eMedicine Specialties > Urology > Common Problems of the Testicle

Varicocele: Follow-up

Author: Wesley M White, MD, Chief Resident, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine, University of Tennessee Medical Center
Coauthor(s): Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center; Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Jul 28, 2009

Outcome and Prognosis

Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery.

While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates (1995) confirmed that varicocelectomy is an effective treatment for male subfertility. Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy.7

Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates.7

In addition, Vasquez-Levin et al (1997) demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria.8

Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates.9 The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis.

The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed.10

The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe.

Future and Controversies

In 1992, researchers introduced a new micromanipulation technique known as intracytoplasmic sperm injection (ICSI). With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization and, eventually, a pregnancy. With the success of this technique, some researchers question the need for varicocele repair.

Conversely, a cost-analysis study by Schlegel shows the significant cost advantage of varicocele repair over ICSI.11 In addition, varicocele repair has the potential for improving the male factor, rather than using unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries some risk for the female who donates surgically removed eggs.

Another current topic focuses on the benefit of varicocele repair in men who are azoospermic or severely oligospermic. Although numerous studies indicate that varicocele repair can improve spermatogenesis in up to one third of azoospermic men, the initiation of spontaneous pregnancy is highly unusual in this population. The remaining two thirds eventually require testicular sperm extraction and IVF-ICSI, even after varicocele repair. Couples must therefore be counseled realistically regarding the benefit of varicocelectomy in this setting.

Other concerns focus on the benefit of varicocele repair in infertile men with poor semen quality who have only ultrasound evidence of a varicocele. While opinions differ about the value of repairing subclinical varicoceles in infertile men, most experts do not recommend it.

 


More on Varicocele

Overview: Varicocele
Workup: Varicocele
Treatment: Varicocele
Follow-up: Varicocele
Multimedia: Varicocele
References
Further Reading
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References

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  2. [Best Evidence] Male Infertility Best Practice Policy Committee of the American Urological Assoc. Male Infertility Best Practice Policy Committee of the American Urological Association; Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril. Sep 2004;82 Suppl 1:S142-5. [Medline].

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  7. Madgar I, Weissenberg R, Lunenfeld B, Karasik A, Goldwasser B. Controlled trial of high spermatic vein ligation for varicocele in infertile men. Fertil Steril. Jan 1995;63(1):120-4. [Medline].

  8. Vazquez-Levin MH, Friedmann P, Goldberg SI, Medley NE, Nagler HM. Response of routine semen analysis and critical assessment of sperm morphology by Kruger classification to therapeutic varicocelectomy. J Urol. Nov 1997;158(5):1804-7. [Medline].

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Keywords

varicocele, varicoceles, scrotal varicocele, varicocelectomy, pampinocele, pampiniform venous plexus, spermatic vein, arrest of sperm secretion, male fertility, male infertility, low sperm count, poor sperm function, dilation of the pampiniform venous plexus, testicular vein, antireflux valve, spermatogonia, Valsalva maneuver, sperm production, sperm function, testicular pain, scrotal pain, testicular swelling, scrotal swelling, spermatogenesis, infertility, fertility treatment, male factor infertility, infertility treatment, testicular thermoregulation, stress pattern of semen, poor sperm production, decreased semen quality

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Contributor Information and Disclosures

Author

Wesley M White, MD, Chief Resident, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine, University of Tennessee Medical Center
Wesley M White, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Joe D Mobley III, MD, MPH is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Endourological Society, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida
Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urogynecologic Society, American Urological Association, Florida Medical Association, International Continence Society, and International Urogynaecology Association
Disclosure: Astellas Honoraria Speaking and teaching; Coloplasty Consulting fee Consulting; Uroplasty Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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