Andrology

Varicocele

A varicocele is a varicose vein of the scrotum. They are incredibly common, being seen in 15% of all men and 40% of men presenting to infertility clinics. Although common, they are not always causative of infertility. The majority of varicoceles are left sided (75–90%), and 33% of the time they are found bilaterally. Although varicoceles can be diagnosed on ultrasound, only the ones that are palpable by a physician are clinically relevant and should be considered for surgical therapy. The key in evaluating varicoceles is to determine which ones need treatment.

Varicoceles are graded clinically on a scale of I to III. A subclinical varicocele is not palpable and is only visible on ultrasound. These should never be treated. A grade I varicocele is a small varicocele, which is not grossly visible and is palpated only when the patients performs a valsalva maneuver (increases their intra-abdominal pressure as if they were trying to have a bowel movement). A grade II varicocele is of moderate size, not grossly visible, easily palpated with the patient in the standing position without valsalva. A grade III varicocele is large and grossly visible while standing.

Varicoceles can cause disruption of spermatogenesis. The typical finding seen a semen analysis is oligoasthenoteratospermia, meaning that the sperm are low in number, do not swim well and look abnormal under the microscope. The cause of these abnormalities is unclear but is thought to stem from the varicocele causing elevated temperatures that disrupt normal spermatogenesis. We tend to not rely solely on a semen analysis to diagnose whether a varicocele is causing significant abnormalities in spermatogenesis and instead focus on an FSH, an endocrine marker of how stressed a man’s sperm production factory is. The reality is that many men may have abnormalities on their semen analysis that are totally unrelated to their varicocele.

We typically only perform surgery for varicoceles when patients have abnormalities on their semen analysis, have an elevated FSH indicating that the varicocele is causing some stress on the sperm production factory, and have a sperm count where surgical repair of the varicocele could significantly alter their chances of conceiving or result in the use of a less invasive treatment modality. Although varicoceles can be fixed by a number of different surgical approaches, we recommend that patients undergo a sub-inguinal microscopic varicocelectomy as it has the lowest complication rate and the highest chance of success. We do refer patients to interventional radiology if they have already failed one ligation of the varicocele through the sub-inguinal microsurgical approach.

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