The Varicocele

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Key points

  • Varicoceles are present in 35% to 40% of infertile men and represent a highly treatable form of male infertility.

  • Varicoceles can result in disordered spermatogenesis, germ cell sloughing within the seminiferous tubules, testicular atrophy, and decreased testosterone secretion.

  • Microsurgical varicocelectomy results in improved semen parameters and reproductive outcomes with low rates of recurrence and postoperative morbidity.

  • Varicocelectomy is more cost-effective than both IUI and in vitro

Historical perspective

The association of the varicocele with male infertility derives back to the first century AD when Celsius reported a link between dilated scrotal veins and testicular atrophy.1 Besides supportive clothing, no known intervention was offered for symptomatic painful varicoceles until the nineteenth century when various methods were established to ligate these dilated veins. Among them was the Woods operation, which consisted of the passing of wire loops around the scrotal vessels and applying

Anatomy

A varicocele is defined as a dilatation or tortuosity of the veins of the pampiniform plexus. Clinically, they are found more commonly on the left side, although there is wide variation among the reported prevalence of bilateral varicoceles, which range from 30% to 80%.12 An isolated right-sided varicocele is extremely rare and raises concern about an underlying retroperitoneal mass.

The reason for the prevalence of left varicoceles can be clarified by retroperitoneal anatomy. The left internal

Pathophysiology

It is well acknowledged that varicoceles can cause progressive testicular damage and infertility. Lipshultz and Corriere demonstrated that varicoceles result in testicular atrophy in both fertile and subfertile men.23 Multiple histologic studies have explored this phenomenon on the microscopic level. Not only is there the loss of testicular mass with varicoceles, but also there can be substantial areas of testicular dysfunction. Scott reported his findings after having performed bilateral

Presentation

Varicoceles are present in 15% to 20% of the general population but in approximately 35% to 40% of men presenting for an infertility evaluation.30, 65 Any man presenting with a known varicocele who has a possible interest in future paternity should be offered a thorough medical and reproductive history, a physical examination, a hormone profile, and semen analysis testing.

Infertility

As per the American Urological Association Best Practice Policy “Report on Varicocele and Infertility,” varicoceles should be treated when all the following conditions are met:

  • 1.

    Varicocele is palpable on physical examination of the scrotum.

  • 2.

    The couple has known infertility.

  • 3.

    The female partner has normal fertility or a potentially treatable cause of infertility.

  • 4.

    The male partner has abnormal semen parameters or abnormal results from sperm function tests.68

With regards to infertility, varicocele

Treatment options

The cornerstone of varicocele treatment is disruption of the internal spermatic venous drainage of the testicle while preserving the internal spermatic artery, the vasal and deferential vessels, and the spermatic cord lymphatics. Definitive treatments for varicocele include surgery and radiographic venous embolization. Although all approaches have been shown to be effective, there is the general preference among many urologists to favor surgery given their expertise with various surgical

Treatment outcomes

Most studies reporting efficacy data on varicocelectomy are nonrandomized retrospective analyses and report improvements in semen parameters and fertility. Although their results are promising, they generally contain a diverse patient population with varied inclusion or exclusion criteria, inadequate study designs, and limited data on preoperative and postoperative parameters, all of which make a meta-analysis of the data challenging. Further, several studies suggest no benefit, especially with

Varicocelectomy in 2034: what does the future hold?

No one has a “crystal ball” or other tool to foresee the future, but that should not preclude one from considering the future and all of the possibilities that it might provide diagnostically and therapeutically. Varicoceles are a highly prevalent condition, and it is known that, although some men suffer marked reproductive or endocrine impairment as a result, other patients remain unscathed. We envision that an additional 20 years of academic investigation and technical advances will afford us

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