from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
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Beyond the
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Table of Contents
What
is a varicocele ?
How
is a varicocele diagnosed?
Is
surgery for varicocele repair useful ?
How
is a varicocele surgically repaired ?
The commonest reason for
male infertility is a low sperm count, and the commonest
reason for this is what doctors called "idiopathic"
- which simply means, we do not know ! This is one of
the reasons why the diagnosis of male infertility is
so frustrating for both patients and doctors - there
are few tests available which allow us to pinpoint the
cause of the problem. This also means that there is
very little in the form of effective therapy which we
can offer these men - if we do not know what is wrong,
how can we treat it?
However, what about those conditions
which we think we do understand? Let's discuss these
in detail.
What
is a varicocele ?
One of the reasons for a low sperm count according to
some doctors is a varicocele. A varicocele is a swollen
varicose vein in the scrotum - usually on the left side
. The condition occurs because blood pools in the varicose
testicular veins (pampiniform plexus) since the valves
in the veins are leaky and do not close properly. The
reason for infertility associated with a varicocele
are unclear. Perhaps the accumulation of blood causes
the testes to be hotter and so damage sperm production;
or the pooled blood brims over with abnormal hormones
which may change the way the testes make sperm. The
effect of the varicocele on an individual's sperm count
is variable - and this may range from no effect whatsoever,
to causing a decreased sperm count. Varicoceles may
also have a progressively damaging effect on sperm production,
so that the sperm count may decline with time.
How
is a varicocele diagnosed?
How is a varicocele diagnosed? The doctor
examines the patient in the erect position and feels
the spermatic cord - the cord like structure from which
the testis hangs. The patient is also asked to cough
at this time. A varicocele feels like a "bunch of worms"
and on coughing, this gets transiently engorged. Confirmation
of this diagnosis is best done by a Doppler test at
the same time. The Doppler is a small pen like probe
which is applied to the cord. It bounces sound waves
off the blood vessels and measures blood flow by magnifying
the sound of blood flowing through the veins. This can
be recorded. Patients with a varicocele have a reflux
of blood during coughing which shows up as a large spike
on the tracing. Other tests which are done uncommonly
to confirm the diagnosis of a varicocele include: Doppler
ultrasound; special X-ray studies called venograms;
and thermograms.
What are the areas of controversy about
the varicocele? Most doctors are still not sure whether
a varicocele causes a low sperm count or not ! It is
possible that the varicocele may be an unrelated finding
in infertile men - a "red herring" so to speak. Strangely
enough, only a quarter of men with varicoceles have
a fertility problem. Thus, many men with large varicoceles
have excellent sperm counts which is why correlating
cause (varicocele) and effect (low sperm count) is difficult.
This means that surgical correction
of the varicocele may be of no use in improving the
sperm count - after all, if the varicocele is not the
cause of the problem, then how will treating it help?
In fact, controlled trials comparing varicocele surgery
with no therapy in men who have varicoceles and a low
sperm count have shown that the pregnancy rate is the
same – so that it does not seem to make a difference
whether or not the varicocele is treated !
Is surgery for varicocele
repair useful ?
Because surgery for varicocele repair
is simple and straightforward , many doctors still repair
any varicoceles they find in infertile men, following
the dictum that it’s better to do something, rather
than do nothing ! However, keep in mind that varicocele
surgery may result in an improvement in sperm count
and motility in only about 30% of patients - and it
is still not possible for the doctor to predict which
patient will be helped. Of course, just improving the
sperm count is not enough - and pregnancy rates after
varicocele repair alone are in the range of 15%. If
a man with a low sperm count gets pregnant after varicocele
surgery, he believes ( as does his surgeon, who is happy
to take the credit !) that the pregnancy was a result
of the surgery ! However, randomised controlled studies
have shown that varicocele surgery does not improve
pregnancy rates in men with low sperm counts. When men
with varicoceles and low sperm counts were divided into
2 groups, of which one was subjected to surgery, and
the other left untreated, 15% in both groups attained
a pregnancy ! One danger of doing a varicocele repair
is that when it doesn’t help, patients get frustrated,
and refuse to pursue more effective options, such as
the assisted reproductive techniques. Today, most infertility
specialists would advise infertile men with varicoceles
to consider going in for IVF or ICSI, rather than for
varicocele surgery.
How is a varicocele
surgically repaired ?
There are 4 methods available to repair
varicoceles - conventional surgery; microsurgery; laparoscopic
surgery and radiologic balloon occlusion.
In conventional surgery, a small cut
is made in the groin; the spermatic cord is lifted out
of the scrotum; and the engorged veins are tied off.
This is the commonest method used. The risks include:
the risk of the varicocele recurring , which is about
20 %, because some of the smaller veins are not identified
and are missed during surgery; the risk of hydrocele
formation - a collection of fluid around the testes
, because lymph vessels are indirectly tied off too,
so that more fluid is accumulated - the risk being about
5 %; and inadvertent damage to the testicular artery
(the blood supply to the testis) - which can actually
decrease sperm production !
Microsurgery is a newer method, in which
under an operating microscope, the surgeon individually
ties off the enlarged veins in the spermatic cord. The
testicular artery and lymphatic ducts can be preserved
confidently, because the surgery is done under high
magnification.
Radiologic balloon occlusion is not
very commonly performed. in this minor procedure, a
silicone balloon catheter is passed under X-ray guidance
to the testicular vein; here the balloon is inflated
and left in place permanently, thus blocking the engorged
veins and repairing the varicocele.
The "subclinical varicocele": These
are tiny varicoceles which cannot be felt by the doctor;
but can be detected by Doppler examination. Whether
correcting them is helpful or not is still a matter
of individual opinion.
Many surgeons will combine varicocele
repair with medical therapy to try to increase the sperm
count by driving the testis to work harder, but how
effective this is still not clear.
In our clinic, we do not believe that
diagnosing or treating a varicocele helps improve fertility
in men with a low sperm count.
continued
. . .
Next page: Diagnosis
and Treatment for Male Infertility -- More Confusion!
(Page 2)
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Beyond the
Semen Analysis (Page 2)
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