3 Years

Today is our fourth wedding anniversary.  It marks the 3-year point of our TTC journey.

Something that I find even more shocking, is that I just realized that this day also marks over 5 1/2 years of suffering from infertility... even if we didn't realize it until we were a couple years into it. But it's the number our doctors really care about.

You see, we went off of birth control due to other health-related issues for me in September 2008.  That was nine months before our June 2009 wedding.  We tried to be careful *most* months, using condoms or abstaining when we thought I might be ovulating, but back then I didn't keep a calendar or chart temps or anything.  And some months we honestly didn't care and went for it anyway.  Back then we thought we were lucky that we didn't have any oopsies before our wedding.

Beginning on our honeymoon, we decided we wouldn't start "trying" yet, but we also wouldn't try to prevent.  So we just did whatever we wanted and let whatever happened happen.  A year went by as I finished up grad school and again, we figured we must have just been lucky, since we still had not gotten pregnant before we were completely ready.

Where the three-year-mark begins:

By our first wedding anniversary, in June 2010, I had graduated from grad school, was interviewing for my first real professional job, and we knew the time was finally right.  We'd been together for seven years, been through a lot of milestones together, and everything had finally fallen into place for us.  We were officially ready for the next step, we were going to start our family!  Although even then, I distinctly remember B voicing a faint concern that was beginning to creep into his mind.... why hadn't we gotten pregnant by "accident" yet?  We hoped nothing was actually wrong and we really were "just lucky."

I remember being so excited, I started buying all kinds of books about what to expect before you're expecting, I downloaded an app for my smartphone to track my cycle, I even bought ovulation kits and pregnancy test kits.  I think I also bought my first basal body temperature thermometer at this time, having heard you were supposed to chart your temp but at the time not fully understanding why.

Nearly six months passed, and we were still not pregnant.  I needed to have my yearly exam anyway, so I figured I'd ask what steps should be taken to get us checked out just in case, since several of my friends and acquaintances had been suffering from various forms of infertility.

My OBGYN recommended we start with B getting tested first.    In January of 2011 he did and we got our first analysis with low numbers.  We tested again in April, same.  I started getting all my tests done, everything checked out until the HSG... those results came back with a blockage.

We got a second opinion with a urologist specializing in male infertility.  He did a special test on B's sample to check for sperm defragmentation.  Like all his other counts, they came back on the low-end of the normal range.  That cost us $400 out of pocket.

The new doc wanted me to get a second HSG, I did in July and they were able to break through the block this time.  He suggested we give it a couple months.  Nothing.  In October we did our first IUI.  It didn't work.  We wasted $1300 this time.

Our doctor recommended another IUI, I read on my health insurance website that we could get IVF for $5000 down in Illinois, and a friend's sister was able to gather free meds for me.  We thought we'd go for it, rather than doing a few rounds of IUI which would add up to the same amount quickly anyway.  You can read about what happened with that here.

When we decided not to do IVF in January 2012, we decided to do one more IUI in case B's counts improved at all post-wash this time.  In February we did an IUI cycle, but B's post-wash count came back so low this time, they couldn't even in good faith recommend we proceed with the procedure.  $900 wasted.

The urologist suggested varicocele repair surgery to see if it improved B's counts.  He agreed to the procedure and went under the knife in April 2012.  His counts did not significantly improve by the three or nine month marks post-surgery.  At least our health insurance covered this one.

Here we are, over a year past his surgery, and exactly three years past our official TTC date, and well over five & a half years of unprotected sex and still no baby.  Still no hope for improving our situation naturally.  Just waiting.  Planning for IVF next year.  Sitting alone together in the empty house we bought last year with plenty of room to grow our family.

But at least we are together.  And this is our four-year wedding anniversary.  We do have a lot to celebrate today, and we will.  But I just wanted to take these few minutes first to pay respect to everything we have been through together the last 3-5 years.  The strength it has taken for us to face these difficulties is something to be honored and celebrated too.  So today, we really do have a lot to celebrate.  And hopefully next year at this time, we will have even more to celebrate and plan for, especially if the IVF early in 2014 works and we have the baby of our dreams on the way :)

New Beginnings?

Coming across this article about turning Mother's Day into an empowering day for the infertile, which I blogged about here, and which was written by someone not too far away and kind of close to home (at least the home where part of my heart still is) reminds me that B & I have been thinking more about getting a second opinion before pulling the trigger on IVF next year.  

We had been putting it off because I've been so busy with work and travel, and honestly, for a long time we still had hoped that B's varicocele repair surgery would have worked, but now things are slowing down and we are fairly confident that one year post-surgery, the lack of improvement in his semen analysis is pretty indicative of the surgery's affect on our fertility.  Which is literally nothing.  Zero improvement.

But come mid-June, we'll return from our last scheduled trip in the foreseeable future.  I have asked B to get one more semen analysis done over the summer sometime just to confirm that 1.25 - 1.5 years out from surgery, nothing has changed.  I was thinking about visiting an entirely new clinic and going through all the rigors of female infertility testing again just to double check and see if in 3 years my hormones or blood levels have changed, or if my fallopian tubes are still open, or if my ovaries, cervix, or uterus are all still okay.  I was thinking we could try to find referrals for places that are very "holistically" focused, so that they would consider my cycle more instead of just doing the bare minimum and pushing us toward IUI & IVF like our current clinic.  Our RE just moved back to Canada, so we need to see someone new anyway.  Maybe this is the time to try someplace new just to make sure we've explored absolutely everything before we go into so much debt for IVF.

If we start hunting around in July and spend the summer getting things checked out.... again.... that would still give us six months before IVF to sort it all out definitively.  I think it would also be nice to start some therapy or find a support group at that time too.

Yes, I think upon our return from this last trip in June, much of our focus and energy will need to shift toward building our family and our future.  I'll be sure to blog about those experiences here, as this is my best place to sort through my feelings and record all that I learn along this crazy journey!

A Return to Blogging

I am risen!  Today marks a return to blogging and chronicling my & B's story as we wade through a sea of infertility during our quest to start a family together.  This blog has been conspicuously dormant for the past four months, and very quite for another six months or so before that.  I have been having a silent rebellion against blogging and sharing my feelings with the world for nearly a year, and have finally decided to open up about what has been on my mind and hopefully get back into a regular routine of blogging again.  How fitting that I should make my return on the first day of National Infertility Awareness Week (NIAW), which is recognized April 21-27, 2013.  This first returning post will be my small contribution to the movement, though my busy work engagements this week will not allow me to be much more active than this until the week is over.

My hiatus all started with some comments from friends and family which were well intentioned or at least not meant to be hurtful, but made me feel bad in a way I didn't like, so I slowly stopped sharing my feelings for a while, since so many people who know me personally also follow my blog.  If this was a completely anonymous blog and nobody knew me, I could have shared my frustrations about other people's comments on here as an outlet.  But as it is, I was finding that opening up on here was leaving me vulnerable to painful comments and so I refrained from writing for a while.

Many have been asking me in person why I don't write any more, and looking for updates on our story.  Here we are, one year out from B's surgery and many are wondering if anything has changed.  

I may choose to blog later about the specific comments that made me think twice about opening up in my blog, but only so that people can understand how truly sensitive I am about this stuff and with the hope that it will prevent them or others from making the same mistake again....  or I may just keep silent about it forever because in the end, I know that I am over-sensitive to everything revolving around babies, motherhood, and fertility and nobody with whom I've shared my blog with has anything but concern and love for me, so why would I want to call them out on something that is really my problem anyway?

But for now, I will satisfy everyone's curiosity with an update on where we are one year post-surgery:

No changes.

B had another sample analysis taken a couple months ago, and there were no improvements to any of his counts.  He's pretty much right where he was before the varicocele repair surgery.  Which honestly, wasn't a bad place then either.  He's always been right on the edge.  Always on the low end of normal, or just low enough to be right on the outside of normal.  We always knew the surgery was a shot in the dark, since his numbers did not indicate that the varicoceles were definitively what was causing our infertility, but it was the only treatment we could consider that was covered by health insurance.

With that last sample analysis, we are now pretty much just biding our time until we can try to finance IVF in 2014.  We are always aware of our infertility, but we are barely even TTC anymore, since we don't have hope that the surgery made a difference and it has been technically four and a half years of trying on our own not working (three years of purposefully/actively TTC).  After a while, you just kind of lose hope and give up.  We know our plan is to try to find a way to afford IVF early in 2014, so the end goal seems tangible, like  a light at the end of the tunnel, like the end of this torture is drawing near, and makes each month that we don't get pregnant seem like less of a big deal than it used to be.  

Sometimes.  

Other times things hurt as much as they always have and I can't pull myself out of the pain and depression of wanting what is natural and my human instinct to have, only for my body to work against me and nobody can even tell me why.  

Unexplained Infertility is the worst.

So you're saying there's a chance...

I'm sitting in the Hyderabad Airport, reading yet another book on infertility. Sometimes I wonder why I even bother anymore. I've read so many books by so many different kinds of authors (doctors, patients, nutritionists, homeopathic experts, former infertiles, etc), that by this point, I feel like I've heard it all and there is nothing new for me to learn. Yet each new book does present information in a new way and every now and then I do get inspired by new ideas.

The book I'm reading now on my iPad has a few words on varicoceles. As we know, B had varicocele repair surgery back in April. He had very large varicoceles on one side, and fairly large on the other. Dr. J had said that with most patients, a significant number see improvement in sperm counts and achieve pregnancy after 3 months post-surgery. Then another large percentage will see improvement and pregnancy success after 6 months. A few more after a year.

This book claims that men with large varicoceles may see improvement within 6-12 months after the repair.



This gives me some renewed hope because we are exactly at the 6 month mark as of RIGHT NOW!

I'd actually already given up faith in us seeing any improvement from the surgery, and just figured we were going to have to wait more than a year until we could afford IVF. But if the stats in this book are accurate, then we may now just be entering into our prime time for TTC!

Best part of all, after my ordeal two months ago, I was relieved to get my period on time (like clockwork) while I was here in India. It did last an extra day or two longer than normal, but that is common when traveling, especially with a nearly 12 hour time change, so I'm not worried about that at all. Anyway, my point is, I'll be in my fertile period next week and should ovulate once B joins me for our vacation in Northern India! Maybe the stars will finally align for us and we'll be able to make our own little Indian baby here together ;)

- Posted using BlogPress from my iPad

Maybe things haven't changed so much afterall

OK, so back in March, I wrote a post claiming that a "change" had occurred.  You can read the original post here: http://inconceivablestory.blogspot.com/2012/03/change-has-taken-place.html, but the point of it was that I was trying to say that I wasn't so sad all the time about my & B's struggle with infertility anymore.  I was even trying to come up with justifications for the idea that it might be better to live "child-free."

So, the truth is, I don't think anything was changing inside of me, and I don't think I'm ready to accept the idea of a child-free future at all.  You see, five days after I wrote that post, one of my best friends emailed me to tell me that she is pregnant again - with her second child.  So she'll have two kids, ages two and under, before B and I are able to conceive our first.

I wept. 

I couldn't help it.  I wasn't upset with her of course, I was just sad for myself.  You see, when this friend announced she was pregnant with her first child, B and I had not been preventing pregnancy for a while, but we had not yet decided to "try" for a baby yet either.  

A couple months after she announced her first pregnancy, B's and my one-year wedding anniversary rolled around and I graduated from grad school with my second master's degree.  It was finally time for my life long dream to come true.  We started trying for a baby.

By the time my friend's first child was born that Fall, she asked if I had "the itch" yet.  I told her I've had the itch since I was about twelve, and that B and I had been trying and were just waiting for that special month to arrive when we'd have the good news we'd been waiting for!  

Of course, in the back of our minds, B and I were already wondering if something was not quite right.  We'd only been "trying" for three or four months at that point, but before that we'd not been preventing for a year, ever since the wedding.  And I'd been off of birth control for medical reasons for about eight months prior to that... with many months of not being careful.  So really, we wondered, why hadn't we gotten pregnant yet?  Just lucky we hoped...

For months after my friend's baby was born I'd spend several days a week visiting her and her baby.  It was great timing because I was finally done with grad school, in my first real job, and finally had free time like a normal person!  Plus, I was able to get the baby fix I needed on a regular basis.  Her child was the most beautiful being.  She was such a good baby, and to this day lights up my world every time I see her.  The best way to describe her is as a perfect little blessing.  And now, as she is getting older, it is such a delight to see her growing and learning.  

So anyway, I spent a great deal of time with this friend right before and ever since the birth of her first baby.  She was such a considerate and thoughtful friend and always asked me how things were going with our own baby making efforts every single month.  Somehow she'd always ironically call on the the day I'd gotten my period.  Oh well, I'd joke, another month of drinking and banking sick time at work for my eventual maternity leave!

By midwinter that year, B & I still were not pregnant and we really started to wonder if there was something bigger going on that we should know about.  For young healthy couples they usually say to wait for a year of unprotected sex before testing for infertility.  But since we'd already been having unprotected sex for over two years (though we'd only been actively trying to time things out for about 6 months), B started getting tested... just in case.

It's best to get the male tested first because it's much less invasive than the female infertility workup.  It's best to rule out male factor infertility first, before you begin poking and prodding the female partner.  In January of 2011, we got our first analysis results back showing that B could potentially have low counts.  But it was January, and we are in the upper-midwest, and he'd done it at home, taken it outside to drive to the clinic, and delivered it to them about half an hour later.  We decided that there were too many variables and we'd get a second opinion.

In April that year we went to the only urologist in the area that specializes in male factor infertility - Dr. J.  B's sample came back slightly better this time, but still just on the cusp of the border between the range of what's "normal" and what's a problem.  We had another sample sent away to a lab out west somewhere... the only one in the country that tests for DNA fragmentation to see if that was our problem.  Again, he was right on the border between normal and the problem zone.

All this meant that B's swimmers could be the reason we hadn't conceived yet, but the evidence wasn't conclusive.  Dr. J did notice that B had varicoceles which could be causing his lower counts, but even that wasn't conclusive as many men get them who don't suffer from infertility.  He suggested we keep trying for 4-6 months and if we had no luck, try an IUI, which should give this counts the little extra boost they needed.  So we started up all the female infertility tests on me in the meantime (just to be sure there wasn't anything additional on my end to worry about while we were trying naturally), which continued throughout the summer.

We were still hopeful that there was nothing wrong, but as each month went by with one negative pregnancy test result after another, eventually my friend stopped asking if this was finally the month.  Instead she started asking how the testing was going and if we knew anything new that could help us.

That summer we did learn that I had a blocked fallopian tube, which sent me into a panic at first, until my OBGYN reminded me that I should still have a 50% chance of getting pregnant because most women ovulate from each side every other month.  Anyway, they were able to go back in and open it up and it's been open now for 10 months and guess what? Still no pregnancies.

Anyway, I've blogged before about all the testing and IUI's and it all ended with B having varicocele repair surgery last month.  Since it takes a man 90 days to produce new sperm, we are now in a waiting period.  We can't test to find out if the surgery improved B's counts until July, so no thoughts of trying for a baby until then.

Apparently, a good percentage of men who undergo this surgery see improvement after those 3 months!  Of those that don't, many of them will see improvement within about 6 months.  Of those that are left, some will have improvement within a year, and a few within two years after the surgery.  

So, we're hopeful about July, but shouldn't get our hopes up too high.  Or, maybe a better way to think about it is that we shouldn't lose all hope if the counts don't improve because there may still be a chance for things to get better down the road with a little more time.

So that's where we are at with the whole TTC thing, and that's the update (for now) on what we know about how B's surgery went.

But what does any of this have to do with my friend telling me she's pregnant and/or me saying things haven't changed so much after all?

Well, my point is that this friend telling me she was pregnant again kind of burst my bubble.  It brought back all the happy hopeful memories of when B and I first started out on our journey toward parenthood.  It reminded me of times when friends having babies was just exciting, not bittersweet.  But it also reminded me how long we've been TTC.  It reminded me of where we started out and all that has happened along the way to bring us to where we are today.

It made me think about the fact that she'll be done having kids before I even start.  Any of our hopes to be pregnant together were thrown out the window.  It made me wonder what it will be like to be going through the baby phase once all my friends are done with it and reclaiming their bodies, sleep, and free-time.  It made me think that once again I was behind all my peers in "life" (committing to a serious boyfriend, getting engaged, finishing school, buying a house), but this time not by my own choosing, and it made me feel sorry for myself.

I know I had written that wonderfully optimistic post about how something had "changed" inside of me and that somehow now other people's pregnancies weren't bothering me as much.  I do think that is still true, but not because something inside me changed.  And to be honest, my friend's being pregnant didn't "bother" me.  The reason it made me cry is not because she is pregnant again (because of course I'm very happy for her, and told her that immediately...and honestly truly meant it), but because it triggered emotions about myself that I hadn't been feeling for a couple months.  But again, not because anything had profoundly changed inside me to make me feel differently.  Rather, I think I was just distracted.

Distracted by B's impending surgery.  Distracted by work.  Distracted by the warmer weather and exercising the dogs.  Distracted by the biggest financial decision that B and I have ever made together....

Distracted by the process of buying our first house!

Stay tuned for more to come on that soon :)

B's Surgery Update

How things can change in a month and a half!  Last time I wrote about our specific infertility story, B was in the OR undergoing his surgery.  I’m very happy to report that the surgery went well.  Afterward, Dr. J came out to tell me that B had done well and that the varicoceles had actually been much larger than he had realized from the previous physical examination.  This is a good thing because larger veins = higher improvement rates (normally).

It’s been about five weeks since his surgery and the patient is doing well.  He was very sore and achy for the first week or so.  In fact, he still gets kind of sore if he moves in the wrong direction sometimes.  But overall I’d say he’s recovered remarkably well.  He did wind up taking one extra day off work, but within about 10 days, he was resuming all activities as normal… he had to.

Stay tuned for my next post on what happened in our family shorty after B’s surgery!

Full Circle

A year ago in April, we found out from Dr. J that Brian has varicoceles.  Now here I sit, in the waiting room of the surgery center at our hospital as Brian goes through varicocele repair surgery. It was a humbling feeling, seeing him in that cap and gown with an IV in his hand as they pumped fluids into him during the surgery prep.  Humbling because it made what he was willing to do for me seem so much more real.  The sacrifice he is willing to make for me gives me a lump in my throat as I realize how deep his love for me must really be. Don't get me wrong, Brian is perfectly comfortable with the thought of having kids with me, and once we do have kids, I know he's going to be the best Dad I've ever met.  But right now, this is much more so something I want, and he is doing everything he reasonably can to make me happy.  He could be happy if it's just the two of us forever.  I'm enough for him.   But for me to be truly happy, I need to know that we did everything we could to try to have a baby.  If it doesn't work out in the end, I'm starting to realize that he's enough for me too.  He's more than enough.  But I've always wanted to be a mother, and before I can let go of that dream, I need to know that we tried everything we could. I'm going to pampering and spoiling that boy rotten once he's done in the OR!  I've already got a brand new gaming mouse waiting to surprise him with when we get home.  Bought him some of his favorite candies for a little Easter basket too... It's not much but I just want to show him in all the l title ways I can think of to show him how grateful for what he has done for us, for me.

A Change Has Taken Place

Sorry I have been MIA lately.  Nothing new has really happened on the infertility front lately so I didn't have much to report.  


Three weeks ago my cousin's baby was born (Madeline Lee....I'm obsessed with baby names!), and later that week my best friend had her second daughter, Kylee Shae.  It's been a rocky couple of week for Kylee's family as she was (I believe) 6 weeks premature and at only 1.5 weeks they brought her back to the hospital because she had contracted RSV, which can be fatal in premies.  It's been a scary couple weeks for my friend, and I feel so much sympathy for her.


One might think that things would be hard for me lately, what with the babies being born and now all the hospital updates.  Rather, I just feel concern for my friend and her daughter.  I spent last weekend with another very close, very pregnant friend, and I had the best time talking with her about baby names and shower gifts.  Another one of my best friend's husband just posted a picture on facebook of her 18 weeks "belly pop" picture, and all I thought was, "She's so cute!!!"  Another friend who has a 8 month old emailed me to warn me she'd posting some pictures of her son on FB.  I was so grateful for the heads up, but when they were posted, I truly enjoyed looking at them and seeing how fast he's growing up.


I guess what I'm getting at (and this relates back to the title of the post), is that something inside me has changed.  Only a little bit, but there has still definitely been a change in me.  I'm less bitter, less angry, less sad.  Don't get me wrong, there are still twinges.  I still feel like I get smacked in the face once in a while with baby news.  But for the most part, I'm not walking around feeling like a defective excuse for a woman.


Here's when it happened:


I started reading about choosing to live "child free."  I prefer this term over childless, because it is more empowering.  If after a few more years of TTC through various methods, we decide we need to stop, then I'd prefer to choose to stop, and not feel like I was forced too.


I started thinking about what this would mean and I kind of liked some aspects of it.

1. More money & freedom to travel, the one activity that makes both B and I the happiest.  The picture at the top of this post is us on our honeymoon in Greece in 2009.
2. Earlier retirement because we won't need as much money to support anyone but ourselves.
3. Smaller house & cars to pay for, and no worries over what school district we live in or how to pay for the college years.
4. No daycare, diapers, kids clothes or baby furnishings to pay for.
5. More sleep and free time for ourselves & our hobbies.
6. More time and attention for our dogs, maybe even enough so that we could get a third in a few years!
7. No teenagers to stress over.
8. Opportunity to become really close with any future nieces & nephews & be the "cool" aunt & uncle.

Of course there are many downsides to living child-free, but I think and talk about those all the time so I won't get into them here.  This post is about opening the door to new possibilities.

I'm not saying I don't want kids anymore.  I'm not saying that B and I aren't still going to do everything reasonable in our power to TTC.  All I'm saying is that if the stars do not align for us to have children, I'm starting to think about ways & situations in which I may be able to accept that.  

I think that's really important because in 2-3 years, if we're still not pregnant, and are not in a financial position to afford IVF, I may need to be prepared to face the fact that we may not be the kind of people in this society who are able to move earth and sun to make a baby.  We are middle class people from middle class backgrounds with a lot of student loan debt and our health insurance doesn't cover it.  We may be able to do it, but I can't count on it right now.  So I've decided not to think about it anymore.  I've just tucked it in the back of my mind and am trying to focus on the here and now.

We're doing B's surgery in 3 weeks, and we plan to give that a couple of years  to reap it's full benefits.  We may throw a few more IUI's in the mix during that time, but other than that, no thoughts of IVF or anything until we've given this a real chance.  So, I've decided to let go for at least a year, and focus on other things, and see what happens.  So far, it's been feeling great :)

Varicocele Surgery: What are the success rates?

Varicoceles are identified in 35% to 40% of men with primary infertility and 81% of men with secondary infertility.  The majority of available evidence favors the surgical treatment of clinical varicoceles in men with infertility, which is thought to halt their duration-dependent effects.

Varicocele repair surgery can result in a significant improvement in semen parameters in 60% to 70% of men, with natural pregnancy rates up to 50%.  Men with larger varicoceles tend to have poorer semen quality than those with smaller varicoceles, and tend to have greater improvement with repair surgery.

Overall, a significant percentage of couples who undergo varicocele repair surgery will go on to achieve pregnancy without ART, and those who do need ART will have optimized their sperm quality.

It takes 90 days (3 months) for the male body to generate new sperm, so no improvements will be seen for 3 months following the surgery, with best results occurring in the first year, and some even into the second year following the surgery.

How this relates to us:

Since B and I have scheduled the surgery for the first week of April, that put our TTC routine on hold until around the week of the 4th of July.  Some things I've read online claim that better results are seen after 6 months, so that will put us at October before we'd really have our hopes up.  If it doesn't happen by the end of the year (trying naturally), then I think we'd be ready to allocate some money into our flex spending account for 2013 to try a few more rounds of IUI next year.

If trying naturally and with IUI's through 2013 doesn't work for us, then the next step would hopefully be saving up for IVF in 2014 or beyond.  I'll be 32, turning 33 by then, so our odds of successful IVF will still be high, but we'd only have a couple of years to get it done before my fertility starts falling.  

But seriously, IVF? The idea of saving up $13,000 for one round of fresh IVF cycle seems plausible by then... but what if that doesn't work what would we do?  With the plan described above, IVF is obviously our last resort.  

We could try to save up for the "shared risk" programs out there, where you pay $20,000 to $26,000 for 3 rounds of fresh and 3 rounds of frozen, and if it doesn't work, you get some or most of your money back.  But where would we come up with that kind of cash?  It would take longer, and then again my fertility will just decline further the longer we wait.

I wish I had a crystal ball.  I'd love to know that I'm just "catastrophe" thinking right now and we'll be pregnant naturally this summer.  Or that one round of IVF will get us twins and we'll be done.  Or that nothing will work but a 3rd frozen IVF cycle and so I should not bother getting my hopes up with anything else along the way.

Also, I wish we'd win the lottery.  That would solve a lot of our problems.

Varicocele Repair Surgery

• There are three methods in which varicoceles can be surgically treated: open surgery, laparoscopic surgery, and the third, which isn't even really surgical (it's performed by a radiologist), is percutaneous embolization.
  Open surgery. This treatment usually is done on an outpatient basis, using general anesthetic or local anesthetic. Commonly, the surgeon will approach the vein through the groin (transinguinal), but it's also possible to make an incision in your abdomen or below the groin.
  Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.
• Laparoscopic surgery. The surgeon makes a small incision in the abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. This procedure requires general anesthesia.
• Percutaneous embolization. A radiologist inserts a tube into a vein in the groin or neck through which instruments can be passed. Viewing enlarged veins on a monitor, the doctor releases coils or a solution that causes scarring to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure is done with local anesthesia on an outpatient basis. This procedure isn't as widely used as surgery.
• So what's best?
• According to Dr. J's article, "Do varicoceles really affect male fertility?" although most methods yield similar short-term results, open micro-surgery tends to have lower long-term complications, such as recurrences and hydroceles.  This is due to the ability to tie off all veins while sparing the arterial blood supply and lymphatic vessels.  
• Although laparoscopic varicocele ligation was once touted as a minimally invasive method of repair, several experts have demonstrated similar recovery rates with open micro-surgical methods along with equal efficacy, fewer complications, and the advantage of not having to enter the abdomen.
• The most common complications from any of these varicocelectomy procedures are hydrocele, varicocele recurrence, and testicular artery injury.  Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries, so that the incidence of these complications can be reduced significantly.  Thus, the microsurgical technique of "open micro-surgery" provides a safe and effective approach to varicocele repair that preserves testicular function, enhances semen quality, and improves partners' pregnacy rates.
• What to expect from Open Micro-Surgery 
  Most men prefer general anesthesia, though the procedure can be performed under local with intravenous sedation.  Time to recovery varies, but most men get back to work within 3-4 days and and resume full activity within 7-10 days.
• From mayoclinic.com:
• You may be able to return to normal, nonstrenous activities after two days. As long as you're not uncomfortable, you may return to more strenuous activity, such as exercising, after two weeks.
  
  Pain from this surgery generally is mild. Your doctor may prescribe pain medication for the first two days after surgery. After that, your doctor may advise you to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others) to relieve discomfort.
  
  Your doctor may advise you not to have sex for one to two weeks. You'll have to wait three or four months after surgery to get a semen analysis to determine whether the varicocele repair was successful in restoring your fertility.

• **Dr. J has recommended Open Micro-Surgery for B.**

What the heck are varicoceles?

A varicocele (VAR-ih-koe-seel) is a dilation of the veins that drain the testis, known as the pampiniform plexus. A varicocele is similar to a varicose vein that can occur in your leg.

As it turns out, varicoceles are present in approximately 15% of the general male population. They account for up to 40% of male factor infertility, yet nearly two-thirds of men with varicoceles are fertile... so could varicoceles be causing mine & B's infertility?

The answer I've been able to come with so far is "maybe."

Causes

Varicoceles are typically not noticed until after puberty because testicular blood flow remains low prior to that and so these veins do not become apparent until adolescence when blood flow increases.  However many are not detected until a man is evaluated for fertility problems later in life. 

It's not certain what causes varicoceles, but many experts believe a varicocele forms when the valves inside the veins in the spermatic cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). 

Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles. 

Our doctor, Dr. Jay Sandlow (I like to refer to him as "Dr. J"), published an article called, "Do varicoceles really affect male fertility?" in Sexuality, Reproduction & Menopause, arguing that it is not the valve that is the issue, so much as the anatomy of the entire drainage system that plays a major role in the the development of varicoceles.

"Because the left side drains into a system with higher resistance (the renal vein), small venules may persist or open during embryogenesis." - Jay Sandlow

Don't ask me what that means... after looking up definitions for venules and embryogenesis, I think it means the way a man's anatomy is formed while still a fetus determines whether he'll have varicoceles, though they aren't detected until after puberty when things really start flowing down there.  Maybe I should ask Dr. J if I understand that correctly though :)

How can they affect fertility?

In cases of where men who have varicoceles happen to be experiencing infertility, varicoceles are thought to cause spermatogenic defects by raising the intratesticular temperature in both the affected and the adjacent testes. However, not all varicoceles affect sperm production, which explains why not all men with varicoceles (in fact, most of them), are fertile.

Diagnosis


When varicoceles are suspected of causing infertility, abnormalities in all of the seminal parameters are usually present.  However, they can also cause isolated defects in sperm count, motility, morphology, or function.  Therefore, according to the article written by Dr. J mentioned above, the results of semen analysis are not a good predictor of the presence or absence of varicoceles.  And so, they are typically diagnosed by physical examination.  Most experts agree that the only varicoceles to worry about are the ones that can be detected by physical examination, though ultrasound can be used to identify them as well.


In our case...


B's were visible right away upon physical examination, and he has them on both sides.  We discovered this back in April 2011, but because the results of his seminal parameters testing were all coming back within the range of normal fairly consistently, Dr. J instructed us to first continue trying naturally for 4-6 months, with timed intercourse (only every other day during the fertile period of my cycle).  


That brought us to September, when we did our first IUI, which failed.  That's also when we learned how low B's "good sperm" counts were post-washing.  It was at that time that Dr. J recommended doing one more IUI, and if the numbers came back that low again post-wash, then he would recommend varicocele repair surgery as our next course of action.


We attempted an IUI earlier this month (February 2012) and his count came back lower than last time, so in effort to save money, we didn't even go through with it.  I was on clomid that cycle for the IUI, so there could have been a chance of increased fertility for us naturally... but I got my period Wednesday night so [sigh] that's disappointing.


So we scheduled the surgery for early April.  I'll post more soon about what that entails and what the success rates are.

Surgery Scheduled

B's varicocele surgery has been scheduled for April 5th.  He'll need 5 days after the surgery to recover so we won't be going home for Easter this year.  This was the best time for us to schedule the surgery though because he only will have 3 days of sick time built up by then and his work gives him Good Friday off.  So between the weekend, the holiday, and his sick time, he'll have just enough time off.


I still plan to post more about what varicocele's are, how they can effect infertility, and what the surgery is all about soon.  In the meantime, we are just mentally preparing for this big next step.