A varicocele is a dilation of veins surrounding the testicle. Forty percent of men with infertility have a varicocele, which is the most correctable cause of male infertility. Varicoceles have been shown to have a negative impact on semen parameters such as sperm count, motility (ability of sperm to swim), and morphology (sperm with normal shapes). They can also have a negative functional impact on the ability for sperm to fertilize the egg as well as potentially increasing the risk of pregnancy loss through a process known as sperm DNA fragmentation. It is believed that the increase in heat from the varicocele has a deleterious impact on the semen parameters and the DNA of the sperm. Varicoceles have more recently been shown to impact testosterone production and can contribute to hypogonadism (low testosterone). Varicoceles may also result in testicular pain. Varicoceles are only significant if they can be felt on physical examination. If a varicocele cannot be felt by the examining physician and requires ultrasound to identify it, it is not considered consequential, and should not be repaired.
Fortunately, the majority of men who undergo varicocele repair will have an improvement in fertility parameters, DNA fragmentation, testosterone production, and pain. This raises the question, how should a varicocele be managed best? While there are a number of surgical approaches to repairing a varicocele, the goals are the same regardless of approach: to tie off the dilated veins, preserve the arterial supply feeding the testicle blood, and do so in the least invasive manner with the highest success rate and the least chance of complications and of the varicocele recurring. There are multiple approaches.
There is a retroperitoneal approach, requiring a more invasive incision in the abdomen or flank with a much more difficult recovery with a much higher recurrence rate (up to 15%). This is nearly never performed today.
There is the laparoscopic approach, placing instruments through incisions in the abdomen with a camera view to repair the varicocele. As is stated in the American Urological Association guidelines and the American Society for Reproductive Medicine/Society for Male Reproduction in Urology committee statement, laparoscopic varicocele repair places an unnecessary risks to organs, such as the intestines, bladder, and major blood vessels in the abdomen and pelvis, which is not the case with open techniques.
There is an inguinal approach, where an incision is made in the area where a hernia repair would be performed in the upper groin. This requires a larger incision than the subinguinal approach, and major strength layers must be opened for adequate access to the varicocele with this inguinal approach which makes for a more invasive surgery and more difficult recovery.
Amongst infertility experts, the subinguinal approach is the technique of choice. This is typically performed through an incision of around half an inch in size and is made lower in the groin. This allows for a small incision without opening any major strength layers, and does not put any other organs at risk of injury. Magnification through the use of an operative microscope is recommended to make sure all the dilated veins are visualized and tied off while preserving the microscopic arterial blood supply to the testicle as well as lymphatic channels to minimize complications. Microscopic magnification also minimizes the risk of recurrence of a varicocele after repair to around a 1% chance in skilled hands. Surgeons with microsurgical training and experience will offer the best results. Dr. Parviz Kavoussi is fellowship trained and has an expertise in microsurgical subinguinal varicocele repair. He does a large number of these cases and states, “It has been shown that the fewer different types of operations a surgeon performs and the more of those he does regularly, the better his outcomes will be for his patients.” Dr. Kavoussi performs multiple varicocele repairs every week with excellent outcomes. He also states, “ I feel very strongly that the microsurgical subinguinal technique offers my patients the best results. If I was to have a varicocele repaired, I would certainly want it done in the least invasive manner, with the easiest recovery, highest success rate, lowest complication rate, with the least chance of it ever coming back in my lifetime.”
An additional approach to treating a varicocele is percutaneous embolization. This involves using fluoroscopic, x-ray and working through the inside of blood vessels to place metal coils or blocking agents to obstruct these veins from the inside. Per the report on varicocele and infertility by the practice committee of the American Society of Reproductive Medicine and the Society for Male Reproduction and Urology, technical problems can prevent access to these veins with embolization in up to 20% of the cases and recurrences are seen in up to 15% of patients, a significantly higher rate than the 1% recurrence with microsurgical approaches.