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Microsurgical Varicocelectomy Treats Male Infertility

Improves Testosterone Levels As Well

New York (Nov 26, 2009)

Dr. Marc Goldstein
Dr. Marc Goldstein

Microsurgical repair of varicoceles is known to improve semen quality and result in two to three times higher pregnancy rates compared to no treatment or other medical approaches for varicocele. (1) However, newer research shows that varicoceles are also associated with low testosterone levels and that microsurgical repair significantly increases serum testosterone levels in more than two-thirds of men. Thus, even men who are not concerned with fertility may benefit from this surgical treatment.

Varicoceles are found in approximately 15% of the general male population but in a higher percentage of infertile men who have never fathered a child (35%) or who once fathered a child but are now infertile (81%). (2,3)

How Do Varicoceles Cause Male Infertility?

The exact cause of infertility among men with varicocele is not clearly understood, however, researchers believe that varicoceles interfere with the countercurrent heat exchange mechanism in the testicles. "As the arteries to the testicles approach each testicle, they become very tightly wound like a radiator coil and are normally surrounded by a fine network of veins. This network helps exchange heat," explained Dr. Goldstein, Surgeon-in-Chief of Male Reproductive Medicine and Surgery and Director of the Center for Male Reproductive Medicine and Microsurgery at the NewYork-Presbyterian Hospital/Weill Cornell Medical Center. If the veins become enlarged because of higher pressure in the veins or poorly functioning valves, the heat exchange mechanism does not work properly causing elevated intratesticular temperature and impairing their ability to make sperm.

In addition to the effects on fertility, research by Dr. Goldstein and others has shown that the elevated intratesticular temperature caused by varicoceles can impair the testes' ability to make testosterone by negatively affecting testicular Leydig cell function. Thus, varicocele may put men at risk for the adverse effects of low testosterone level, such as low sex drive, erectile problems, decreased muscle strength, osteopenia/osteoporosis, and depression.

A Study That Supports This Theory

Dr. Goldstein and colleagues performed a retrospective chart review on 327 men ages 18-70 years who had undergone subinguinal microsurgical varicocelectomy for clinically palpable varicoceles. (4) These men had significantly lower serum testosterone levels compared with a control group of men with or without varicoceles who did not undergo the procedure (416 ± 164 ng/dL versus 469 ± 192 ng/dL, P<0.001). This association was not altered by patient age. Compared with baseline, the patients' serum testosterone levels were significantly higher after microsurgical varicocelectomy (358 ± 126 ng/dL versus 454 ± 168 ng/dL, P<0.001). In addition, 70% of men who underwent the procedure showed an increase in serum T levels post-operatively. The findings were presented at the 2007 annual meeting of the American Society for Reproductive Medicine and are expected to be published shortly.

What is a Microsurgical Varicocelectomy?

Dr. Goldstein uses the mini-incision, subinguinal microsurgical varicocelectomy with delivery of the testicle. The gubernacular veins and external spermatic perforators are also inspected and divided. Gubernacular veins in particular have been shown to cause of up to 10% of varicocele recurrences. The testicle is then returned to the scrotum and the spermatic cord is placed on a large Penrose drain. He then inspects the spermatic cord under a microscope and divides and ligates or clips all dilated internal spermatic veins. Postoperatively, venous return is via the deferential (vasal) veins, which drain into the internal pudendal veins and usually have competent valves. This approach allows the varicoceles to be removed while preserving the testicular artery, which is only 0.5-1.5-mm in diameter. The magnification also allows for identification and preservation of the lymphatics surrounding the testes, which reduces the risk of hydrocele. The procedure was pioneered by Dr. Goldstein (5) as well as Joel L. Marmar, MD, of Robert Wood Johnson Medical School, Camden, New Jersey.

Patients who respond best to varicocelectomy are those with large varicoceles in whom the veins can be felt and seen from the outside (ie, grade III varicoceles). Varicoceles first appear in adolescence and worsen slowly over time. Dr. Goldstein advocates repairing large varicoceles when they first appear in adolescents because "it is much easier to prevent future infertility than to treat it once the damage has already occurred." The sooner varicoceles are repaired the better the chance of halting future damage, he said.

NewYork-Presbyterian Hospital/Weill Cornell Medical Center, has the largest experience in the world in the use of microsurgical techniques for the treatment of male reproductive disorders, including varicocelectomy and vasectomy reversals, Dr. Goldstein said. "Very few major IVF [in vitro fertilization] centers have a reproductive urologist on staff. If a man has any sperm at all, they bypass the male altogether and start IVF. Here, physicians from the male and female reproductive divisions work together as a team to provide optimal care for the couple rather than just treating one partner separately." In at least half of these couples, the man could be treated and the couple could achieve a pregnancy without IVF, notes Dr. Goldstein. "We can use simpler, more economical treatments that are easier for women like IUI (intrauterine insemination) or a natural conceived pregnancy." In addition, for men who have zero sperm count, varicocelectomy can allow for enough sperm to be produced in their semen to allow for IVF or, if they remain at zero sperm count, can improve sperm production enough inside the testicle that it can be extracted with an operating microscope (microdissection testicular sperm extraction) for use in IVF/Intracytoplasmic sperm injection.

Faculty Contributing to this Article:

Marc Goldstein, MD is Surgeon-in-Chief of Male Reproductive Medicine and Surgery, Executive Director of the Men's Service Center of the Cornell Institute for Reproductive Medicine, and Director of the Center for Male Reproductive Medicine and Microsurgery at the NewYork-Presbyterian Hospital/Weill Cornell Medical Center. He is also the Matthew P. Hardy Distinguished Professor of Reproductive Medicine and a Professor of Urology at Weill Cornell Medical College. Additionally, he is a Senior Scientist with the Population Council's Center for Biomedical Research, located on the campus of Rockefeller University.

References:

  1. Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007;88(3):639-648.
  2. Thomas AM and Fariss BL. The prevalence of varicoceles in a group of healthy young men. Mil Med. 1979;144:181-182.
  3. Gorelick JI and Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59: 613-616.
  4. Tanrikut C, Choi JM, Rosoff JS, Nelson CJ, Mulhall JP, Goldstein M. Improvement in serum testosterone levels after varicocelectomy. Fert Stert. 2008;88(suppl):S386.
  5. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: An artery and lymphatic sparing technique. J. Urol. 1992;148:1808-1811.

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