Varicocele is the enlargement of testicular veins, that is, varicose veins. It is usually seen on the left. It is a disorder seen in approximately 15-20% of men. Varicocele disease, which is not life-threatening, causes problems such as infertility and erectile dysfunction (ED, erectile dysfunction, erection failure, premature ejaculation). Male infertility due to this disease is highly corrected with surgery. One of the questions our patients frequently ask and wonder about is whether it is possible to have children after varicocele surgery. In this article, I will give up-to-date information about being able to have children after varicocele surgery (varicocelectomy) and its possibilities, with the help of our own experiences and the literature.

Do all varicocele diseases cause infertility?

Varicocele is one of the main diseases that causes infertility in men. The most important feature is that its treatment is possible. If there is infertility due to this disease, the chance of treatment with surgery is high. It is one of the causes of infertility that can be corrected by surgery. It is a disease that occurs in 30-40% of the causes of infertility. In other words, 30-40% of men who cannot have children have this disease.

Which is the most effective method of treatment?

There are various treatment methods for varicocele treatment. The most effective treatment is surgery, that is, surgical treatment. Recently, the embolization method has also been used. Here, dilated veins are embolized with special substances. This method is a very old method. It is a method that has been abandoned because its success rate is low. It has come to the fore again in recent years due to advances in embolization materials and techniques. Successful results have been reported. The most important disadvantages of this surgery are that it cannot be performed everywhere, it requires experience and recurrence. In varicocele, there is not always enlargement of the veins within the spermatic cord, but in some cases there may be abnormally located veins. These veins may be missed during embolization. For these reasons, the most effective and successful method in the treatment of this disease is varicocele surgery performed with microsurgery. We also apply this method to our patients. The recurrence rate with the microsurgery method is low and the success rate is quite high.

What is the rate of having a child after varicocele surgery?

Success after varicocelectomy varies from patient to patient. The success rate of surgeries performed using the microsurgery method is high. On average, there is an improvement in sperm values ​​in 60-80% of patients who undergo varicocelectomy surgery. The normal pregnancy rate is 43% one year after the surgery and 69% two years later. The average pregnancy rate after this surgery is generally between 20-60%. As a result of comparing patients with varicocele disease with those who did not have surgery, 44% of those who had surgery had children within 1 year, while the rate of having children within 1 year was found to be 10% in those who did not have surgery. As can be seen from these results, surgery significantly positively affects the rate of having children. For these reasons, we strongly recommend surgery, especially in patients with high-grade (grade 2 and grade 3) disease.

What are the factors affecting success after surgery?

The success of this surgery varies depending on the patient. The same results cannot be achieved in every patient. We can list the factors affecting success after varicocele surgery as follows:

• Age of the patient: Studies have reported that the success rate is lower in surgeries performed at later ages. Recovery after varicocelectomy was found to be lower in patients aged 40 and over than in younger patients. In this regard, patients should have surgery as early as possible. The age of a woman is also very important in order to have children.
• Presence of testicular atrophy: Due to this disease, unilateral or bilateral atrophy (shrinkage) may occur in the testicles, depending on whether the disease is unilateral or bilateral. The success rate after surgery is lower in those who develop testicular atrophy.
• If the sperm count is very low: If the sperm values ​​of the patients are extremely deteriorated before the surgery, the possibility of recovery after the surgery is lower. Studies have shown that if preoperative values ​​are below 10 million, the chance of recovery is less. Improvement can be achieved with additional supportive treatments.
• Grade of varicocele: Some studies have reported that postoperative success is related to grade. The success rate is also low if the disease is advanced and sperm values ​​are very deteriorated and testicular atrophy has developed. Some studies have shown better recovery in patients with higher grades.
• General health condition of the patient: If the patient has diseases such as high blood pressure and diabetes, recovery after surgery is less likely.
• Obesity: Excess weight negatively affects testicular functions. If patients are obese, it is very important for them to reach their ideal weight.
• Alcohol and cigarette use: Excessive alcohol and cigarette use affects testicular functions very negatively. Sperm values ​​in these patients are lower than normal. Alcohol and cigarettes are directly toxic to the testicles. In order to achieve high success after surgery, patients must quit alcohol and smoking habits.
• Sedentary life, unhealthy diet: Fertility functions of patients with inactive, sedentary lives and poor nutrition are negatively affected. It is important for patients with varicocele to eat healthy and live an active life after surgery.
• Female factor: Sometimes infertility may not be solely due to men. The female side should also be evaluated by a Gynecologist. If there is a female factor, then the pregnancy rate after surgery will not be very high.
• Genetic causes: Infertility may also be due to genetic causes. In such cases, the improvement in sperm values ​​and the pregnancy rate are lower after varicocelectomy. In these cases, detailed genetic evaluation should be performed.
• Surgical technique: One of the factors affecting success after varicocelectomy is the surgery performed and the experience of the surgeon. Microsurgical varicocelectomy gives successful results if performed in experienced hands.

Are additional treatments necessary to increase the success of the surgery?

During follow-ups after varicocelectomy surgery, additional supportive treatments may be given depending on the situation. These treatments should be given with the recommendation of an experienced specialist. With supportive treatments, an improvement in sperm values ​​and an increase in the pregnancy rate can be observed. Since unconscious treatments may have negative effects, a Urologist should definitely perform this treatment.

Is in vitro fertilization successful in a patient with varicocele?

In vitro fertilization is a successful method for couples who cannot have children in appropriate cases. Here, patients need to be evaluated carefully. If assisted reproductive techniques are to be performed on hedges, the man must be evaluated by a Urologist. Studies have shown that the success of assisted reproductive techniques is low in men with varicocele. It has been shown that the results are more successful in cases where in vitro fertilization method is applied after varicocelectomy.

Will testicular atrophy be corrected after surgery?

One of the important complications of varicocele is testicular atrophy. Particularly in patients with grade 2 and 3 varicocele, testicular size reduction (testicular atrophy) may develop over time. If this condition occurs in childhood before puberty, it is corrected by surgery and the testicle returns to normal size. If testicular atrophy due to varicocele develops in adulthood, this condition cannot be corrected by surgery. Surgery is effective in preventing subsequent testicular damage. In patients over the age of 18, atrophic testicles cannot return to normal size with surgery.

Is testosterone therapy required after surgery?

Testosterone is important for sperm production. Hormone levels may also be irregular in infertile patients. Hormone levels should also be checked in these patients. Testosterone levels may be lower than normal in patients with testicular atrophy. Appropriate treatment should be planned for patients with hormonal imbalance.

Do unmarried patients need surgery?

These patients can be detected during or after adolescence. Unmarried patients generally do not go to the doctor because they have no complaints. Most of the time, they consult a doctor with complaints of swelling around the testicles and visible vascular dilation. As the disease lasts longer, it can cause more damage to the testicle and cause infertility in the future. In this regard, especially those with significant varicocele (grade 2, grade 3) need to undergo surgery as it will cause infertility in the future, even if they are single.

What is the importance of varicocelectomy surgery for having children?

After varicocelectomy surgery, not all patients recover and have children. Postoperative recovery varies from person to person. We can list some important advantages of this surgery as follows:

• It is possible for some patients to have children through normal intercourse.
• Some of the patients who cannot have children normally can have children through intrauterine insemination (IUI), that is, vaccination, without the need for advanced assisted reproductive techniques.
• If assisted reproductive methods are to be used, the success of these methods is higher after varicocelectomy.

Is the pregnancy rate high after subclinical varicocelectomy?

Subclinical varicocele means varicocele that cannot be detected in the urological examination of the patient but is detected by scrotal ultrasonography (scrotal USG). Surgery in these cases is controversial. In such cases, there is not much improvement in sperm parameters after surgery. Surgery provides more significant improvement in patients with significant varicocele. Therefore, surgery is controversial in subclinical cases. Other reasons should be investigated.

Is it possible to have children with varicocelectomy in cases of genetic infertility?

Couples who cannot have children and have varicocele may sometimes have genetically-related infertility. In these cases, the chance of improvement in sperm values ​​and having children after surgery is low. It is necessary to investigate patients in this aspect and make appropriate treatment planning.

In conclusion

Varicocele is an important disease among the causes of male infertility. It is highly possible to treat it with surgery. The most effective and gold standard treatment method is varicocele surgery performed using microsurgery. Recovery and having children do not always occur in every patient. The success rate in subclinical cases is lower than in grade 2 and 3 cases. To increase post-operative success, additional treatments can positively affect sperm quality and the chances of having a child. After the surgery, the Urologist starts appropriate supportive treatment. Even if surgery is not always successful, it increases the success of assisted reproductive techniques.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY