By Marc Goldstein, MD
Published in Resolve for the future and beyond, Summer 2012
The most common identifiable cause of infertility in men is a varicocele (pronounced VAR-ih-koe-seel)), an abnormally enlarged vein draining the testicles. Approximately one third of infertile men who have never fathered a child have a varicocele, and 50 to 80% of men who were once fertile, but are now infertile, also have a varicocele. This means that varicocele causes progressive time-dependent decline in fertility.
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Varicocles are just like varicose veins in the legs or hemorrhoids. They cause pooling of blood in the scrotum and a rise in testicular temperature. Even a one degree rise in testicular temperature can have an adverse effect on sperm production and testosterone function.
The good news is that varicoceles are treatable. Dozens of reports have been published demonstrating the benefit of varicocele surgery to improve sperm counts. Yet, varicocele repair remains controversial, particularly for small varicoceles that cannot be seen or felt on a physical exam. Studies have known greater improvements in semen quality for repair of large varicoceles compared with smaller ones.
Microscopes were not used in older surgical procedures to repair varicoceles, which made it extremely difficult to locate the tiny arteries that provide the major source of nourishment for the testicles. These arteries were often tied off, which is unlikely to enhance testicular function. Tiny lymph ducts were also inadvertently tied off, often causing a condition called hydrocele, which is a bag of fluid that develops around the testicle.
These results led to the development a technique of varicocele repair using an operating microscope. This enables the identification and preservation of the arteries and lymph ducts, eliminating potential damage to the testicle as well as virtually eliminating the complication of hydrocele. Using this technique in several thousands of patients the average healthy sperm count after repair of large varicoceles has been shown to increase 128%. Microsurgical repair of varicoceles improves semen parameters and fertility with less postoperative pain and fewer complications and failures compared to non-microsurgical techniques.
In addition, varicocele repair decreases sperm DNA fragmentation, or the breaking up of DNA strands into pieces. Sperm parameters are significantly improved, and sperm DNA fragmentation is significantly decreased, after varicocele repair. This leads to improved clinical pregnancy rates and live birth rates, even when IVF with intracytoplasmic sperm injection (ICSI) is employed in infertile couples in which the male partner has a clinical varicocele (a varicocele that can be easily felt by the urologist).
What’s more, microsurgical varicocelectomy can induce spermatogenesis and help achieve pregnancy for couples in which the man has a zero sperm count (azoospermia) or a severely low sperm count and low sperm motility (oligoasthenospermia).
Varicocele repair has another important function. The testicles have two purposes: one is the production of the sperm, and the other is to produce testosterone. Testosterone is the male hormone necessary for a normal sex drive, erections, muscle strength, energy levels and bone health. The presence of varicocele causes significantly lower testosterone levels, and following microsurgical varicocele repair, testosterone levels are greatly improved in more than two-thirds of men.
In conclusion, varicocele repair is a cost-effective treatment for infertility. Men can upgrade to normal semen, which can allow for a natural pregnancy, or upgrade to semen of adequate quality for intrauterine insemination. Men with azoospermia may produce ejaculated sperm adequate for ICSI. Even if a man remains azoospermic, varicocele repair may enhance spermatogenesis allowing enough sperm production for ICSI. Finally, microsurgical varicocelectomy will improve testosterone levels in a majority of men, which is a men’s health issue aside from infertility.
Marc Goldstein, MD, DSc (hon), FACS, is the Matthew P. Hardy Distinguished Professor of Reproductive Medicine and Urology at the Weill Cornell Medical College of Cornell University, and Surgeon-in-Chief, Male Reproductive Medicine and Surgery at the New York Presbyterian Hospital, Weill Cornell Medical Center in New York. He is internationally renowned for his pioneering work in microsurgical repair of varicoceles, vasectomy reversal and repair of obstructive azoospermia (blockages). He has authored or co-authored over 270 journal articles, book chapters and books, including the book A Baby at Last! (Simon & Schuster, 2010) with Dr. Zev Rosenwaks and the upcoming Surgical and Medical Management of Male Infertility (Cambridge University Press, 2012) with Dr. Peter Schlegel. He is listed in the books Best Doctors in America, America’s Top Doctors and New York Magazine’s – Best Doctors in New York.