By Marc Goldstein, MD
The most common identifiable cause of infertility in men is a varicocele. Approximately one third of infertile men who have never fathered a child have a varicocele, and up to 80% of men who were once fertile, but are now infertile, also have a varicocele. Varicoceles are abnormally enlarged veins draining the testicles. They cause pooling of blood in the scrotum and a rise in testicular temperature. Even one degree rise in temperature in the scrotum can have an adverse effect on sperm production and testosterone function.
The good news is that varicoceles are treatable. Dozens of reports have been published demonstrating the benefit of varicocele surgery to improve sperm counts. Yet, varicocele repair remains controversial, particularly for small varicoceles that can’t be seen or felt on a physical exam. Studies have shown greater improvements in semen quality for repair of large varicoceles compared with smaller ones.
Microscopes were not used in older surgical procedures to repair varicoceles, which made it extremely difficult to locate the tiny arteries that provide the major source of nourishment for the testicles. These arteries were often tied off, which is unlikely to enhance testicular function. Tiny lymph ducts were also inadvertently tied off, often causing a condition called hydrocele, which is a bag of fluid that develops around the testicle.
These results led me to develop a technique of varicocele repair using an operating microscope. This enabled the identification and preservation of the arteries and lymph ducts, eliminating potential damage to the testicle as well as virtually eliminating the complication of hydrocele. Using this technique in several thousands of patients, the average healthy sperm count after repair of large varicoceles has been shown to increase 128%. Using microscopic varicocele surgery, our group can help couples achieve a 43% naturally conceived pregnancy rate one year after surgery and a 69% naturally conceived pregnancy rate after two years. This compares to only a 17% naturally conceived pregnancy rate after one year in couples if the man declined surgery.
Microsurgical repair of varicoceles improves semen parameters and fertility with less postoperative pain and fewer complications and failures compared to non-microsurgical techniques. Yet most urologists who perform varicocele repairs do not use a microscope because very few urologists have been trained in microsurgery.
In addition, varicocele repair decreases sperm DNA fragmentation, or the breaking up of DNA strands into pieces. Sperm parameters are significantly improved, and sperm DNA fragmentation is significantly decreased, after varicocele repair. This leads to improved clinical pregnancy rates and live birth rates, even when IVF with intracytoplastic sperm injection (ICSI) is employed in infertile couples in which the male partner has a clinical varicocele.
The cost of varicocelectomy can also be less than IVF with ICSI. Varicocelectomy is cost-effective and successful. The cost of delivery with varicocelectomy alone is about $39,000 compared to about $68,000 using IVF with ICSI, with similar deliver rates (33% varicocelectomy, 34% ICSI).
What’s more, microsurgical varicocelectomy can induce spermatogenesis and help achieve pregnancy for couples in which the man has a zero sperm count (azoospermia) or a severely low sperm count and low sperm motility (oligoasthenospermia). Our Weill Cornell group has found that 55% of men with azoospermia show return of motile sperm, and 74% of men with severe oligospermia show improvement in motile sperm.
Varicocele repair has another important function. The testicles have two purposes: one is the production of the sperm, and the other is to produce testosterone. Our research at Weill Cornell shows the presence of varicocele causes significantly lower testosterone levels, and following microsurgical varicocele repair, testosterone levels are greatly improved in more than two-thirds of men.
Testosterone is the male hormone necessary for a normal sex drive, erections, muscle strength, energy levels and bone health.
In conclusion, varicocele repair is a cost-effective treatment of infertility. Men can upgrade to normal semen, which can allow for a natural pregnancy, or upgrade to semen of adequate quality for intrauterine insemination. Men with azoospermia may produce ejaculated sperm adequate for ICSI. Even if a man remains azoospermic, varicocele repair may enhance spermatogenesis allowing enough sperm production for ICSI. Finally, microsurgical varicocelectomy will improve testosterone levels in a majority of men, which is a men’s health issue aside from fertility.
Marc Goldstein, M.D. is the Matthew P. Hardy Distinguished Professor of Reproductive Medicine and Urology at the Weill Cornell Medical College of Cornell University, and Surgeon-in-Chief, Male Reproductive Medicine and Surgery at the New York Presbyterian Hospital, Weill Cornell Medical Center in New York, and co-author of “A Baby at Last”!
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