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? 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 !
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 IVF, rather than for varicocele surgery.
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.
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