PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1631-1633 (doi:10.1542/peds.2003-0625-F)
Paternity After Adolescent Varicocele Repair
* Department of Urology, State University of New York, Downstate Medical Center, Brooklyn, New York
Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. Varicocelectomy has long been a therapeutic modality used in the treatment of male infertility. In the past decade, adolescent varicocelectomy has become a frequent procedure to preserve testicular growth and to help prevent future infertility. Because our clinical population includes a large portion of orthodox Jews who traditionally marry early and are forbidden to use birth control by religious law, we thought that by studying our patients, we might be able to accelerate our follow-up regarding paternity. In addition, we wanted to learn whether adolescent varicocelectomy might have any negative impact.
Methods. Questionnaires inquiring as to the marital and paternity status, postoperative course, and complications were sent to 50 patients who had undergone a unilateral or bilateral varicocele repair during adolescence and who were at least 21 years old at the time of this review. In addition, a careful chart review was performed to examine the perioperative and postoperative parameters of each respondent.
Results. Of the 43 responses (86% response rate), 18 of 18 patients who had attempted to father a child were successful. The remaining 25 were not married or had never attempted to father a child. In the paternity group, 10 of the fathers had undergone an Ivanissevich repair; the remaining 8 had a Palomo repair. Sixteen of the 18 had unilateral varicocelectomies, and 2 underwent bilateral repairs. Of those with a unilateral varicocele, the indication for surgery in 10 was a grade 2 to 3 varicocele associated with a >20% volume difference when compared with the right testicle. Three had 10% to 20% volume loss, whereas the remaining three had unusually large grade 3 varicoceles without concurrent volume difference.
Conclusions. Varicocelectomy in the adolescent population has been proposed as a therapeutic intervention to preserve both fertility and testicular growth. Although not showing a cause-and-effect relationship, it is our contention that varicocelectomy in adolescence at worst does no harm and at best preserves fertility.
Key Words: paternity • fertility • varicocele • adolescence
A varicocele is a palpable dilation in the pampiniform plexus of veins in the scrotal sac secondary to the retrograde flow of blood to the testicle. In male adolescents, just as in adult counterparts, the incidence of varicoceles is 15% to 20%, with a majority presenting unilaterally on the left side.1 Less frequently, bilateral varicoceles are present. Right-sided-only varicoceles are exceedingly rare and should prompt investigation for a retroperitoneal mass that is compromising venous return from the right testicle.
Varicoceles are typically identified in the standing position and are rarely palpable with the patient supine. A painless compressible mass, often referred to as "a bag of worms," will be found superior to and sometimes surrounding the testicle with increased turgidity in the veins as abdominal pressure is increased. During examination for a varicocele, the size and the consistency of the testicle are assessed. The severity of a varicocele is graded as follows2: grade 1, mild, difficult to palpate; grade 2, moderate, easily palpable; grade 3, severe, visible through scrotal wall.
Adult varicocelectomy is an essential therapeutic modality used in the treatment of male infertility.3 The progressive nature of infertility as a result of varicoceles can be seen in the increased incidence from 40% of primary infertility to >80% of secondary infertility (individuals who have previous children and no longer can impregnate their otherwise fertile partners).4,5 In addition, various authors have shown directly in both animal models and human observational studies that both testicular consistency and semen parameters deteriorate over time when varicoceles are not repaired.4,6,7 In addition, when a varicocelectomy is performed in an infertile male adult, the ability to conceive does not necessarily follow. These data have led many urologists to pursue early treatments for varicoceles.
In the adolescent population, as the testicles enlarge, varicoceles begin to develop. As a corollary, varicoceles are rarely seen before the onset of puberty. Although it is impossible to predict which child with a varicocele may present with infertility in the future, there is at least 1 special consideration in this age group: a smaller testicle is often observed on the side of a varicocele. The size discrepancy can be marked and has been coined "hypotrophy." In adolescents with ipsilateral testicular hypotrophy, it has also been shown that catch-up growth can be readily achieved in 50% to 80% of adolescents after varicocelectomy.8–11 Although semen analysis is mostly impractical in this population, at least 1 report has shown improvement in semen parameters after adolescent varicocele repair.12
As adolescent varicocelectomy has been widely performed only in the past decade, there are currently no long-term studies on subsequent paternity. Our clinical population includes many orthodox Jewish male individuals with a large component being drawn from the ultra-orthodox Hassidic community. Considering the customary early age of marriage along with a religious prohibition on contraceptive use, we thought that a follow-up of our patients might provide an early glimpse into the paternity potential after adolescent varicocelectomy. We immediately recognized that any long-term study in this population would have the inherent limitation of an inability to obtain semen analysis studies because such studies are prohibited by religious law. However, as the primary endpoint in our study was achieving fatherhood, not improved semen parameters, we believed that studying the paternity results of our patients would shed some light on the many questions surrounding this disease. Although numerous studies have demonstrated ipsilateral testicular growth and improved semen analysis after adolescent varicocelectomy,5–12 the effect on paternity has not previously been reported; it is in this specific area that we decided to focus.
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METHODS |
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Included in the study were men who underwent a varicocele repair during adolescence and were now at least 21 years old. Patients were included regardless of repair type, indication for surgery, or unilaterality versus bilaterality. Fifty such patients were identified in this manner. Preoperative and postoperative notes were reviewed regarding indications for surgery, grade of varicocele, size of testes, laterality, presence or absence of varicocele, and testis size on follow-up evaluation.
Questionnaires inquiring as to the marital and paternity status, postoperative course, and complications were sent to these patients, and follow-up telephone calls were made when the questionnaire was not returned within 4 weeks. In this manner, we were able to maximize our response rate to 86%. The average age of our respondent at the time of his surgery was 15. The average age of our respondent at the time of review was 24, for an average follow-up of 9 years.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Of the 43 respondents, 18 had attempted to father a child and all were successful (paternity group). The remaining 25 had never attempted to father a child. There was 1 spontaneous miscarriage in the first trimester of pregnancy. In the paternity group, 10 of the fathers had undergone an Ivanissevich repair (inguinal incision, which preserves the testicular artery) and 8 had a Palomo repair (high ligation in the retroperitoneum through a muscle-splitting incision; in this approach, the testicular artery is ligated along with the internal spermatic vein and the vascular supply to the testicle is left dependent on the vassal and cremasteric arteries). Sixteen were operated on for a unilateral varicocele, and 2 were operated on for bilateral varicoceles. The average age of the respondent in the paternity group was 25.
The indication for surgery in 11 of the 16 patients with a unilateral repair was a corresponding testicle that was at least 20% smaller by volume as compared with the contralateral testicle. Three of the 16 had a 10% to 20% volume difference between the affected left testicle and the normal right testicle. The final 3 patients in the unilateral group had unusually large grade 3 varicoceles with very turgid veins on valsalva. Of the 11 patients with a 20% or greater testicular size asymmetry, catch-up growth had been achieved in 9; 1 had failed to achieve catch-up growth, and 1 patient was lost to follow-up. Of the 2 patients who underwent bilateral varicocelectomy, both had small testicles bilaterally, which grew appropriately after repair of their varicoceles.
Complications included a mild recurrence/persistence in 3 of the 18 patients. Redo varicocelectomies were not performed in 2 of the 3 because of the subclinical size of the varicocele (grade 1) and the successful catch-up growth achieved in the affected testicle. A third patient underwent a reoperative varicocelectomy 2 years after his initial repair. Three patients developed postoperative hydroceles, 1 of which required operative repair; the other 2 were small and asymptomatic. One patient complained of a mild pain in the left groin for several months, which subsided in the first year after surgery.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Approximately 40% of men who are evaluated for infertility have varicoceles, and after varicocelectomy
50% of these men ultimately will father a child.3 In adolescence, controversy still shrouds the procedure and which boys should undergo it. Most would agree with repairing a varicocele in an adolescent with ipsilateral hypotrophy, because follow-up studies have demonstrated an 80% incidence of catch-up growth.8,9 Testicular asymmetry with ipsilateral hypotrophy has been defined by Skoog et al13,14 as a testicular volume differential of 2 mL or more. Others have used a percentage difference in volume as the criteria for hypotrophy. For example, Kass and Bellman9 suggested a volume difference of 20% or more, whereas Gershbein et al8 used a volume differential of 15%. We prefer using a percentage differential when evaluating hypotrophy because a 2-mL differential between the much smaller testicles in early puberty will represent a much more significant difference than in late puberty, when the testicles are much larger. Some have suggested considering an unusually large grade 3 varicocele as an indication for surgery, even without compromised testicular growth.14,15 Sixteen (88%) of the 18 patients in the paternity group in this study were orthodox Jews. This group forbids contraception and places an emphasis on early marriage and child bearing. The typical man in this community marries in his early 20s and has a child by 25 years of age, thus allowing for a study of paternity at an early age. Although comments regarding the outcome of semen analysis in this community are not possible as providing semen specimens is prohibited by religious law, semen analysis after adolescent varicocelectomy has been described elsewhere.12
As men continue to father children well into their fourth, fifth, and even sixth decades of life, the long-term paternity potential of adolescent varicoceles becomes more significant. The literature is replete with studies demonstrating the progressively untoward effects that a varicocele has on fertility with age.4–7,16 Whereas testicular catch-up growth occurs in adolescents who undergo varicocele repair, reversal of atrophy after a varicocele repair in adults does not seem to occur.15
The higher rate of conception in our couples as compared with that reported in the general population is hard to explain. That 100% of couples conceived within 1 year of trying compared with 88% of couples in the general public17 may be explained by the small number in our series and by the younger age of the couples involved.
When obtaining informed consent from parents for varicocelectomy on their adolescent children, often the most important considerations for them regard the effect that surgery or lack thereof will have on their child's future ability to father a child and whether the surgery will cause harm. The data in this series suggest that at least during the first 10 years after adolescent varicocele repair, fertility is preserved. As adolescent varicocele repair has become a more common procedure in the arsenal of the pediatric urologist, the long-term fertility effects beyond the first 10 years will become apparent and studied. As for the second concern, our patient outcomes mirror those in the literature regarding postoperative hydroceles formation and varicocele recurrence.2
A prospective, randomized trial of adolescents with significant varicoceles including both observational and surgical arms would be difficult to accrue patients yet certainly would settle the controversy surrounding this procedure one way or the other. Until that time, these data add to the abundance of literature in favor of surgery in carefully selected patients. We at least have shown that adolescent boys can undergo varicocele repair without significant morbidity and with preserved fertility at least in the first 10 years of postoperative follow-up.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Varicocelectomy in the adolescent population has been proposed as a therapeutic intervention both to preserve fertility and to preserve testicular growth. Although not showing a cause-and-effect relationship, we contend that varicocelectomy in adolescence at worst does no harm and at best preserves fertility and testicular growth.
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FOOTNOTES |
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Accepted May 31, 2004.
Reprint requests to (K.I.G.) Morgan Stanley Children's Hospital of New York-Presbyterian, 3959 Broadway, BHN-1118, New York, NY 10032. E-mail: kglassberg{at}aol.com
No conflict of interest declared.
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- Stern R, Kistler W, Scharli AF. The Palomo procedure in the treatment of boys with varicocele: a retrospective study of testicular growth and fertility. Pediatr Surg Int. 1998;14 :74 –78[CrossRef][Web of Science][Medline]
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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