The terms 'varicocoele' and 'varicocele' mean the same thing. The first is the British* spelling, and the second's the American one. There are already many other content-heavy varicocele sites out there in cyberspace. Many of these are comprehensive sources of information to medical professionals, varicocele afflicted patients, and lay surfers.
This site doesn't intend to be another such. It is a very basic varicocele information site that's been created especially for men and boys with varicoceles and will restrict itself to practical FAQs that these males or those interested in these males might want answers for. It also provides links to other men's health and andrological conditions, Andromeda Andrology Center, and Dr. Sudhakar Krishnamurti, who is the first Indian infertility microsurgeon to perform microsurgical varicocelectomy surgery (since 1988).
|Half of all infertility (50 %) is male factor related and a varicocele is the commonest detectable and correctable cause.
What is a varicocele?
Varicoceles are found in approximately 15% of the general population, 35-40 % of men with primary infertility (men who have never fathered a child) and in 75-81% of men with secondary infertility (men who have fathered children in the past but are now unable to). A varicocele is a condition in which the veins of the scrotum get enlarged and tortuous, much like varicose veins in the legs, a problem that many of us are familiar with. The veins in the scrotum are collectively known as the pampiniform plexus. This is a network of vessels that surrounds the testes and regulates its temperature even as it takes blood back to the heart. Physiologically, it is important for the testes to have a temperature that is a few degrees lower than body core temperature in order for sperm production to occur normally. This is why nature has placed the testes outside the body in many mammals, including man - the higher internal core body temperature is deleterious to sperm production. This also explains why many men with undescended testes are infertile. Testes that are trapped higher up in the body do not have the heat regulating protection of the pampiniform plexus. The presence of a varicocele interferes with this temperature regulation mechanism and often increases testicular temperature. This can cause infertility in many men. Infertility is a condition where a man, woman, or couple cannot have children by natural methods, even after a year to a year and a half of regular, unprotected sexual intercourse.
A classical left varicocele
Half of all infertility (50 %) is male partner related, and a varicocele is often the culprit.
A varicocele frequently presents as a visible swelling in the scrotum, and the scrotum itself may hang lower than usual. Damage to the testis, with reduction in size and function, can sometimes occur. Often, there is a dull, dragging pain accompanying this condition. Frequently, however, the varicocele is not prominent, and may be completely asymptomatic, i.e. without symptoms. It is only discovered incidentally during a male infertility evaluation. varicoceles occur more frequently on the left side and are somewhat more common in lean, tall males.
The varicocele is the commonest treatable cause of male infertility.
What about varicoceles in adolescents? Is this something to worry about?
The adolescent varicocele has been studied quite well over the years. Many of these disappear with age and do not cause any problems in later life. Infertility is uncommon. However, regular examination of the boys until the disappearance of the varicoceles is recommended. Only persisting varicoceles and those causing complications like reduction in testis size must be treated.
Why do varicoceles occur?
There are many theories for this, and a detailed discussion is outside the scope of this FAQ page. Most varicoceles are idiopathic, i.e. without cause, or cause unknown. However, sometimes, tumours in the abdomen and other conditions may compress the veins of the testes and cause varicoceles. Vascular malformations in the scrotum, such as haemangiomas, may sometimes present as varicoceles.
Are all men with varicoceles infertile?
No. Only 35-40 % of patients (about a third) with varicoceles will develop infertility. Others won't. The relationship between a varicocele and infertility in men is not completely understood. Maybe there is a variation in susceptibility among men. Even in men with varicoceles, the varicoceles may not always be the (only) cause of the infertility. Other causes may well coexist with the varicocele. These must be looked for and addressed. If there are other causes, and the varicocele is hastily treated instead, the results may not be fruitful. This is very important to bear in mind.
About 35-40 % of all men with varicoceles will be infertile as a direct consequence of the varicocele.
What about diagnosis? Is it very difficult?
The diagnosis of a varicocele is essentially clinical, i.e. one made by a skilled physician through physical examination. An enlargement of the veins is easy to assess with the fingers. By asking the patient to cough, a reversal of blood flow can also be ascertained. For academic purposes, many grades of varicoceles have been described. However, it is necessary to understand that there is no direct correlationship between the size and severity of a varicocele, and the harm it can cause. Men with very large varicoceles may yet father children (Figure 1), while those with smaller varicoceles may have severe afflictions of their sperm counts and other seminal parameters, with consequent infertility (Figure 2).
Figure 1: One of Dr. Sudhakar Krishnamurti's patients with a large varicocele. The patient had neither infertility nor pain.
Figure 2: This man with a moderate sized varicocele had infertility with very poor semen quality. After microsurgery by Dr. Sudhakar Krishnamurti, his counts improved considerably, and he fathered three children subsequently.
How about tests? Are they necessary to confirm the diagnosis?
Tests like scrotal ultrasound (Figure 3) are performed to corroborate the clinical diagnosis, and are also useful in measuring vein size and the degree of reflux (backflow) of blood. Testis size can be measured at the same time, and gives some indication of its function. Besides these, hormonal studies, of serum FSH, LH, and testosterone, may be performed to assess testicular function. More elaborate tests like venography (phlebography) are usually performed for research purposes or if there is recurrence after surgery (Figure 4), to look for anomalous venous pathways. A venogram is also necessary if therapeutic embolization is planned as a treatment option. It must be stressed, however, that the diagnosis of a varicocele is essentially clinical, and examination of the patient should therefore only be performed by an expert in varicoceles. Varicoceles that are too small to be felt by experts are usually not significant (important from the standpoint of infertility), and it is doubtful if treatment for such varicoceles can confer benefit. The entity of 'sub-clinical' varicocele, which means a varicocele that cannot be felt clinically but can be seen ultrasonographically, was popular in the eighties, but results of surgery in these patients were very poor. The concept of a sub-clinical varicocele has now been abandoned. Further, it has been shown that reflux (backflow) of blood into the scrotum occurs even in normal males on coughing (or the performance of a Valsalva manoeuvre) and that this is not indicative of a varicocele. Reflux of venous blood during rest or quiet respiration is considered more significant (see Figure 3). Another reason for performing tests is medico-legal. Since guarantees about the efficacy of varicocele surgery cannot be always given even at the best microsurgical centers, such tests are sometimes important to establish bona fides and ethical intentions.
Figure 3: Shows an uncommon, large, refluxing varicocele on the right side. (Picture courtesy: Andromeda Andrology Center, Hyderabad, India)
Figure 4: Shows phlebograms (venograms) of two patients with unusual presentations of varicocele. (Picture courtesy: Andromeda Andrology Center, Hyderabad, India)
What about treatment? Does it work? There seem to be many opposing views on this.
If the varicocele is truly the cause of the infertility and the man's poor sperm quality (oligo-, astheno- , teratospermia), then it usually will not respond favourably to any other ministrations than operation. A sub-inguinal, microsurgical varicocelectomy is then the treatment of choice. When performed at centers of excellence in carefully selected patients, results are very good, and there is marked improvement in sperm counts and spontaneous pregnancy rates. There is usually no need for any medicines to improve sperm counts. The operation is generally performed as a day care case under epidural, spinal, or local anaesthesia, and the patient is discharged the same day or the next morning.
Microsurgery for varicoceles requires microsurgical training for surgeons, assistants, and staff, special operation theatre infrastructure, and instrumentation. The use of optical loupes (magnifying spectacles) is not microsurgery. Microsurgery requires a special operating microscope (see Figure 5). All urologists, andrologists and other surgeons offering surgery for varicocele are not trained microsurgically. Varicoceles can be operated upon even without a microscope, like it was done in the past, but the results are just not as good as those obtained with microsurgery that is performed by skilled microsurgeons with great experience.
Figure 5: Dr. Sudhakar Krishnamurti performing varicocele microsurgery, and (below), a close-up of the operating microscope
Microsurgery allows selective ligation of the veins and avoids injury to the testicular artery and lymphatic channels in the spermatic cord, thus preventing post-operative complications such as testicular damage, atrophy, azoospermia, hydrocele formation, etc.. Recurrence rates with microsurgery are very low too.
|All urologists, andrologists and other surgeons offering surgery for varicocele are not trained microsurgically.
Other operative approaches, including laparoscopic varicocelectomy, are much less effective than microsurgery, and carry significantly higher complication rates.
Will patients require IVF (in vitro fertilization) or other ART (Assisted Reproductive Technologies) after varicocele treatment? Or is it better to avoid varicocele surgery altogether and go in for these procedures
The disrepute that varicocele surgery has achieved is partly deserved, but mostly undeserved. Surgeons who are not specialized in this kind of microsurgery are unable to offer the same results as those who are trained to do this, and this brings varicocele surgery on the whole into disrepute. At the best centers, fertility rates of 50 % at one year and 70 % at two years after operation can be achieved. If the operation works, the man can go on to have many children. Figure 2 shows one such patient.
However, the reason why many men with varicoceles are not offered varicocele microsurgery as an option at all, and are persuaded instead to undergo assisted reproductive technologies (ART) like IUI (intra-uterine insemination), IVF (in vitro fertilization) or ICSI (Intra-Cytoplasmic Sperm Injection), is that many of these men have landed up at infertility clinics where the doctors and staff are only trained in such therapies. Most infertility centers do not have an andrologist or uroandrologist on their staff, and often, the man is not even examined physically. He is only asked to furnish samples of semen on the dates his partner ovulates. It is in the interest of these centers to malign varicocele surgery and persuade the patient to undergo other treatments instead. Also, some of these centers see patients who have failed varicocele surgery performed by regular surgeons, and therefore think that it doesn't work. It must be noted that the high success rates boasted with many assisted technologies at infertility centers is a cumulative success rate after many attempts, and that the success rate per attempt (all technologies across infertile women of all ages combined) is hardly ever greater than ten to twenty per cent at most of these centers. The other point to note here is that if a varicocele operation is performed at a center of microsurgical excellence, the man is able to father many children naturally thereafter (see Figure 2) and usually will not need any further medical assistance whatsoever. By contrast, if the first pregnancy in a varicocele patient has been achieved by treating his semen sample and his partner, rather than by treating his varicocele, these torturous ART processes have to be repeated every time the man wants to father a child, until a pregnancy ensues. Each 'cycle' requires the woman to take medicines and injections to induce ovulation (egg release) for several days mid-cycle each month. The lady is also subjected to serial ultrasound scans to confirm ovulation. And then, of course, there are the pokes to pick up the ova (eggs) and all that. Many of these women are working women and some have to travel to the bigger towns to undergo all this. Not too many doctors explain all this to the patient.
Also, it must not be forgotten that the treatment of a varicocele is not for fertility alone. The varicocele is already harming the testis in an infertile male. If only the semen sample is treated, and not the varicocele, this damage continues and the testicular damage becomes worse. Over time, sperm counts may decline dangerously, and testosterone levels may drop, causing additional problems. Also, on the whole, ARTs like IVF and ICSI (Intra-Cytoplasmic Sperm Injection) carry much higher costs than varicocele microsurgery.
|Most infertility centers do not have an andrologist or uroandrologist on their staff, and often, the man is not even examined physically.
The surfer must beware of the websites/ specialists that do not address these aspects, and engage instead only in false propaganda that suits their interests more than the patients'.
Lastly but importantly, in male dominated societies, it is common for men to shy away from treatment for their own infertility. Instead, they persuade the partner to seek treatment. This is unfair, unscientific, and, as has been discussed above, is not in the best interests of the couple.
To summarize, it may be quite accurate to state here that if, in an infertile couple, there is a varicocele male factor that is impairing semen quality and causing infertility, that varicocele must be treated microsurgically at a center of excellence. This is especially important if the woman is normal.
So what's the 'take home' message?
The 'take home' message would be that in all cases of infertility, the male must be physically examined by an expert in male infertility (andrologist, urologist), and if a varicocele is discovered, and is found to be causing abnormalities in the semen analysis that are contributory to the couple's infertility, a microsurgical varicocelectomy operation at a center of microsurgical excellence must be performed.
Microsurgery in Male Infertility
In addition to the varicocoele (varicocele), there are some other conditions in male infertility that can be treated successfully with microsurgery too. The following other microsurgical operations are being routinely performed at the Andromeda Andrology Center, Hyderabad, India, by Dr. Sudhakar Krishnamurti:
Microsurgical Vaso-vasostomy (vasectomy reversal, vaso-vasal anastomosis, VVA, micro VVA):
If a patient has undergone vasectomy, and wants it reversed for some reason, excellent success rates can be provided microsurgically, at a center of excellence. With the rising divorce and remarriage rates in society worldwide, and an increase in geriatric sexuality, this operation is being performed more frequently than ever before. Also, people are more aware about the possibility of a surgical reversal, and thus come to the male infertility microsurgeon first, without going to other infertility centers where only TESA/ TESE (TEsticular Sperm Aspiration/ Extraction ) - ICSI (Intra-Cytoplasmic Sperm Injection) can be performed. A microsurgical vaso-vasostomy may also be required when the vas deferens is blocked due to other injury or disease, e.g. tuberculosis (TB), filariasis, etc.. These are common in tropical countries.
There are various techniques of microsurgical VVA available. These are outside the scope of a detailed discussion on a FAQ site such as www.varicocoele.com.
Microsurgical Vaso-epididymostomy (vaso-epididymal anastomosis, VEA, micro VEA):
Sometimes, the sperm conduction block is in the epididymis, not in the vas. The epididymis is the structure that connects the testis to the vas deferens. It is a long, convoluted tubule that nourishes the sperms during transit and allows for their maturation. To bypass such a block, the tubule of the epididymis is anastomosed (joined microsurgically) to the vas deferens using a variety of complex techniques.
Microsurgery of the epididymal tubule is generally conceded to be the most demanding and technically challenging of all microsurgical operations across all branches of surgery.
Microsurgical TESA/ TESE:
This is a procedure in which the male infertility microsurgeon uses the operating microscope to obtain sperms from the testis for an ICSI procedure. Multiple biopsies or aspirates may be obtained. Sometimes, the testis is incised open and a micro-dissection is performed before obtaining the best sperms from the best sperm-producing areas. These sperms are then transferred to a container and handed over to the reproductive biologist/ embryologist/ gynaecologist for further management.
Microsurgery for impotence (erectile dysfunction, ED):
Occasionally, vascular or vasculogenic impotence (ED), arterial or venous, may require to be treated microsurgically, e.g. in young men who have had pelvic fractures or bicycle injuries causing impotence.