Overview
A varicocele (VAR-ih-koe-seel) is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum). A varicocele is similar to a varicose vein you might see in your leg.
Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. Varicoceles are present in 15-20% of healthy men, but up to 70% of men with infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to fail to develop normally or shrink. The surgery to repair is a varicocele is called varicocelectomy or microsurgical varicocele repair.
Symptoms
A varicocele often produces no signs or symptoms. Rarely, it might cause pain. The pain may:
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Vary from sharp to dull discomfort
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Increase with standing or physical exertion, especially over long periods
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Worsen over the course of a day
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Be relieved when you lie on your back
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Impair fertility
With time, varicoceles might enlarge and become more noticeable. A varicocele has been described as looking like a "bag of worms." The condition might cause a swollen testicle, almost always on the left side.
Causes
Your spermatic cord carries blood to and from your testicles. It's not certain what causes varicoceles.
However, many experts believe a varicocele forms when the valves inside the veins in the cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). This might cause damage to the testicle and result in worsened fertility.
Varicoceles often form during puberty. Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein.
Types
Microsurgical Varicocelectomy
There are a few different ways to repair a varicocele. The most common method used is a microsurgical varicocelectomy. It is a procedure that takes approximately 1 hour. It can be performed in the office using numbing medication and either nitrous gas (laughing gas used at the dentist office) or medication to help relax you. Alternatively it can be performed in the operating room under general anesthesia. Regardless of where the procedure performed, you will be able to go home the same day.
During the procedure we will make a 3 cm opening in the skin in the groin area. We will then locate the spermatic cord (cord that carries blood vessels, nerves, and lymphatic vessels to and from the testicle). Will then bring in the operating microscope which allows magnification up to 40 times so that we can locate all the individual veins. As we locate the veins we will then clip and cut them to prevent the backflow of blood into the varicocele. We will use an ultrasound at the time of the surgery so that we can locate the artery to the testicle as well as any additional arteries that supply blood flow to the testicle. These arteries will remain intact. When we are done we will close the skin with dissolvable sutures.
Your insurance may cover this procedure. To verify with your insurance company whether not they will cover this procedure the billing code number (CPT code) that you will need to verify coverage is 55530. If cost is a significant factor in your decision making, it is typically most cost effective to perform this procedure in the office.
Success Rates
Success rates for microsurgical varicocele repair are 90-99%. For men who are having this procedure done for fertility reasons, semen quality improves in the vast majority of men. The degree of improvement often depends on the patient's baseline semen parameters. For men who have extremely low sperm counts at baseline, varicocele repair may allow them to improve their sperm counts enough that they can pursue intrauterine insemination instead of in vitro fertilization.
Studies have demonstrated that pregnancy rates improve to 33-66% compared to patients who have a varicocele that goes untreated (10-15%). The average time to improvement is 3-6 months after varicocele repair.
Laparoscopic Varicocelectomy
Another method to repair varicocele is using laparoscopic varicocelectomy. During this procedure your incisional make a small opening in the abdomen to pass a tiny instrument through that opening to repair the varicocele. This kind of procedure requires general anesthesia must be done in the operating room. The disadvantage of this procedure as that recurrence rates are significantly higher compared to microsurgical varicocelectomy.
Percutaneous Embolization
Lastly, a varicocele can also route be repaired using a technique called percutaneous embolization. During this procedure a radiologist answered to tube into a vein in the groin area or neck through which instruments can be passed. Ewing urine large veins on a monitor, the doctor releases coils or a solution that causes scarring to create a blockage in the testicular veins, which interrupt the blood flow and repairs the varicocele. This procedure isn't as widely used as surgery because recurrence rates are significantly higher. It is also a highly specialized procedure that must be performed by a radiologist with experience. Up to 20% of the time the radiologist may be unable to locate the correct vein to embolize. Your surgeon may recommend this technique if you have already undergone a varicocele repair in the past and it has failed.
Recovery
Regardless of how your procedure is done, recovery instructions are typically the same. All sutures that are used to close the skin are dissolvable therefore you will not need to return to have anything removed. A dressing will be placed on the incision, which can be removed 24 hours after your procedure and you can resume showering. We would ask that you void any soaking in water like a swimming pool, hot tub, or bath tub until the skin has healed ,which typically 1-2 weeks. Most men can return to work within 48 hours of their procedure. We would ask the avoid heavy lifting greater than 10 pounds or strenuous physical activity which would include squatting, jogging, or cycling for 4 weeks. You can resume having intercourse in 1 week. If your procedure was done for fertility reasons, we would ask that you perform a semen analysis 3-6 months after the procedure to see if your counts of improved.
Complications and Risks
Complications with microsurgical varicocele repair are rare, and occur less than 5% of the time. Complications may include the following:
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Wound infection
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Hydrocele (collection of fluid around testicle)
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Persistence or recurrence of varicocele
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Disruption to blood flow of the testicle
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Chronic pain of the testicle
Why it's done
Reasons to fix a varicocele include a varicocele your doctor can feel on exam and at least one of the following:
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Pain due to the varicocele
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Abnormal semen analysis (sperm concentration or motility)
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Difficulty getting partner pregnant (partner has had negative workup)
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Adolescents and young men not actively trying to conceive with significant decrease in testicle size compared to normal side.