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Varicocele Ligation

What is a varicocele?

A varicocele is a bundle of enlarged veins in a man's scrotum, which is the sac that holds the two testicles. The veins are usually visible as lumps on the scrotum and feel like a bag of worms when massaged gently. The veins become enlarged because some of the tiny valves inside the veins don't close properly. The valves normally prevent blood from draining backwards. When the valves fail, blood pools in the veins, causing them to swell. Many men don't realise they have a varicocele because the veins typically don't hurt and don't change the feeling of orgasm or ejaculation.

How common are varicoceles?

About 20% of the male population have some kind of varicocele. Varicoceles are probably the result of very subtle genetic effects which, at present, remain unknown. Sometimes varicoceles begin to form in the teen years, which is cause for concern. Untreated adolescent varicoceles can result in under-sized testicles, lower semen volumes, and lower sperm counts.

But varicoceles can happen at any age…and in general, the older you are the more likely you are to have a varicocele.

How does a varicocele affect my fertility?

Sperm are made in the testicles, which hang in the scrotum away from the body. This design is required because testicles need to be slightly cooler than normal body temperature to make sperm. Anything that warms the testicles will hurt sperm production. This is what a varicocele does. The extra blood pooling in the enlarged veins warms the nearby testicle unnaturally and cuts sperm production.

How are varicoceles diagnosed?

Since they seldom cause any pain or discomfort, most varicoceles are discovered during routine physical exams, or exams associated with an infertility work-up. Urologist typically diagnose varicoceles by asking the man to stand up, take a deep breath, and bear down while the physician feels the scrotum above the testicle. If a varicocele is suspected, the urologist may order a scrotal ultrasound test.

How can a varicocele be fixed?

Varicocele repair surgery is relatively simple. The goal is to locate the distended veins and tie them off to prevent blood from pooling. There are three main surgical techniques used to correct a varicocele and one non-surgical technique. Which method is best depends on the particulars of a man's anatomy, the nature and location of the varicocele, whether previous surgery has been performed, and other factors such as surgeon preference and/or amount of experience.

Most commonly, surgery is performed through a single incision in the lower abdomen on the affected by the varicocele. Complications from varicocele repair are rare, but include the persistence or recurrence of the varicocele, formation of a fluid-filled space called a hydrocele, and injury to the testicular artery.

The affected veins are ligated, or tied off, to detour the flow of blood into normal veins. Sometimes a laparoscope is used to perform the surgery. Recovery time depends on the type of surgery, but most patients require up to six weeks before heavy lifting and other strenuous activities can be performed. Light activities may be resumed more quickly.

The non-surgical procedure for varicocele repair is called percutaneous embolisation and it is much less commonly used than surgery. In this procedure a special tube is inserted into a vein in either the groin or neck and guided to the varicocele. Once in position, a tiny coil or balloon is released that blocks the veins.

What are the advantages of varicocele embolisation vs varicocele surgery?

Unlike varicocele surgery, embolisation requires no incision, stitches, or general anaesthesia. Further, embolisation patients almost never require overnight admission to the hospital. In addition, several studies have shown that embolisation is just as effective as surgery. Studies have also shown that with embolisation, patients return to full activities in a day or two, but varicocele surgery patients may need to avoid strenuous activity for several days or even weeks. Some complications of varicocele surgery, such as hydrocele (fluid around that testicle) and infection are virtually unheard of after embolisation. Minor complications such as bruising at the catheter site, nausea or low-grade backache may occur after embolisation but are uncommon.

Do I need any special tests before surgery?

No special preoperative tests are needed before a varicocele repair other than the standard lab tests required by some hospitals.

What type of anaesthesia is used?

Varicocele repair is performed under general anaesthesia because it affords maximum patient comfort during the surgery.

What should I expect after surgery?

Varicocele surgery is usually done as a day case procedure, and recovery is usually rapid. Pain is usually mild. Swelling around incisions usually goes away after several days, and discoloration of the scrotum will resolve in a week or so. You shouldn't lift anything heavy or exercise strenuously for two weeks, although office work can typically be done one to two days after surgery.

How soon can I have sex after surgery?

It is generally best to wait three weeks after the surgery before resuming any type of sexual activity.

When will I know if the surgery was successful?

If the procedure is performed for infertility, It takes about three months for sperm cells to be created and matured. A follow-up semen analysis is thus usually obtained three to four months after the surgery. The physician will evaluate the number and health of the sperm and compare this with a sample taken before the procedure. Improvement is often seen within six months, but may not be observed until one year after the surgery. Semen quality is improved in about 60 percent of infertile men undergoing correction of a varicocele.

What are my options if the repair doesn't solve the problem?

If a man's semen quality does not improve after varicocele repair, and if other potential sources of infertility are ruled out (such as an infection in the reproductive tract) several options remain to allow the man to father children. One option involves taking healthy sperm from a man's ejaculate and using this for in-vitro fertilization (IVF). If a man has no sperm in his ejaculate, sperm may still be obtained through a minor surgical procedure (sperm retrieval) which extracts sperm directly from the testicles and/or epididymis.