Varicoceles Impact on Male Fertility
A male factor fertility problem is identified in up to 40% of all infertile couples and it is therefore prudent to evaluate the male early on in the diagnostic process. The causes of male factor infertility can be hormonal, genetic, environmental, medication side-effects, and even structural. One structural condition that is at times associated with male factor infertility is the presence of dilated veins in the scrotum. This condition, called scrotal varicoceles, can disrupt the precise temperature requirements that are critical for normal sperm production. Scrotal varicoceles are primarily located on the left, as these veins are longer in length.
Varicoceles typically develop during adolescence, yet in some men, the negative impact on fertility occurs over an extended period of years. In fact, infertility related to a varicocele appears to be more common in couples who have already achieved parenthood, a situation known as secondary infertility.
A physical examination by a qualified male fertility specialist coupled when indicated with a scrotal ultrasound can confirm the diagnosis of a varicocele. Scrotal varicoceles can impact semen parameters like concentration motility and shape (morphology) as well as more advanced evaluations of sperm performance such as DNA fragmentation and the ability to undergo required physiological steps for fertilization such as capacitation. We are one of the few fertility centers offering an assay to assess sperm capacitation and thus better define sperm competency and the potential impairment associated with a varicocele.
One of the goals of diagnosing the presence and impact of a varicocele is to consider repair of the condition to enhance and optimize the male factor contribution. For trained male reproductive specialists and in the absence of confounding female fertility concerns a surgical correction utilizing a sub inguinal microscopic technique is often preferred. This is performed as an ambulatory procedure utilizing a small 2 cm incision in the region above the scrotum and men can often return to normal physical activity within 5 – 7 days of the procedure.
The goal in correction of a scrotal varicocele is to improve semen parameters and thus potentially enable a couple to improve their chances of conceiving naturally or with minimally invasive interventions such as intrauterine inseminations. The positive impact of a varicocele repair on IVF/ICSI outcomes as well as in cases with severely low or absent sperm while documented in the literature is more controversial. The process of performing an IUI entails the production of a fresh sperm ejaculate, subsequent filtering and concentrating the semen sample and then injecting it directly into the female uterus where it is much closer to the oocyte. This procedure is timed to the female ovulation period and can be done naturally or with medications that would either produce additional oocytes and or precisely time ovulation. An IUI’s success rate is approximately 10-20% per attempt and thus may need to be repeated several times to achieve a pregnancy. An IUI is a significantly less involved intervention than IVF /ICSI, and in the right subset of patients, repairing a scrotal varicocele may increase the chance of an IUI working and of a couple to achieve parenthood.