Varicocele

Male infertility has been found to be the major cause of a couple's inability to conceive in 50% of childless marriages. There are many causes of male infertility including: deficiencies in sperm production; blockage of the conducting system; antibodies against sperm; injury to the testicle; hormone problems; poor descent of one or both testicles; and finally the presence of a Varicocele.

In order to understand what a varicocele is, one must be aware of some basic anatomy and physiology. The testicles are the paired male genital organs that contain not only sperm but also cells that produce and nourish the sperm. These organs are located in a sac called the scrotum. The epididymis is a small, tubular structure attached to the testicle. It is a reservoir where the sperm mature and are stored. The vas deferens connects the epididymis to the prostate gland and is the tube through which sperm travel during ejaculation. The vas deferens is not situated by itself but is a part of a larger tissue bundle called the spermatic cord. The spermatic cord contains many blood vessels as well as the vas deferens, nerves, and lymphatic channels. The vein of the spermatic cord are known as the pampiniform plexus. These veins drain blood from the testes, epididymis and vas deferens, eventually becoming the spermatic veins that drain into the main circulation at the level of the kidneys. The pampiniform plexus of veins may at some time become tortuous and dilated much like a varicose vein of the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus around the testicle.

The scrotal varicocele is a well-recognized cause of decreased testicular function and is present in about 40% on infertile males. In order to understand the significance of this abnormality in the infertile patient, a brief review of the historical background, current concepts of its anatomy and function, and methods and results of surgical repair must be considered.

History

Varicoceles have been recognized as a clinical problem since the 16th century. Ambroise Pare (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality as containing "melancholic blood." It was not until the late 19th century that the relationship between infertility and varicocele was first proposed by the British surgeon Barfield. Shortly thereafter, other surgeons reported an association with "an arrest of sperm secretion" and subsequent restoration of fertility following varicocele repair. Through the early 1900's reports by other surgeons continued to describe the association of infertility with a varicocele. It was not until the 1950's, after a report of fertility following varicocele repair in an individual known to be azospermic (i.e. without sperm), however, that the concept gained support as a clinical entity among American surgeons. Research then continued with studies characterizing semen of men with varicoceles having degrees of impaired sperm quality. From these studies a pattern of low sperm count, poor motility, and a predominance of abnormal sperm forms was documented. This became known as the "stress pattern" of semen. Although not synonymous or specific for a varicocele, it consistently suggests early evidence of testicular damage. Clinically, urologists evaluate male infertility through the study of sperm. The sperm are evaluated for their number (sperm count), the percentage of motile forms, their forward movement and their morphology (shape and form). Although varicoceles do appear in about 25% of normal, fertile men, their presence is significantly higher in the subfertile population. In fact, scrotal varicoceles have been found to be the most common identifiable and surgically correctable factor contributing to poor testicular function and decreased semen quality.

Anatomy of the Varicocele and Mechanism of Effect Varicoceles are more common on the left than on the right for multiple anatomic reasons. They may vary in size and can be classified into three groups: 1) large - easily identified by inspection alone, 2) moderate - identified by palpation without bearing down or straining, and 3) small - identification only by bearing down which increases the intraabdominal pressure, further impeding drainage and thus increasing the size of the varicocele. It is important to remember, however, that the size of the varicocele is not related to the degree of changes in the sperm. Several theories have been proposed to explain the deleterious effect of the varicocele on sperm quality. These include possible effects of oxygen deprivation, heat injury or toxins. Despite considerable research, none of these theories have been unquestionably proven although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. The fact that creation of a varicocele in the experimental animal can lead to poor sperm function with elevated intratesticular temperature does give support to this concept. Regardless of the mechanism of action, varicocele indisputably is a significant factor in decreasing testicular function and changing the semen quality in a large percentage of men seen for infertility.

Diagnosis Because of its potential role in causing significant testicular damage, it is important to identify the varicocele on physical examination. Reasons for surgical correction include the presence of significant testicular pain, impairment of testicular function, as evidenced by decreased semen quality, and loss of testicular size (atrophy). The mere presence of a varicocele does not mean that surgical correction is necessary. Usually, the varicocele is asymptomatic and the patient is seen primarily for evaluation of a possible male factor in an infertile marriage. However, the patient may sometimes complain of pain or heaviness in the scrotum. Careful physical examination remains the primary method of varicocele detection. It is important to examine the patient in the standing position, having him perform the Valsalva maneuver, i.e., take in a deep breath and bear down to magnify a small varicocele. When small varicoceles are difficult to diagnose, more objective means can be used such as the Doppler Stethoscope and venography. The Doppler technique is painless and evaluates the motion of blood in the peritesticular veins using soundwaves. Venography requires a small incision in the groin, insertion of a needle into a groin vein and injection of "dye" (contrast solution) which will flow into the spermatic vein. This technique is relatively pain-free, performed on an outpatient basis and allows direct visualization of the varicocele by x-ray.

Surgery and its Results Once a varicocele is diagnosed, reasons for surgical correction include: testicular discomfort or pain unrelieved by routine, symptomatic treatment; testicular atrophy (loss of size); or the possible contribution to unexplained male infertility. There are four commonly used surgical approaches for the correction of a scrotal varicocele. These are the transinguinal (groin), the retroperitoneal (abdominal), laparoscopic and microscopic approach. The transinguinal and retroperitoneal approaches were the operations of choice for many years. Recent advances in surgical techniques and equipment have brought newer ways to remove the varicoceles. With the laparoscopic approach a small incision is made under the belly button and two small holes on either side of the abdomen are created. Through these ports, instruments are placed to tie off the offending veins. The advantage of the laparoscopic method is that there is much less pain involved. The disadvantage is that there is a small risk of injury to the intra-abdominal organs. With the microscopic approach, the abdomen is not entered, but a larger incision in required and placed over the top part of the scrotum. This seems to cause more pain, but there is no risk of damage to the abdominal contents. Although the mechanisms whereby varicoceles cause impairment in sperm production and semen quality remain theoretical, the statistical association between varicocele and male infertility is unquestionable. Furthermore, improvement in semen quality after varicocele correction has been repeatedly demonstrated. The resultant improvement seen in sperm motility rather than in sperm count. The pregnancy rate is as high as 40% with the average pregnancy occurring 6 to 9 months following surgery.

The scrotal varicocele remains the most correctable factor when treating poor semen quality. Therefore, when present in the infertile male with abnormalities of semen quality, surgical correction should strongly be considered. The side effects following varicocele repair are remarkably low, and successful surgery will often increase the incidence of eventual pregnancy in the infertile couple.

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