Friday, June 30, 2006

Who does varicocele surgery help?

As an IVF specialist, I see a lot of couples who have male factor infertility because of a low sperm count. The technical name for this conditon is a tongue-twister, and is labelled oligoasthenospermia - quite a mouthful for the infertile man to have to swallow. Once he recovers from the blow that he is "shooting blanks", the next question every man wants to know is how to improve his sperm count. Lots will try home remedies such as a high-protein diet; or wearing boxer shorts to cool off their testes, but none of these work. They then attempt medical therapy or alternative medicine, both of which have a dismal track record. They then end up being referred to their friendly urologist, who usually diagnoses that they have a varicoele.

A varicocele is a swollen varicose vein in the scrotum - usually on the left side . The condition occurs because blood pools in the varicose testicular veins (pampiniform plexus) since the valves in the veins are leaky and do not close properly. The reason for infertility associated with a varicocele are unclear. Perhaps the accumulation of blood causes the testes to be hotter and so damage sperm production; or the pooled blood brims over with abnormal hormones which may change the way the testes make sperm. The effect of the varicocele on an individual's sperm count is variable - and this may range from no effect whatsoever, to causing a decreased sperm count. Varicoceles may also have a progressively damaging effect on sperm production, so that the sperm count may decline with time.

How is a varicocele diagnosed? The doctor examines the patient in the erect position and feels the spermatic cord - the cord like structure from which the testis hangs. The patient is also asked to cough at this time. A varicocele feels like a "bunch of worms" and on coughing, this gets transiently engorged. Confirmation of this diagnosis is best done by a Doppler test at the same time. The Doppler is a small pen like probe which is applied to the cord. It bounces sound waves off the blood vessels and measures blood flow by magnifying the sound of blood flowing through the veins. This can be recorded. Patients with a varicocele have a reflux of blood during coughing which shows up as a large spike on the tracing. Other tests which are done to confirm the diagnosis of a varicocele include a Doppler ultrasound, which confirms the "diagnosis" in colour !

Most doctors are still not sure whether a varicocele causes a low sperm count or not ! It is possible that the varicocele may be an unrelated finding in infertile men - a "red herring" so to speak. Strangely enough, only a quarter of men with varicoceles have a fertility problem. Thus, many men with large varicoceles have excellent sperm counts which is why correlating cause (varicocele) and effect (low sperm count) is difficult.

This means that surgical correction of the varicocele may be of no use in improving the sperm count - after all, if the varicocele is not the cause of the problem, then how will treating it help? In fact, controlled trials comparing varicocele surgery with no therapy in men who have varicoceles and a low sperm count have shown that the pregnancy rate is the same – so that it does not seem to make a difference whether or not the varicocele is treated or not!

Because surgery for varicocele repair is simple and straightforward , many doctors still repair any varicoceles they find in infertile men, following the dictum that it’s better to do something, rather than do nothing ! However, keep in mind that varicocele surgery will result in an improvement in sperm count and motility in only about 30% of patients - and it is still not possible for the doctor to predict which patient will be helped. Of course, just improving the sperm count is not enough - and pregnancy rates after varicocele repair alone are in the range of 15%. However, one danger of doing a varicocele repair is that when it doesn’t help, patients get frustrated, and refuse to pursue more effective options, such as the assisted reproductive techniques.

The only group of men varicocele surgery consistently seems to help are the surgeons who perform it !


  1. Anonymous6:01 AM

    This is a very interesting article. I have been diagnosed with Varacoce veins in the left testis now for app. 10 years. I am now 32 years old. Initially, they were very small and did not cause me any trouble. Five years on, they became very painful and much larger. My doctor reluctantly did the surgery because of my complaint of the pain. One year after I did a follow up ultrasound and no varicose veins were observed. 5 years on, the vins have re-occured and are again very painful(burning, tingling pain). My doctor has prescibed anti-biotics and pain killers but so far it does not seem to have helped. At times there is little or no pain and at other times, it is very chronic.

    Do you have any suggestions as to what maybe helpful for me ( I have changed numerous briefs trying to find the one that is more comfortable and supportive).

    Any particular diet, exercise, medication, anything that may be suggested.

  2. Anonymous8:51 PM

    Guys i had finally undergone Micro surgery for the treatment to varicocele on this February 2009.I had a very Horrible Experience throughout out pre and post operation.
    This is the first surgery that i had undergone in my life. I got treated in Bangalore in Sagar apollo hospital. The hospital is good and they take individual care. I had bilateral varicocele(varicocele on both sides) and it costs around 20000 Indian rupees to get operated. This is how the whole process take place: A day before the surgery i have given samples of blood ,urine , semen and ECG and Doppler tests. I had spent around 2000 bugs for all the tests and samples.

    The next day i went to hospital , collected all the test results and paid some amount for the surgery and got admitted in the hospital. Before operation all the hair on my body was removed and one injection needle was pierced into one my vein on my left hand and wore operation suit(a very long and loose fork kind ) and they covered my head with a green light mess cap so that hair wont interrupt during the operation. I was taken to the operation theater on a stretcher. Then an anesthesiologist came and introduced herself to me and gave an anesthesia on my back bone right above the butt. With in 10 min i lost sensation of all the part that is below my waist. Then urologist has started doing his part. I did not feel any pain when they made incision , but i could feel nurse pressing cotton near the incision area i.e when the nurse is absorbing the overflowing blood with a cotton (when she presses the cotton bud to collect the blood around the incision zone). I felt so scared all the time during operation, shivering and thinking of the operation images of varicocele that I have seen earlier. As anesthesia was given u cant move after the operation, so nurses will help u shift u to another stricture and direct u to ward. The only problem what i faced that night is i could not pee(pour toilet) as there is no sensation because of anesthesia .U cant open the tap to let out the urine. so i suggest u not take more water after the surgery. Gradually as the body looses the anesthesia i slowly started peeing. There should at least one person after the operation for a day to escort you. I got discharged from hospital after 3 days. I could feel the pain for at least 10 days, its terrible you can not sit freely, cant stand straight and should sleep in only 2 to 3 positions.

    I guess this information will be helpful. Good Luck

  3. Nagaraj8:22 AM

    Dr. Thanks for the article.
    I have been diagnosed with Vericocele, and I have medium sperm count but less motality rate. Is motality rate also related to verecocele??. My doctor did not suggest a surgery though!.

    My wife also has infertility problem like PCOD. We went through 3 IUI cycles and 2 IVF cycles All unsuccessful. It's been almost 2 years since we are pursuing infertility treatment.

    Doctor says, all medical conditions to conceive have been achieved but she says "I'm unable to explain you medically why it's failed (2 ivf cycles)".

    Today I saw your post after it's published 3 years ago to search any help that I can get. :)

    Since 1 year, i'm feeling pain near my abdomen and testicle area also.

    Doctor pls comment.


  4. Its great that you've highlighted some of the myth's and facts about Varicose Veins. These kinds of articles provide fantastic initial ideas surrounding an often overlooked condition, and can lead to an initial almost self diagnosis that, if nothing else, may prompt the individual to seek further professional medical advice. This cannot be understated when concerning the sensitive issue of IVF. Patients want to increase their chances of conception so they need to know as many ways to do this as possible. Blogs like this do just that, and as such, are an invaluable resource.

    Fantastic work.

    Great stuff.

  5. Anonymous12:54 AM

    This post is good because of the information it provides but I am it does not seem to be thorough. Other sites have listed a higher Sperm DFI as a possible side effect of Varicocele (the testes beign kept warmer being cited as a reason). Another thing it does not cover is how age factor can add tot eh varicocele with the DFI. What are the chances of improving the Sperm quality (Both motility and its DNA integrity) for men above 35/40 who have had Varicocle for a while and would they constitute the larger of the 30%?.


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