Varicocele repair, intrauterine insemination (IUI), and in vitro fertilization / intracytoplasmic sperm injection (IVF-ICSI) are options for the management of couples with male factor infertility associated with a varicocele. The decision to proceed with any of these management options is influenced by a number of factors (e.g. presence of female factors that necessitate IVF, symptoms like pain due to the varicocele, time available for conception). It may be potentially more cost-effective to do varicocele surgery compared with IVF + ICSI.
Surgical treatment successfully eliminates over 90 - 99% of varicoceles. Improvement in semen parameters, however, may take 3 to 6 months. There, however, is no agreement on the definition of what constitutes “improvement”.
Factors that may help to predict improvement including size of varicocele, follicle-stimulating hormone level, and preoperative total motile sperm count should be taken into consideration. Also, failure to treat a varicocele may result in a progressive decline in semen parameters, which may further compromise future fertility.
How much improvement in semen parameters can be expected after varicocele surgery?
Most studies have reported that semen quality does improve in a majority of patients after varicocele surgery, as defined by a comparison of pretreatment and posttreatment semen parameters.
The sperm count has been shown to increase by a mean of 12 million sperm/mL with a mean 11% increase in motility and variable effects on sperm morphology. Although accurate, these numbers need to be interpreted with caution. It does not mean that someone with a varicocele and a sperm count of say 1 million, will see his sperm count increase to 13 million (increase of 12 million) after varicocele surgery!
This improvement could result in the patient having less invasive treatment. Men with severe male factor who would otherwise require IVF-ICSI to conceive may have adequate improvement in semen analysis to allow IUI instead of IVF-ICSI, and those with mild male factor may have sufficient improvement in semen parameters to allow natural conception instead of IUI.
What about men with zero sperm count (non-obstructive azoospermia)?
Select cases with non-obstructive azoospermia (hypospermatogenesis or late maturation arrest) may respond to varicocele repair. Varicocele surgery may result in restoration of low numbers of sperm in the ejaculate (10 – 50% chance of success). In such cases, varicocele repair is associated with return of sperm to the ejaculate, thus potentially making it possible to perform IVF-ICSI without testicular sperm aspiration or extraction (TESA or TESE). These studies have also shown that men with Sertoli-cell only or early maturation arrest histology did not have sperm return to the ejaculate. It is important to remember that men previously found to be azoospermic may also have sperm found in the ejaculate with no intervention. Therefore, testicular biopsy/testicular sperm extraction or varicocele repair may be offered to such men, although the value of varicocelectomy in all patients with nonobstructive azoospermia remains controversial.
What are the pregnancy rates after varicocele surgery?
A recent study examined 145 couples who were randomized to varicocelectomy (study) versus observation (control). The control group had a natural conception rate of 13.9%, while the study group had a rate of 32.9% with an odds ratio (OR) 3.04 (95% confidence interval [CI], 1.33–6.95). The baseline characteristics of both groups were statistically similar. No crossover was done.
The most recent Cochrane review concluded that treatment of a varicocele in men from couples with otherwise unexplained subfertility may improve a couple's chance of pregnancy.
The diagnosis of varicoceles is based primarily on physical examination.
Only clinically palpable varicoceles have been clearly associated with infertility.
Adolescents and young men not actively trying to conceive who have a varicocele and objective evidence of reduced ipsilateral testicular size may be offered varicocele repair.
Most studies show improvement in semen parameters and fertility after repair of varicocele.
Time to improvement in semen parameters is approximately 3 to 6 months.
Treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve.
In vitro fertilization with or without ICSI may be considered the primary treatment option when such treatment is required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters.
The treating physician's experience and expertise, including evaluation of both partners, together with the options available, should determine the approach to varicocele treatment.
Dr. Karande is Board Certified in the specialty of Obstetrics and Gynecology as well as the subspecialty of Reproductive Endocrinology and Infertility. He is a Fellow of the American College of Obstetricians and Gynecologists and Member of the American Society for Reproductive Medicine.