Many men with a low sperm count also have a varicocele, which is a swollen varicose vein in the scrotum - usually on the left side. The reason for infertility associated with a varicocele is unclear and it's possible that it's coincidental rather than causal. After all, lots of men with a normal sperm count also have a varicocele !
What Causes it?
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.
In the past, urologists believed that a varicocele could a progressively damaging effect on sperm production, and cause the sperm count to decline with time.
The reason for infertility associated with a varicocele is 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.
How is a varicocele diagnosed?
- The doctor examines the patient 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
- A colour doppler ultrasound scan also be done to confirm the diagnosis. This is expensive
- Other tests which are done uncommonly to confirm the diagnosis of a varicocele include- 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.
Does Surgery Help?
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 !
Why is surgery advised - and why is this a bad idea ?
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 will 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%. However, 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 In Vitro Fertilisation, rather than for varicocele surgery. There are 4 methods available to repair varicoceles:
- Conventional surgery
- Laparoscopic surgery
- Radiologic balloon occlusion
These are tiny varicoceles which cannot be felt by the doctor; but can be detected by a 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. Men with a low sperm are best treated with ICSI, and there's little point in wasting their time and money or repairing a varicocele for them.