Varicocele and Fertility

Varicoceles are present in 15% of all men and up to 40% of men with infertility. Varicoceles are also implicated in 80% of previously fertile males who are unable to conceive another child (i.e. secondary infertility). Hence 8 in 10 men with varicoceles can conceive naturally without any medical treatment (e.g. surgery, medication). Although this is most likely to occur in males with normal sperm parameters who have not already been trying to conceive already for 12 months or longer.

After 12 months of trying to conceive, unsuccessful couples are encouraged to see their doctor for a preliminary examination. If no female and male factors are found (e.g. palpable varicoceles), and both partners are still young (<30 years old), the doctor may recommend to continue trying to conceive for another 12 months (watchful waiting) as studies show 50% of infertile couples manage to get pregnant naturally during this time.

However, if the age of either partner is a contraindication to watchful waiting the doctor may recommend varicocele treatment especially if semen analysis, sperm DNA fragmentation, hormone levels, varicocele grade or venous reflux indicate a negative effect on fertility.

Grade 0 Varicocele

Contrary to clinical practice guidelines, studies show that men with grade 0 varicocele and at least one abnormal sperm parameter see a statistically significant improvement in sperm parameters and hormone levels after varicocele treatment.

In fact, studies show that even men with normal sperm parameters and grade 0 varicocele who have been unable to conceive (i.e. subfertile) see a significant increase in sperm concentration 6 months later after surgery.

Experts report this improvement in sperm concentration is most likely to occur among men with undeniable subclinical varicocele displaying long or very long venous blood reflux.

However, sperm DNA fragmentation fails to decrease significantly post-surgery for the majority of men with grade 0 varicocele according to a small study by García-Peiró et al.

Overall, this improvement in sperm quality post-surgery of grade 0 varicocele is enough to increase the chances of natural conception (Table 4) and decrease the need for IVF or IUI in some cases (Table 5).

Grade 1 Varicocele

Men with grade 1 varicocele have on average 19% lower sperm count per milliliter than men without palpable varicocele. As a result, a higher percentage of men with grade 1 varicocele have low sperm count and thus abnormal sperm quality (35.1% vs. 31.4%).

Accordingly, men with grade 1 varicocele and abnormal sperm quality normally see a significant improvement in sperm parameters, 6 months post-surgery, which increases the probability of spontaneous pregnancy according to a validated nomogram. This is most likely to occur in men presenting with poor testicular tissue health and or testosterone levels below average.

Grade 2 Varicocele

Men with grade 2 varicocele have on average 32% lower sperm count per milliliter than men with grade 0 varicocele. As a result, a much higher percentage of men with grade 2 varicocele have low sperm count and thus abnormal sperm quality (40.4% vs. 31.4%).

These men also display increased levels of reactive oxygen species, lower testicular volumes and decreased tissue health compared to men with grade 1 varicocele. Consequently, men with grade 2 varicocele and abnormal sperm quality often see a significant improvement in sperm parameters, 6 months post-surgery.

Grade 3 Varicocele

Men with grade 3 varicocele have on average 64% lower sperm count per milliliter than men with grade 0 varicocele. As a result, a majority of men with grade 3 varicocele have low sperm count and thus abnormal sperm quality (54.9% vs. 31.4%).

These men also display significantly lower testicular volume and tissue health compared to men with grade 2 varicocele resulting in significant changes to hormone levels (low testosterone, high FSH). Therefore, men with grade 3 varicocele and abnormal sperm quality normally see the greatest improvement in sperm parameters, 6 months post-surgery.

This improvement in sperm parameters and of course testicular health means 16% of men with grade 3 varicocele achieve spontaneous pregnancy 6 months post-surgery. Comparatively, only 1% of men with grade 3 varicocele had a spontaneous pregnancy whilst waiting 6 months for surgery.

As shown above, the probability of pregnancy slowly increases to 41% of men 3 years after varicocele surgery. This suggests the reversal of testicular atrophy and restoration of spermatogenesis is a slow process with no guarantees. In fact, 3 years after grade 3 varicocele surgery, almost 6 in 10 men would still need Medically Assisted Reproduction (MAR) treatment to help them conceive.

A Final Tip from Fertility SCIENCE

Determining whether or not varicocele treatment will improve your sperm quality and fertility is challenging for doctors.

Although sperm concentration (i.e. sperm count per ml) is negatively impacted by varicocele, experts consider total sperm count a better indicator of spermatogenesis function since it is less variable (i.e. not affected by fluctuating semen volume).

However, natural conception also requires motile sperm. Thus studies reporting fertility outcomes always report total motile sperm count (TMSC) or total progressive motile sperm count (TPMSC).

So even though studies clearly show that varicoceles negatively affect sperm parameters, only 1 in 2 infertile men see a significant improvement in TMSC post-surgery. Unfortunately, this means for almost 50% of men with varicoceles corrective surgery fails to downgrade the initial fertility treatment option according to Samplaski et al.

In this same study 40% of men (82/205), who initially required IVF or IUI treatment, recorded a sufficient TMSC post-surgery for natural conception. This corresponds with the results of Abdel-Meguid et al. which found 1 in 3 men achieve spontaneous pregnancy within 12 months following varicocele surgery.

Overall, most studies report that the greater the change in TPMSC (and TMSC) post-surgery the more likely the male will conceive naturally. A large increase in TMSC is most likely to occur among men with:

• Larger varicoceles
• Low testosterone
• Elevated testicular shear-wave elastic modulus
• Testicular atrophy

In men with normal sperm parameters, but elevated sperm DNA fragmentation, varicocelectomy significantly decreases DNA fragmentation after 12 months (14.8% vs. 22.3%).

However, only 1 in 3 of these men achieve spontaneous pregnancy during the 12-month follow-up period. This result highlights the need for men to undergo thorough examination of other known causes of infertility (i.e. anti-sperm antibodies, genetics etc) before electing for varicocele treatment.

fertilPEDIA

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