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From the book
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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.
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 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.
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.