Varicocele Embolization

Background and indications

Varicocele is a dilation of the spermatic cord veins, comparable to varicose veins, present in approximately 15% of men and up to 40% of men consulting for infertility. It is most commonly left-sided (85-90% of cases) due to the anatomy of the left spermatic vein draining into the renal vein at a right angle. Varicocele can cause testicular pain, scrotal heaviness, and impaired sperm parameters (oligospermia, asthenospermia).

Embolization is indicated for symptomatic varicocele (pain, discomfort) or varicocele associated with infertility and abnormal semen analysis. It is an alternative to surgery (microsurgical ligation, laparoscopic surgery).

Pre-procedure assessment

Assessment includes clinical examination with varicocele grading (grades I to III), scrotal Doppler ultrasound confirming venous reflux, and semen analysis in cases of infertility. Hormonal testing (FSH, LH, testosterone) may be requested.

Procedure

Under local anesthesia, a catheter is introduced through the right femoral vein or jugular vein. Under fluoroscopic guidance, the interventional radiologist catheterizes the dilated spermatic vein and performs phlebography to visualize reflux. Embolization is performed using coils (metallic spirals) and/or a liquid sclerosing agent (polidocanol). The procedure takes approximately 30 to 60 minutes.

Results and scientific evidence

A meta-analysis of 3,505 patients compared percutaneous embolization with surgery and showed a technical success rate of 96% for embolization, with a recurrence rate of 5-6%, comparable to surgery (Ghosn et al., Journal of Vascular and Interventional Radiology, 2022; DOI: 10.1016/j.jvir.2022.07.013).

Improvement in sperm parameters is observed in 60-70% of patients treated for infertility, with a mean delay of 3 to 6 months. Spontaneous pregnancy rate after treatment is approximately 30-40%. Pain resolution is achieved in over 85% of cases.

Risks and complications

Complications are rare: local pain at the puncture site (< 5%), coil migration (< 1%, generally without clinical consequence), contrast reaction (exceptional). The risk of testicular atrophy is virtually nil, unlike some surgical techniques.

Recovery

Return to normal activities is possible the following day. Intense sports activities should be avoided for 1 week. A follow-up Doppler ultrasound is performed at 3 months to check for recurrence. In cases of infertility, a follow-up semen analysis is performed at 3-6 months.

Practical information

The procedure is performed as an outpatient or short inpatient stay depending on the case. It is performed by an interventional radiologist, in coordination with the urologist or fertility specialist.