Varicocele surgery or continue with IVF?

[zbexbj]

My partner (32M) and I (32F) are supposed to be starting IVF in 4 weeks. We're in the UK and this will be our only NHS funded round, after this we'd have to self-fund.

However, this morning he was told he has a grade 2 bilateral varicocele. This is really frustrating because this is the second test he's had for a varicocele and the first urologist said he didn't have one (I'm thankful we double checked now!). His SA results aren't awful - most recent had count at 150m, progressive motility at 58% (total 76%) and morphology at 4%.

For context, we are also waiting for the results of a DNA fragmentation test which seems to be linked to varicoceles. So, if that's high, I'm conscious that may impact our chance of successful IVF.

So here's our dilemma: do we push back the IVF and get the varicocele removed or do we press ahead?

Pros of pushing it back: 1) his SA could be improved, maybe even to the point we could conceive naturally, and 2) given we only have one NHS funded round, we want to give ourselves the best possible chance of success.

Cons: 1) We've already waited so long to get here. NHS wait times are probably ages (it took 8 months to get a urology appt) and it looks like it costs >£3k to do it privately. 2) From what I can tell, surgery doesn't guarantee improved fertility so we could be taking a hit financially and prolonging the heartache for nothing, 3) the procedure carries risk, although that seems relatively low.

Has anyone been in this situation or can offer any advice? We will speak to the fertility clinic but would be interested to hear advice and experiences to help us weigh up the decision. Thanks!

[DianeArnold Partner Nurse Fertility Network UK]

Hi. Unfortunately, I don’t think surgery would guarantee success, nut he would feel more comfortable, and he wouldn’t be generating extra heat. I suppose it depends how long your funding lasts for, then decide. Good luck. Diane

[zbexbj in reply to DianeArnold]

He doesn't have any discomfort so any surgery would be purely to try to improve fertility. Do you know how we find out how long the funding lasts? Thanks for your response!

[DianeArnold Partner Nurse Fertility Network UK in reply to zbexbj]

Hi. You would need to contact who issued your funding, and get it in a letter or email for proof. Diane

[soccerkt6]

Hi lovely,

Once you get the results of the DNA frag test back it will help clarify a lot of these questions for you but, assuming your partner's DNA frag comes back high, I would defintely recommend pushing the IVF back and having the varicocele treated first.

As for the concerns you've noted:

1) the NHS won't treat varicoceles unless they're causing the man pain or discomfort. Infertility isn't considered a valid reason for treatment. 😑 So, unless the varicoceles are causing your partner discomfort or he's willing to say they are, you're going to have to go private anyway. ☹️

2) it's true that treating a varicocele doesn't guarantee an improvement in fertility, but it's good to remember that IVF doesn't guarantee anything either. And in the grand scheme of fertility treatments, treating a varicocele is less invasive, less costly and less physically and emotionally draining than IVF. To me, it's a sensible thing to check off the list before starting down the IVF route.

3) financially, if you treat the varicocele first and then do the IVF cycle (which, let's assume you're lucky and is successful on the first round), you'll have spent £3-£5k on the varicocele that maybe wasn't necessary...but, you'll have a baby and you won't care about the money spent. 🙌 However, if you go straight to IVF and it's not successful, you're then looking at paying another £5k or so for a fresh IVF cycle, plus you'll prob want to treat the varicocele (£3-£5k) before starting the next round. That's a potential £10k outlay all at once, which is quite a bit more daunting. (Of course, there's also the possibility that you go straight to IVF and it works the first time, but the reality is it takes more than one IVF cycle for most people to get pregnant. Personally, I wouldn't wager on this outcome though it does of course happen for some.)

4) the risk with varicocele treatment is very low. It's no more risky than the surgeries (ie. egg collection) that happen with IVF. That being said, I would seek out a doctor that specialises in varicocele treatment in order to minimise any risk. Dr Steven Moser (varicocoeleuk.co.uk/) came highly recommended by our urologist and he was brilliant. We went with him for my husband's varicocele embolisation and wouldn't hesitate to go to him again. (Just in case you're not aware, there are two ways to treat varicoceles - embolisation or surgery. Our urologist said not to bother with surgery and to go with embolisation. It's less invasive, has a much faster recovery time, and when done by a specialist like Dr Moser, has a higher success rate than surgery.)

I'm happy to answer any other questions you have! Hopefully you'll get the DNA frag results back soon so you can figure out next steps! xx

[zbexbj in reply to soccerkt6]

Thanks so much (again!) for your very helpful response!

This all makes total sense and is exactly what I’m thinking. If the DNA fragmentation results come back okay, I think we’ll probably go ahead with the cycle as planned (subject to the fertility clinic’s recommendations). If it’s high then we’ll push it back and do the varicocele embolism first.

Thanks for sharing your recommendation for Dr. Moser. Out of interest, do you know how much success varies for the procedure? I ask because there’s a chance we may be able to get it covered through my work medical insurance but it doesn’t look like he’s registered there. I’m wondering how important the choice of consultant is.

[soccerkt6 in reply to zbexbj]

Of course! I think male factor issues in fertility are so often waved away or under-diagnosed that I'm happy to share what I've learned. Sorry my responses are so lengthy though... 😂

I think normal success rates for varicocele embolisation are around 90% and Dr Moser's are around 99%. So the vast majority of them seem to work no matter what. If you're curious though, I would contact Dr Moser via the contact link on his website. We did that and actually got a random call from him around 8pm a few nights later to discuss our case (apparently he sometimes calls patients on his drive home from work! lol). You could tell him what you're thinking and ask if he has any recommendations for other doctors who specialise in varicoceles that might be covered under your insurance. He's such a lovely man so I'm sure he'd be happy to help.

PS - Just out of curiosity, which IVF clinic are you with? I know you'd mentioned earlier that they suggested doing a DNA frag test after your husband's low morphology result and I was pleasantly surprised. I hadn't really heard of any clinics proactively suggesting DNA frag tests until couples had gone through several failed cycles.

[zbexbj in reply to soccerkt6]

Oh please don’t apologise for lengthy responses! We’ve waited so long to get any answers so it’s so so useful. Just trying to make the best choices to try minimise cost, time and stress we have to put into this!

Also totally with you on MFI being so overlooked - I found it crazy that I went through so many tests before they even knew my partner’s name 🤣

That’s a good idea to give him a call, will do that. He’s managed to get an appointment with a well reviewed specialist on Monday through BUPA so hoping that will move things along.

We’re at Kings in London and yeah, cause our case is borderline unexplained, I guess that’s why she suggested it. It’s slightly frustrating as we asked to have it a few months but they refused until we were ‘under their care’

Thanks again!

[Hopewhite in reply to soccerkt6]

Hi thank you for sharing this , I hope you’re well. I’ve PM you if you don’t mind sharing more of your wisdom on this topic , as I feel is something we should explore although our NHS doctor hasn’t recommended anything other than ICSI , so a bit lost on where to start with it ! Thank you 🙏

[soccerkt6 in reply to Hopewhite]

Hi lovely, I'm so sorry for not responding to your PM yet! I started writing something and then got interrupted, and next time I went to my computer my message had disappeared. 🙄 I'll reply to you now xx

[Sarakht]

we had severe male factor. Please don’t waste time with the nhs! Go straight to ivf