For a young couple faced with infertility, surgery may be one of the most difficult decisions they have faced, as it may produce financial hardship in the form of medical bills or lead to partner frustration, guilt, or blame. Care should be taken to counsel both partners correctly on all potential outcomes of varicocele repair in the presence of infertility. In the following brief review of the literature, each of the following concerns is addressed: predictive factors (i.e., men who have been shown to benefit from varicocele repair), surgical and nonsurgical options and complications, and the expected effects on semen analysis, testicular growth, and fertility rates after repair.
When counseling patients on varicocele treatment, it is helpful to consider certain clinical parameters as predictive factors for improved outcome. In fact, a key to providing appropriate patient counseling for the treatment for varicoceles involves an understanding of varicocelectomy outcomes data. Three recent series have demonstrated an inverse relationship between preoperative semen values and varicocele size, with greater improvement in semen parameters and pregnancy rates after repair of larger varicoceles. Varicocele repair has been shown to be efficacious in patients with a “total motile sperm count” that is greater than five million and in patients with low to normal morphology in the presence of oligospermia. As discussed previously, testicular hypotrophy is associated with decreased sperm count, and, in correlation, Yoshida et al. found testicular volume greater than 30 cc to be an independent predictor of fertility following varicocelectomy. Repair of subclinical varicoceles remains controversial, as two poorly designed studies suggested a statistical improvement in seminal parameters but did not demonstrate a meaningful effect on pregnancy rates. A large noncontrolled trial in men with subclinical varicocelectomy showed no change in mean sperm count in over 260 men.
Men with Y-chromosome microdelerions or Sertoli-cell-only azoospermia do not typically benefit from a varicocelectomy. Normal serum follicle-stimulating hormone levels were shown by Yoshida to be predictive of increased postoperative fertility following repair. Strengthening this finding, Schrepferman et al. found that men with varicoceles and elevated follicle-stimulating hormone levels demonstrated a poor response to varicocelectomy.
In all, these outcome data are meant to guide the decision-making process. It is important to note that factors of anatomy, physiology, and endocrinology are often interrelated and, therefore, each patient’s infertility evaluation should be treated as a unique continuum of gonadal effects.
Treatment options include surgical repair or nonsurgical management via transvenous varicocele ablation. Surgical repair of varicoceles may occur by any one of five different approaches: retroperitoneal, laparoscopic, inguinal, subinguinal, or scrotal. Transvenous varicocele ablation includes embolization (using detachable coils or balloons) or sclerosing therapy. The advantages and disadvantages to each approach are briefly reviewed here.
The retroperitoneal (also called “high ligation” or “modified Palomo”) approach involves splitting the abdominal musculature low along the midaxillary line and offers easy access to the spermatic vein just above the level of the internal inguinal ring. The vein is freed, anastomosing collaterals are identified, and all veins are ligated as superiorly as possible toward the renal vein. This approach offers a greatly reduced risk of damage to the testicular artery, as it is distinctly separate from the spermatic veins at this level. Most authors, however, report increased postoperative hydrocele formation (7-33% of adults and 15-45% of children) as well as high varicocele recurrence rates in both men and children (up to 15%); both of these trends are likely due to the large number of crossing vessels present prior to the confluence of the tesricular veins. This procedure may now be performed with laparoscopy, allowing for excellent visualization of the spermatic veins and easy preservation of the lymphatics. While the laparoscopic technique results in a similarly high rate of recurrence, laparoscopic complications are rare (less than 1%) and are related to initial abdominal access (solid organ, bowel, or vascular injury), pneumoperitoneum (ventilation impedence, hypotension secondary to impeded venous return, and gas embolism), tissue dissection, or incisional hernia formation. Even with the possibility of improved technical precision, the significant disadvantages of increased operative time and the associated high equipment costs have caused the laparoscopic approach to fall out of favor.
The inguinal approach or modified Ivanissevich procedure is one of the most commonly used techniques today, as it allows for high ligation of both external cremasteric and testicular veins. After induction with general anesthesia or under local anesthesia, access to the spermatic cord is obtained by incising the external oblique aponeurosis, similar to the technique used in performing inguinal hernia repair. Surgical loupes, papaverine, and intraoperative Doppler sonog-raphy may aid in the identification of the testicular artery. Preservation of the lymphatics is extremely important in decreasing the risk of postoperative hydrocele formation.
Although similar to the inguinal approach, the subinguinal (or low inguinal) approach is performed just below the external oblique fascia, obviating the need to disrupt this aponeurosis. Intraoperative magnification by use of a microscope is commonly employed, and most patients have less postoperative pain and activity restrictions after surgery as a result. The major drawbacks of subinguinal varicocelectomy include a greater risk of damage to the numerous branches of spermatic veins as well as to the testicular artery, which maintains a more intimate relationship with the veins at this level. This procedure is also more technically challenging than the inguinal approach. Yet, subinguinal varicocelectomy remains ideal for patients with a history of previous inguinal surgery, including hernia repair or previous varicocelectomy.
The oldest technique for varicocelectomy, the scrotal approach, has largely been abandoned by modern urologists. Although somewhat effective, high complication rates include injury to small branches of the testicular artery, testicular atrophy, and hydrocele formation in as many as 40% of the patients.
Nonoperarive, percutaneous methods of varicocele treatment are offered by the interventional radiologist. Venography is first performed through a jugular, basilic, or femoral vein stick. Varicocele ablation then occurs either by the use of balloon or coil placement or the injection of a sclerosing agent. The success of these procedures is highly operator dependent and cannot always account for anatomic variations. There is also a higher recurrence rate (15-25%) when compared to newer surgical techniques (0-1%). Rare but serious complications include vascular perforation, coil or balloon migration, sclerosis of testicular or renal veins, and allergic contrast reaction. As percutaneous interventions may be performed under local anesthesia, this treatment option is often chosen for those patients who cannot tolerate general anesthesia for their varicocelectomy or for men with recurrent varicocele following open varicocelectomy.
In addition to technique-associated complications and routine postoperative wound infections or hematomas, varicocelectomy is associated with three specific major complications: hydrocele formation, recurrent varicocele, and testicular atrophy secondary to damage of the testicular artery.
The most frequent complication of varicocelectomy is hydrocele formation, occurring in as many as 30% of the patients, depending on the technique. The etiology is likely that of lymphatic obstruction, evidenced by the high average protein content of postvari-cocelectomy hydroceles compared to that of edematous fluid produced by venous obstruction. Formation of hydrocele requires surgical intervention due to scrotal discomfort in at least 50% of the cases. Use of magnification to identify and preserve lymphatics can virtually eliminate the risk of hydrocele formation after varicocelectomy.
Incidence of vascular compromise via injury or ligation of the testicular artery during varicocelectomy is impossible to measure, but scattered case series have been published. Startzl reported a 14% incidence of frank testicular atrophy when the testicular artery was purposefully ligated during renal transplantation, but Goldstein and coworkers reported neither the development of pain, testicular atrophy, nor a worsening of semen parameters after the inadvertent ligation of the internal spermatic artery in 18 patients during varicocelectomy. In most adults, if intentional or inadvertent testicular artery ligation occurs, collateral circulation will be provided by the cremasteric and vasal arteries. Rare cases of testicular ischemia and even complete testicular loss, however, have been reported in men with a history of previous groin or scrotal surgery, especially vasectomy. Care should be taken to forewarn patients of this terrible potential complication.
Recurrent or persistent varicocele after surgical repair varies from 0.6% to 45% depending on the technique. The microsurgical approach using optical loupes lowers the incidence of varicocele recurrence to only 1% to 2% amongst children, adolescents, and adults equally, compared with 9% to 16% using non-magnified inguinal techniques. As previously stated, venography is recommended in the case of recurrent or persistent varicocele, as an interventional radiologist may be able to locate and occlude the aberrant venous drainage.
Effect of Repair
Semen Parameters and Testicle Growth
Improvement in seminal parameters has been extensively demonstrated in men after surgical varicocele repair, including motility (70% of patients), sperm density (51% of patients), and morphology (44% of patients). Varicocelectomy has also been performed in men with nonobstructive azoospermia, resulting in the induction of spermatogenesis and the successful return of sperm to the ejaculate in approximately 40% of cases. Over 25% of these men were able to father children, including 5% who did so without the help of assisted reproduction interventions.
Varicocelectomy has also been used successfully in other conditions not directly related to a dysfunction in semen parameters. Peterson et al. in 1998 followed up 35 men who underwent varicocelectomy for orchal-gia. Of these, 30 (86%) had complete resolution of pain, one man had partial resolution, and the remaining four had persistent pain or a worsening of it. Further, varicocelectomy has been shown to significantly increase serum testosterone levels in young, infertile men, possibly reflecting an improvement in both hormonal and spermatogenic function. Although still under contention, varicocelectomy has also resulted in significantly increased serum testosterone levels in selected older men, supporting the concept that varicocelectomy may halt or even partially reverse Leydig cell dysfunction and age-related andro-gen deficiency — a clinical condition increasingly referred to as “andropause”. In adolescents, varicocele repair can also result in catch-up growth of the affected ipsilateral testicle, a result that has not been replicated in adults.
Perhaps the most controversial issue with respect to varicocelectomy is the effect of repair on pregnancy rates. Most studies examining the effect of varicocele on fertility have been uncontrolled, with average pregnancy rates of 30% to 60%. In a study designed to compare cost and pregnancy rates between inrracytoplasmic sperm injection ( intracytoplasmic sperm injection (ICSI) and varicocelectomy, Schlegel reported an average collated pregnancy rate of 33% in the varicocele repair group (305 / 928, or 95%, with a CI of 28-39%) compared with 16% in the control group (164 / 999, or 95%, with a CI of 13-20%). Since 1979, only eight randomized controlled trials have been published. The results of these studies are limited by low pregnancy rates in both treatment and nontreatment groups, raising the question of contributing female factors, biased nontreatment arms, publication bias, and the unintentional inclusion of men with normal semen parameters or subclinical.
In the three trials of clinically present varicoceles, all are limited by high dropout rates, poor methods of randomization, and significant differences in male selection factors such as age, duration of infertility, and varicocele grade. Madgar et al. reported a 60% pregnancy rate after one year in the treatment group (15 / 25 couples) as opposed to a 10% pregnancy rate in the nontreatment arm (2 / 20 couples). In this convincing, crossover-design study, the nontreated arm was followed for one year of infertility, at which point varicocele repair was performed. Pregnancy rates rose fourfold (44%) in the observation group during the first year after surgical correction. Hargreave published only limited results from a small population observed in a WHO varicocele trial. A larger study by Nieschlag et al. in 1998 showed no relative benefit in 125 couples who received either surgical treatment or psychological counseling. Unfortunately, nonmicrosurgical techniques were used for the repairs, and follow-up was inadequate to determine recurrence, with most of the varicoceles repaired being small or moderate in size. Overall, further randomized, controlled clinical trials in men with clinically apparent varicoceles are necessary as there is as yet no conclusive evidence that varicocele repair alters pregnancy rates.