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Microsurgery for Male Infertility

New York (Nov 26, 2009)

Dr. Marc Goldstein
Dr. Marc Goldstein

Varicoceles – widening and swelling of veins in the scrotum that are similar to varicose veins in the legs or hemorrhoids – are a treatable cause of male infertility and low testosterone levels in men. Men who have undergone microsurgical repair of varicoceles have shown improvement in semen quality and a two to three times higher pregnancy rate compared to men who are untreated or treated with other medical approaches.

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%). In all veins, one-way valves help blood flow back to the heart. However, when these valves are not working properly, as in varicocele or varicose veins, blood can pool in the veins causing them to become swollen and enlarged.

How Do Varicoceles Cause Male Infertility?

The exact cause of infertility among men with varicocele is not clearly understood, however, researchers believe that varicoceles can cause the testicles to retain too much heat, which makes it difficult for sperm to live. The testes function best when they are 3 to 4 degrees C lower than body temperature. The testes remain cooler because they hang outside of the body, but also because of something called countercurrent heat exchange mechanism. "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 doesn't work properly causing the testes to retain heat and impairing their ability to make sperm.

In addition, new research by Dr. Goldstein and others has shown that the excess heat caused by varicoceles can also impair the testes ability to make the hormone testosterone. The enzymes in the testes that are responsible for testosterone production are also temperature sensitive and work best at the same temperature that is best for sperm production. Low testosterone levels may negatively affect sex drive, the ability to get erections, muscle strength, and energy level. In addition, low levels of testosterone have been linked to bone thinning (osteopenia and osteoporosis) and depression in men. Thus, in addition to impotence, varicoceles also put men at risk for these adverse effects of low testosterone levels.

What is a Microsurgical Varicocelectomy?

Because the blood vessels going to and from the testes are quite small in diameter, use of a microscope to surgically repair varicoceles (or microsurgery) helps a surgeon find the veins that need to be removed while preserving the tiny arteries that brings blood to the testes. Magnification also allows identification and preservation of the lymphatics, the vessels that drain fluid from the space between the testes and the surrounding sac, eliminating the risk of hydrocele (an accumulation of fluid around the testis) after surgery. Microsurgical varicocelectomy is done through tiny cuts (one inch or less) in the skin typically as an outpatient procedure. The procedure was pioneered by Dr. Goldstein 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 (known as grade III varicoceles). Varicoceles first appear in adolescents and worsen slowly over time. Dr. Goldstein believes that large varicoceles should be repaired when they first appear in adolescents because "it is much easier to prevent future infertility and hormone deficiency 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. At the Cornell Institute for Reproductive Medicine, 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. "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," Dr. Goldstein explained. "In at least half of these couples, the man could be treated and the couple could achieve a pregnancy without IVF. Furthermore, at our institution 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.

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