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Varicocele surgery for male factor infertility
Advanced Fertility Center of Chicago
Gurnee & Crystal Lake, Illinois

Numerous sperm - at high magnification on a counting chamber

More images of sperm

About 25% of all infertility is caused by a sperm defect and 40-50% of infertility cases have a sperm defect as the main cause, or a contributing cause. This is referred to as male factor infertility.

A varicocele is an abnormal tortuosity and dilation of veins of panpiniform plexus within the spermatic cord. It could possibly affect sperm by increasing testicular temperature - at least that is one theory.

Varicoceles are found in:

• 20-30% of infertile males

• 10-15% of males in general population - large majority have normal sperm and are fertile

Urologists often diagnose and surgically repair varicoceles. However, correcting a varicocele (surgical procedure) many times will not improve the semen quality enough to change the mode of therapy that will be required to result in a pregnancy for the couple. Several studies have shown that varicocele surgery can improve sperm counts or motility but randomized and controlled trials do not consistently show improved pregnancy rates (see below). Are we wanting higher sperm counts, or children?

In other words, if a couple will need inseminations with husband's sperm, or possibly in vitro fertilization anyway, why waste time, money, etc. on surgery for a varicocele. These treatment options depend on the degree of abnormality in the semen and other factors involved in the individual couple's case.

For example, if the count is under about 5-10 million per cc, or the motility below about 30%, it is unlikely that the semen quality will improve enough after varicocele repair to result in pregnancy without inseminations or IVF. These couples should be referred to an infertility specialist immediately for a discussion of their options. Couples with a male partner's sperm count of less than about 5 million per cc, or the motility below about 30% will most likely need IVF with ICSI in order to conceive. In our opinion, varicocele surgery should not be considered for men with such low numbers.

Men with counts that are just slightly low (15-20 million) may be more reasonable candidates for varicocele surgery. Many couples with sperm parameters in this range will conceive on their own, as well. However, the female should also be evaluated prior to the surgery - if her tubes are blocked or she has anovulation (no ovulation), or an ovarian reserve problem, surgery on the male is not indicated.

The best type of study to prove whether a medical "treatment" is effective is a controlled randomized trial. The treatment is done on some patients and not done on others, and the patients that are treated are randomly selected. That is supposed to eliminate bias in the study. Then we compare the outcomes in the 2 groups to see if there is any difference.

There are 6 controlled randomized published trials of varicocele surgery vs. no surgery:

• 3 studies had lower pregnancy rates with surgery

• 3 studies had higher pregnancy rates with surgery

• Meta analysis of these 6 studies (a statistical technique that combines results from multiple studies) showed no significant effect of surgery on pregnancy rates

Perhaps the jury is still out on varicocele surgery as a treatment of male infertility. However, it is clear that (at best) the waters are murky in this area... 

Any couple considering varicocele surgery should see an infertility specialist and educate themselves about all of their options before proceeding.