Varicoceles are enlarged scrotal veins that lie next to the testicle or testicles. Varicoceles can be associated with loss of testicular size, testicular pain and infertility. Varicocele repair, also known as varcocelectomy, has been reported to improve results of semen analysis and its use in the treatment of male factor infertility has been well established.
In Vitro Fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI) has also been used very effectively in the treatment of male factor infertility. IVF with ICSI involves the injection of single sperm into individual eggs in order to produce embryos. These embryos are allowed to mature outside the body into blastocysts. A single blastocyst is then, typically, transferred back to the female partner.
Because so few sperm are required for IVF-ICSI, many have questioned whether varicocelectomy has any role in improving outcomes. Even in cases where sperm counts are too low to pursue the more primitive technique of Intrauterine Insemination (IUI), there are often a million sperm or more beyond what is necessary to pursue IVF with ICSI. So even if varicocele repair results in improved semen parameters, does it actually matter? Are IVF pregnancy results improved?
The surprising answer is that literature supports the fact that it does. A 2016 retrospective meta analysis by Kirby at al, (Fertil Steril. 2016;106(6):1338) examined the effect of varicocelectomy repair on pregnancy rates after IVF with ICSI. Although pregnancy rates did not show significant improvements, live birth rates actually did.
Within that meta-analysis, one study cited, Esteves et al (J Urol. 2010; 184: 1442), revealed significantly higher pregnancy and live birth rates in a report comparing results of 80 men who underwent varicocelectomy prior to IVF vs162 men who did not.
Still, the decision of whether to perform varicocelectomy involves additional considerations. First, it is a minor surgical procedure for the male. Every procedure (including IVF with ICSI) involves risks and benefits. Second, improvements in semen parameters usually don’t occur for at least 3 months after the procedure is performed, adding more waiting time for the couple.
On the other hand, varicocelectomy sometimes offers a chance at avoiding IVF-ICSI altogether. I have personal recent experience in performing varicocelectomy on a patient who had a sperm count well below one million per ml (referred as severe oligospermia). The patient elected to have a microsurgical varicocelectomy. Four months after surgery, his sperm density increased to nine million per ml and a few months later, he and his wife conceived naturally. Certainly, that is not what always happens, but it is important to realize that sometimes it can.