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Varicocele and male infertility

Varicocele is a common male disease characterized by venous dilation in a testicle and the spermatic cord. The detection frequency of varicocele in males comprises about 15-20% in the population and rises up to 35% in males with infertility. 

Varicocele is thought to occur due to a number of reasons, the most significant of them being the anatomic features of the entrance of the testicular vein into the renal vein, a congenital weakness of the venous wall and the incompetence of venous valves. The leading mechanism of the disorder is retrograde blood flow (reflux) in the testicular veins and the resulting dilation of the venous network surrounding the testicle. In more than 80% of cases, varicocele occurs on the left. 

Varicocele usually starts to develop in adolescents at the age of 12-13, in puberty. In the majority of cases, varicocele has no symptoms and is detected purely by chance, during an examination by a urologist. About 5% of men with varicocele experience occasional dull or nagging pain in the scrotum, especially after some physical activities or a sexual intercourse. 

The exact mechanism of spermatogenesis disorder in men suffering from varicocele is unknown. The dilated veins of the scrotum are believed to disrupt the thermoregulation process in a testicle resulting in its overheating. In the environment with an increased temperature, the number of active oxygen radicals in ejaculate increases and the normal spermatogenesis becomes suppressed. A sperm analysis in men with varicocele can show a decrease in the number of sperm cells (the so-called oligozoospermia), sperm motility problems (astenozoospermia) and the abnormal morphological structure of sperm cells (teratozoospermia). However, not all men with varicocele are infertile. This is due to the fact that the severity of testicular dysfunction depends on the degree of varicocele as well as on a person’s age. But as a rule, all men with varicocele eventually show a decreased testicular function responsible for sperm cell and male sex hormone production. Due to a gradual decrease in testosterone, the primary male sex hormone, the overall male health is impaired as well. Still, a timely elimination of varicocele can lead to the normalization of the testicular function. 

At examination, the palpation of varicose veins of the scrotum gives a sensation of a “doughy” scrotum. If there are doubts (if varicocele is not very pronounced), a special ultrasound investigation of scrotum organs is employed. The diagnosis and treatment of varicocele fall within the competence of doctors who specialize in male health - urologists-andrologists. 

Varicocele can only be treated surgically, but the mere presence of varicocele is no reason to turn to surgery. A surgery for varicocele elimination is recommended by specialists, if a couple’s attempts at conception remain unsuccessful for a year and if at least two spermograms show an impaired quality of ejaculate. If a man with varicocele is not going to become a father any time soon but has some abnormalities in the sperm, he should consult an andrologist. The best candidates for surgery are: 
  • Men with oligozoospermia and the so-called clinical, “large” varicocele;
  • Adolescents with large varicocele and testicular growth retardation due to varicocele.
Such indications as large varicocele and azoospermia as well as the combination of varicocele and low levels of the male sex hormone testosterone are considered. The result depends on how correctly the indications are determined.  A surgery should not be undertaken until the expected benefits have been discussed (see below).

The most effective method of varicocele treatment is the surgical one – varicocelectomy. Its main purpose is to ligate all dilated venous vessels with blood reflux. As a result of this surgery, the testicular blood flow recovers and testicular functions gradually improve. The surgical treatment of varicocele is carried out under general or spinal anaesthesia. There are presently four primary surgical approaches to the elimination of the given pathology:
  • Via open (traditional) access;
  • Via Marmar mini-access;
  • Using an endoscopic technique;
  • By embolization. 
The so-called subinguinal microscopic varicocelectomy, or Marmar technique, is considered to be the best one. It is exactly this method that is used at the leading clinics of the world, being the safest as well as the most effective one. A skin incision is placed in the lower third of the inguinal fold, slightly above the root of the scrotum, and comprises no more than 2-3 cm.  The surgery takes about 40-60 minutes. Patients remain in the in-patient facility for 8 to 24 hours whereafter they can choose to go home.

Complications after Marmar varicocelectomy are relatively rare. A new occurrence of the disease (a relapse) is identified in no more than 1-2% of cases. The reasons behind it may be associated with the individual course of the disease, in particular, with a large number of varicose veins (the distributed type). For the timely identification of a varicocele relapse, it is recommended to undergo an examination in 3 months after a surgery. Another complication is the development of hydrocele – the collection of fluid in the scrotum area (5%). This condition may require an additional surgery on the scrotum. Testicular and ejaculatory duct damage are exceptionally rare. 

On the whole, varicocelectomy is low-traumatic. In some cases, on the first day after the surgery, the administration of painkillers may be required. The next day after the surgery, a surgeon examines a patient and applies a dressing. Further on, dressings will be changed by the patient himself at home. The patient should return to the clinic on day 7 to remove stiches. One can get back to his normal lifestyle and work in 2-3 days, the only exception being physical activities. Lifting heavy weights is limited to a maximum of 10 kg for 2 weeks after the surgery. 

Reviews of the conducted well-organized studies point to the fact that varicocele has a negative impact on male fertility but at the same time, the efficacy of a surgery in case of male infertility is widely disputed. An improvement in the quality of sperm and the occurrence of pregnancy are expected in 30-60% of operated men, which usually happens by the 6th-9th month after the surgery. In other cases, there is no recovery because the disease has already dealt irreparable damage to the testicular function, or because the cause of male infertility is associated with other factors. Unfortunately, it is not possible to identify such a condition before surgery. In cases when varicocele treatment did not result in a full recovery of the quality of sperm and the occurrence of a spontaneous pregnancy, one can turn to assisted reproductive technologies (IVF-ICSI).

The modern medical science has a wide range of tools for infertility treatment including such innovative ones as the assisted reproductive technologies. One of the main questions posed to a couple at a consultation with a fertility specialist as regards infertility is the question whether a husband should undergo a surgery or not. Let us remember the two factors that the probability of pregnancy occurrence depends upon. First of all, it is the age of a woman. The second most important factor is the ovarian reserve, AMH and FSH levels. Varicocele elimination can be chosen as a priority treatment method, when the quality of sperm of a man with varicocele is reliably impaired, whereas a woman is young and healthy, and we have no suspicions that there are any pathologies in the ovaries, the fallopian tubes or the ovarian cavity. In this case, we can truly afford to wait for some effect from the surgery for 0.5-1 year, hoping for a natural conception. In all other cases – a woman’s age of more than 38 years old, a medical history of ovarian resections, a diminished follicular reserve, a long period of pregnancy planning, the persistence of a problem in each marriage – it is like waiting for things to take care of themselves, that is, virtually worthless. At times, it may be even dangerous, as we lose sight of a patient for a long time, and when a couple finally visits a fertility specialist, the probability of our success decreases dramatically. 
In this respect, it is very important that an andrologist and a fertility specialist should manage a couple in close cooperation, so that neither of us, be it doctors or patients, would take any unnecessary actions resulting in our “going round in circles” and not getting any effect from treatment. 

Man health