Varicocele is the presence of abnormally dilated veins in the scrotum. A recent blog gave an introduction to varicocele and infertility, including diagnosis and treatment. The question remains, when is varicocele surgery indicated? The Practice Committee of the American Society for Reproductive Medicine addressed this very question in a recently published opinion. I will summarize the recommendations in this blog.
When is varicocele surgery indicated?
Historically, there was a marked discrepancy in the recommendations made in the Ob/Gyn versus the urology literature. The urologists suggested that surgery was indicated in the majority of cases. The Ob/Gyn literature on the other hand suggested that in most cases, varicoceles did NOT require surgery. This was especially so in older males where the “damage” was already done. Since the early days, there have now been several studies addressing this very important issue and there seems to be consensus on when surgery is indicated.
Surgery for varicocele should be considered when most or all of the following conditions are met:
- the varicocele can be felt (palpated) on physical examination of the scrotum.
- The couple has known infertility
- the female partner has normal fertility or a potentially treatable cause of infertility, and time to conception is not a concern; and
- the male partner has abnormal semen parameters.
Varicocele surgery is not indicated when
- the semen analysis is normal
- the only abnormality is with sperm shape (morphology, teratospermia)
- the varicocele is NOT palpable (subclinical varicocele – diagnosed with ultrasound only).
Other special conditions when varicocele surgery may be considered
- the couple is not currently attempting pregnancy, has a palpable varicocele, abnormal semen analysis and a desire for future fertility, and/or pain related to the varicocele.
- Young adult males with clinical varicoceles who have normal semen parameters may be at risk for progressive testicular dysfunction and should be offered monitoring with semen analyses every 1 to 2 years to detect the earliest sign of reduced spermatogenesis. More recently, there is increased evidence that larger varicoceles may impact testosterone production, and some advocate repair in the setting of diminished testosterone levels.
- In teenage boys, with reduction in the size of the testes (one side or both) may be candidates for surgery. If the testes are not reduced in size, it is reasonable to examine them on a yearly basis or with periodic semen analyses. Varicocele repair may be offered on detection of testicular or semen abnormalities, as catch-up growth has been demonstrated as well as reversal of semen abnormalities; however, data are lacking regarding the impact on future fertility.
The success rates with varicocele surgery will be discussed in a follow up blog.
To see a fertility specialist who regularly diagnoses and treats male factor patients, make an appointment at one of InVia Fertility Specialists’ four Chicago area fertility clinics. Dr Robert Brannigan, who is an urologist with fellowship training in male infertility, is available for consultation by appointment.
