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Varicocele – A Dilemma for the Urologist
Awareness of the potential damage associated with long-standing
Figure 1: Algorithm of Indications and Benefits of
varicoceles has motivated urologists to become more conscientious in
Varicocele Repair
their pursuit of adolescent varicoceles. The decision of when to treat
Subclinical
adolescents with varicocele is controversial, since 80% of adults with
Varicocele
varicocele are fertile.
57
Routine surgery is inappropriate for all
Treatment not
adolescents since it is not cost-effective and fertility will not necessarily
recommended
be affected by the varicoceles. Non-selective surgical intervention Palpable lesion
would submit a large population of boys to unnecessary surgery. On
the other hand, it is unacceptable to allow potentially irreversible
Adult men
Adolescents
Infertile couples
testicular damage to manifest with infertility as adults. Adolescent
Normal female partner
not attempting
to concieve
varicoceles are often associated with testicular volume loss, endocrine
abnormalities and abnormal seminal parameters.
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After varicocele
Reduced ipsilateral Abnormal seminal Abnormal
testicular size parameters
Azoospermia
semen analysis
diagnosis, patients should be evaluated for testicular volume and
consistency. Varicocelectomy is indicated when a palpable varicocele is
associated with ispilateral testicular growth retardation greater than
Preserve testicular Improve semen quality May avoid invasive Varicocele repair
growth and fertility May improve fertility testicular sperm may be offered to
2ml or two standard deviations compared with the normal testicular
Downstage or shift the retrieval procedures preserve fertility
level of ART needed
curve. Additionally, it should be considered in boys with bilateral
varicoceles or a solitary testis, since testicular growth retardation may
not be evident in this population. Physicians may discuss the possibility
of seminal analysis for older adolescents to help with the decision to concerning the optimal management of asymptomatic varicocele in
treat, although few studies have evaluated the normality of seminal adolescents, parents should be made aware of the possibility of
parameters in adolescents with varicocele, most likely because of subsequent infertility.
ethical concerns related to the procurement of semen specimens in
young boys.
59,60
If seminal parameters are abnormal and high-grade Induction of Spermatogenesis after Varicocelectomy in
varicocele is present, surgery should be considered even with bilateral Azoospermic Men
normal testicular volume. Non-obstructive azoospermia in association with a varicocele is
estimated to range between 5 and 10% in adults.
73–75
Tulloch, in 1955,
As in adults, exaggerated GnRH response to stimulation has been reported the return of spermatogenesis and subsequent pregnancy after
detected in adolescents with varicocele.
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Adolescents with a palpable varicocele repair in an initially azoospermic patient, renewing attention
varicocele and abnormal gonadotropin stimulation test responses may on varicocele treatment.
76
After varicocele repair, motile sperm are
benefit from varicocele surgery.
62
In addition, in adolescents large found in the ejaculate of azoospermic men in 21–55% of cases,
varicoceles that are associated with debilitating ispilateral testicular although spontaneous pregnancies are rare.
74,75,77
Varicocele repair in
pain should be considered for repair.
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this population may avoid the need for subsequent testicular sperm
retrieval procedures because they can provide sperm via ejaculation.
A rapid catch-up growth of the affected testis after varicocelectomy has
been consistently reported in 50–80% of adolescents and suggests that Even though an improvement in spermatogenesis is seen in up to half
early intervention is effective as well as defensible.
59,64–67
In addition, of the patients, assisted reproductive techniques will be necessary for
semen quality improvement has been demonstrated.
68–70
Recently, in an the majority of these couples to initiate pregnancy.
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Fertilising ability
uncontrolled study Salzhauer et al. showed high paternity rates among and ICSI success rates are superior when fresh motile ejaculated sperm
men who underwent a varicocele repair during adolescence.
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is used compared with sperm provided by testicular biopsy or
microsurgical testicular sperm extraction.
79,80
In some boys, a varicocele develops immediately before puberty when
the testis is immature and vulnerable. Based on testicular size, Although azoospermic patients may exhibit an improvement
evidence suggests that the time of development of a varicocele in in spermatogenesis after varicocelectomy, a gradual decline in
spermatogenesis and return to azoospermia has been reported in up to
55.5% of patients 12 months after surgery.
78
These patients may
Based on testicular size, evidence
experience intermittent sperm production, and varicocele repair
suggests that the time of development
may have solely a temporary effect, resulting in the induction of
spermatogenesis for a short period of time. Since these patients may
of a varicocele in relation to puberty
not be able to maintain spermatogenesis, semen cryopreservation is
may be the critical factor in the strongly recommended following the initial improvement after surgery.
subsequent development of infertility.
As mentioned previously, a high prevalence of Y chromosome
microdeletions in azoospermic infertile men exists. Karyotype and
relation to puberty may be the critical factor in the subsequent Y chromosome mapping is crucial in the evaluation of men with varicocele
development of infertility.
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The recognition and treatment of an early- and azoospermia. These patients should be aware of chromosomal
developing varicocele may help to reduce the infertility associated with abnormalities so that they can obtain genetic counselling to stratify their
this condition. In the absence of prospective controlled studies risk of transmission to offspring.
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