play button Created with Sketch.
 
Deep Dive

Varicocele

For something that effects nearly 15% of all men, you’d expect to hear more about varicocele. Varicocele is an enlargelement of the veins in the scrotum as a result of a breakdown in the blood drainage system of the testicles. In extreme cases of varicocele, the testes stop producing sperm efficiently. Varicocele appears to have a strong hereditary link, as men who have a first-degree relative with a varicocele have an 8-fold higher likelihood of developing one themselves.

Progressive and Increases with Age


Roughly 10 – 15% of men develop varicocele around the time puberty hits, and the incidence climbs approximately 10% with each passing year. Varicocele develops with age for the same reason varicose veins do: the valves in veins degrade with age and cause blood to pool and back-up. That said, many varicoceles are small, undetectable by the patient, and have no meaningful medical implication.

Role in Male Factor Infertility


The ways in which varicocele interferes with sperm production are not completely understood, but they include heat and pressure damage to the testicles, along with a drop in testosterone production. Roughly 25% of men who have an abnormal semen analysis have a varicocele, and approximately 25 – 35% of men who suffer from primary male factor infertility have a varicocele. Yet when we look at men who suffer from secondary male factor infertility (meaning they have fathered at least one child and subsequently are diagnosed with infertility), nearly 80% have a varicocele.

Diagnosing Varicocele


Our methods for diagnosing varicocele are pretty rudimentary. If a doctor can feel the varicocele when pressing on the skin, the varicocele is considered “clinical” and the patient is referred for treatment. For men who are obese, or have a small scrotum, a large varicocele is not detectable by touch, so an ultrasound is used. Around 85% of varicoceles reside on the left side of the body.

Candidates for Surgical Repair of Varicocele


Generally speaking, repairing varicocele is useful in addressing male factor infertility when a few conditions are met: first, the varicocele is large enough to be felt on examination. Removing a small, relatively insignificant varicocele is unlikely to improve semen parameters. Second, the couple has been trying to actively conceive with no success for a number of months. Third, the semen analysis results are out-of-range. Fourth, the female partner has no major impediments to conceiving naturally (namely, a blocked tube or diminished ovarian reserve). If you’re being treated by a urologist and you meet these criteria, there is a good chance he or she will want to intervene.

Varicocele Surgical Outcomes


There are surprisingly few prospective, randomized studies comparing pregnancy rates between groups of varicocele patients who underwent surgery to correct varicocele and those who didn’t. There are two studies the field of urology most respects on the subject, and while both showed the surgically-treated group recorded a dramatic improvement in semen parameters, only one showed a statistically significant improvement in actual pregnancy rates after one year.

There is some debate about what the right end-point is here. On one hand, the ultimate goal is to take home a baby, and so pregnancy rates are relevant and live birth rates are what should matter. On the other hand, pregnancy is also a function of the female partner’s level of fertility, which varicocele clearly cannot address. Within these studies, the female partners’ ages (a proxy for fertility) did not meaningfully differ, so that would not likely explain why these two studies demonstrated dramatically different results.

Nature of Varicocele Intervention


There are two types of varicocele interventions, and both involve closing the veins that have difficulty draining. Subinguinal varicocelectomy is a surgery performed by a urologist that takes approximately 15 – 30 minutes and involves tying off the vein below the varicocele.

Embolization is a less invasive procedure, performed by an interventional radiologist, that involves placing an artificial blockage in the vein. Both procedures have relatively short recovery times and modest rates of adverse events. Typically, both interventions are covered by insurance.

Varicocele Surgery or IUI


One alternative to surgery is to use the male’s sperm for artificial insemination. While there is not much literature comparing surgery to artificial insemination, one small study performed nearly 15 years ago showed that for men with a varicocele and an abnormal semen analysis, those surgically treated for varicocele before their partner was artificially inseminated had higher live birth rates than when the man was not surgically treated and the partner underwent artificial insemination.

Varicocele Surgery or IVF (with ICSI)


Generally speaking, employing IVF (with ICSI) has come to be seen as a powerful tool to treat any couple trying to conceive with male factor infertility. There is currently disagreement between urologists and reproductive endocrinologists as to whether varicocele should be treated surgically first (or at all), or if the couple should advance directly to IVF (with ICSI).

If the female partner has an unmistakable fertility challenge, most would agree proceeding to IVF (with ICSI) is a logical choice. It’s less clear what a couple should do when the issue solely resides with the male who has a sizeable varicocele.

At the moment, there are no good studies comparing surgical intervention versus IVF (with ICSI), when the man suffers from varicocele and his male factor infertility is the only diagnosed issue. Below, we compare the pregnancy rates recorded in previous varicocele surgery studies with live birth rates for men with diagnosed male factor infertility (though not necessarily varicocele) when treated with IVF (with ICSI).

Risks and Costs


Both procedures carry risks typically recorded in the low-single digits. IVF risks reside most specifically around hyperstimulation of the female partner, and there has been some mild concern about the potential health implications for offspring conceived using ICSI.

While varicocele repair is typically covered by most forms of insurance, IVF is usually not and costs run in the range of $23,050 per cycle, depending upon where you live, and whether you pay for PGS to help your doctor select which embryo to transfer.

Surgery + IVF (with ICSI) or IVF (with ICSI) Alone


There are three studies that compare varicocele surgery plus IVF (with ICSI) versus IVF (with ICSI) alone in men with varicocele and who have a modest amount of sperm (oligospermia). In two of the three studies, the groups that underwent surgery plus IVF (with ICSI) recorded higher live birth rates than the groups that undewent IVF (with ICSI) alone. In November, 2016 a meta-analysis (a pooling of data from multiple studies) was conducted on all three studies and live birth rates were higher still for the surgery plus IVF (with ICSI) group.

These same investigators then looked at studies of men who had varicocele and azoospermia. Two studies exist that compare varicocele surgery plus IVF (with ICSI) versus IVF (with ICSI) alone. Neither study showed a difference in outcomes between the two groups but when the data was pooled in the meta-analysis, the results were close to statistical significance in favor of the varicocele surgery plus IVF (with ICSI) arm. In both of these studies the men treated underwent TESE and in the pooled results, rates of sperm retrievel were higher in the men who had varicocele surgery before the TESE and IVF (with ICSI) treatment.