What is the treatment of varicoceles?

A varicocele is a varicose vein(s) involving the veins that drain the testicles/scrotum. They result from the same mechanism that causes varicose veins in other parts of the body. The venous dilatation comes from venous hypertension exacerbated by gravity causing incompetent veins. This changes the direction of venous blood flow from towards the heart (away from the scrotum) to towards the scrotum. The venous blood pools in the these dilated scrotal varices, which raises the temperature of the scrotum and can lead to diminished sperm counts. 
Varicoceles are a leading cause of male infertility and they may be treated for this or for the pain and discomfort that they can cause. They can be treated also to prevent testicular atrophy in young men. There are two general types of treatment: non-surgical (percutaneous) with an interventional radiologist or surgical with a urologic surgeon. 
The percutaneous approach has a higher success rate. It is performed as an outpatient with a 1-2 day recovery. The approach is either from the groin (right femoral) or neck (right jugular). A catheter is placed into the spermatic veins that drain the venous blood from the scrotum. Varicoceles are most commonly left-sided only but they can be bilateral. A "sandwich" of 2 nests of coils with liquid/foam sclerosant in between is the most common technique. The sclerosant is the same that is used for varicose veins elsewhere in the body. This sclerosant can get in to the numerous collateral venous channels that are often present in order to obliterate them, and explains why the recurrence rate is lower with this approach over the traditional surgical approach. 
The traditional surgical approach is the open inguinal varicocelectomy. Other surgical approaches include retroperitoneal and subinguinal. Some centers are doing this procedure laparoscopically as well. The veins draining the scrotum are ligated but the collateral channels are often above the surgical site, which again accounts for the higher recurrence rate. 
Mark Perloe, MD
Reproductive Endocrinology
Not all varicoceles need to be treated. If you are not having pain or discomfort and are not concerned about your fertility, then treatment may not be necessasry. If you experience and aching discomfort or pain, careful evaluation by your physician is needed to determine whether this symptom is actually related to the varicocele.

It is unlikely that small to medium varicoceles cause problem. Most urologists believe that only those varicoceles that are large enough to view without resorting to ultrasound are likely an issue when it comes to fertility. Then the issue is whether or not one should attempt surgical correction by either laparoscopy or whether you should choose to consider IVF with ICSI [sperm injection] to achieve a pregnancy. Varicocele repair is associated with an improvement in the semen analysis in approximately 60% of those who undergo treatment. About half those who show improvement or about 30% of those who undergo surgery will acheive a pregnancy. When the cumulative pregnancy rate per IVF retrieval [combined pregnancy rate after fresh and frozen embryo transfers] is considered, IVF may be more cost effective in the long run. If you choose to go the IVF route, please consider freezing sperm if future pregnancy is desired. In some men the damage from varicocele can be progressive over time, and while you may achieve a pregnancy now, the continued damage resulting from the varicocele may reduce future options for pregnancy.

There is certainly no one size fits all answer. Please discuss with both your fertility trained urologist and a reproductive endocrinologist prior to making any decisions. Factors such as the size of the varicocele, your age, future pregnancy plans, the semen analysis results and insurance coverage will all inform your decision making process.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.