varicoceles were left untreated as teens. Not only were future paternity rates significantly higher among men with repaired varicoceles (77%) compared to men with untreated varicoceles (48%), but the time to conception was also faster (6.9 months vs. 11.2 months) in the treated group. Fact is, you can talk all you want about sperm counts, movement and shape with varicoceles, but nothing beats paternity as a measure of success. It is the royal flush of outcomes.
The room was quiet for a moment after I finished summarizing this study. The parents then took a quick look at each other, and then at their son, and then toward me, and said, “When’s your next available surgery date?”