Aetna considers percutaneous embolization (by means of balloon or metallic coil) medically necessary for the treatment of varicocele for any of the following conditions:

1. Adolescents with grade 2 or 3 varicoceles associated with ipsilateral testicular growth retardation; or
2. Males with infertility problems who have decreased sperm motility and lower sperm concentrations; or
3. Scrotal pain associated with varicoceles; or
4. Post-surgical (ligation) recurrence of varicoceles.

Aetna considers percutaneous embolization of varicoceles for persons who do not meet these criteria experimental and investigational.

Varicoceles (dilations of the pampiniform venous plexus) are found in 10 to 15 % of the male population and they occur predominantly on the left side. The etiology may be a longer left spermatic vein with its right-angle insertion into the left renal vein and/or absence of valves, which results in a higher hydrostatic pressure in the left spermatic vein causing dilatation. Also, the left renal vein may be compressed between the superior mesenteric artery and the aorta. This “nutcracker phenomenon” may result in elevated pressure in the left testicular venous system. Moreover, the incidence of varicocele in men with impaired fertility is about 30%; varicoceles are the most common surgically correctable cause of male infertility. A clinical grading system classifies varicoceles into three grades: (i) grade 1 (small) -- palpable only during a Valsalva maneuver, (ii) grade 2 (moderate) -- palpable without the need of the Valsalva maneuver, and (iii) grade 3 (large) -- visible.

Although varicoceles can be diagnosed by a thorough physical examination, ultrasonography is the most practical and accurate non-invasive method in diagnosing this condition. Surgical ligation (varicocelectomy) is the conventional approach in managing varicoceles. However, percutaneous embolization by means of balloon or metallic coil has been shown to be a safe and effective alternative to ligation in treating varicoceles. Embolization (of spermatic veins) of varicoceles in males with semen abnormalities has been demonstrated to improve sperm count and motility in up to 75% of patients, and reported pregnancy rates after ablation of varicoceles vary from 30 to 60%. Furthermore, embolization therapy has been reported to increase testicular size in adolescents with testicular hypotrophy.

Polito and colleagues (2004) stated that the impact of varicocele on male infertility is still controversial since its role on the impairment of semen quality has never been fully demonstrated. These researchers studied a series of young adult males (n = 426) undergoing percutaneous treatment of varicocele and semen parameters were evaluated at baseline and 12 months of follow-up. They concluded that the correction of varicocele in young adults is not a major indication when semen alteration is the only clinical problem. This is in agreement with the findings of Nabi et al (2004) who compared the semen quality in men with or without pregnancy after percutaneous embolization of varicoceles in the management of infertility (n = 102). They concluded that varicocele embolization is a technically feasible, minimally invasive, outpatient procedure that improves semen quality significantly in patients with a pre-embolization semen density of 10 to 30 million/ml. However, no correlation was found between the improvements in semen quality and the pregnancy rate.