Varicocele And Infertility - Myth or Reality

Varicocele And Infertility

The Varicocele is the widening and dilatation of the veins around the spermatic cord inside the scrotum, usually on left side.

It affects around 15-20% of the masculine general population, most of them are fertile with normal semen analyzer and affect 20 to 40% of infertile men.

Average age is 15-25 years old.

Symptoms and signs of Varicocele:

1- Asymptomatic.
2- Dull discomfort.
3- Heaviness in scrotum that increase while sitting and standing and worsen over the day and it can only be relieved by lying on the back.
4- Feeling a lump or swelling in the scrotum.
5- By examination it may feel like twisted congested veins and sometimes described as bag of worms.

Causes of Varicocele:

Varicocele is due to an abnormal valve function inside the veins in scrotum, which will cause blood to back up and lead to swelling and widening of the veins.
In addition to the kidney tumor for old men which is considered a rare cause.

Diagnosis of Varicocele:

1- Physical examination:
a. Standing position
b. Valsalva maneuver.
2- Scrotum ultrasound may be done if the physical examination wasn’t enough.

Consequences and complications of Varicocele:

Varicocele is usually harmless and doesn’t need to be claimed but it in some cases, it may lead to a shrinkage case (Atrophy) of the Testis due to the exposure of joints to toxins. After treatment, some blood dots may be noticed resulting from inside the veins.

Varicocele Treatment:

1- Scrotal support - Sung underwears
2- Surgery and repair including:
a. Open surgery: Usually it is outpatient operation, under general or local anesthesia through a small incision in the groin.
Varicoceleb. Microsurgery: microscope can be used.
c. Laparoscopic surgery; this require general anesthesia.
d. Percutaneous embolization this can be done under local anesthesia.

Complications of Varicocele surgery:

1- Testicular atrophy.
2- Blood clot formation.
3- Infection.
4- Vascular damage.

Varicocele and Infertility:

Varicocele and Infertility are pretty much related, Varicocele appears 2 to 3 times more in infertile men than normal men.
However the result of many studies is highly controversial.

Varicocele increases the temperature of the scrotum and the intratesticular pressure and reduces the blood flow that may lead to Hypoxia and reflux of toxic metabolites from adrenal gland.
This may damage the DNA in the sperm head due to oxidative stress.
However, those results were confirmed both for fertile and infertile men having Varicocele, so it is difficult to link between it and fertility status.
 

Varicocele

Varicocele

Many studies showed that Varicocele surgery can increase the sperms and count improvability, but randomized controlled trials didn’t show improved pregnancy rate so it is important to take into consideration the pregnancy rate despite getting high sperm count in such studies.
Six randomized controlled trials were published comparing varicocele surgery versus no surgery, three of them showed that pregnancy rate increased after surgery, and the other three showed a lower pregnancy rate after surgery.
By meta-analysis of these studies, pregnancy rate shows no improvements.
So, many scientists believe that surgical repair of varicocele should be individualized and include very slight group of infertile men, there is still no criteria to select this group, but we should take in consideration the following aspects:

1- Duration of infertility.
2- Very low count and very low motility: In such cases it is unlikely that surgery will improve the count to result in pregnancy u/s IUI or ICSI.
3- Presence of other factors that affect fertility like advanced maternal age, block tubes anovulation, ovarian reserve problem in the pregnancy of such problem it is not advised to do surgery.
4- Varicocele that is not detected clinically only diagnosed by Doppler ultrasound should not be operated, because u/s is not very accurate in diagnosis.
5- If the couples didn’t achieve pregnancy within 6-9 month after surgery, then IUI or ICSI should be considered.