Varicocele and its treatment..
Varicocele is a varicose vein that occurs in the veins that return from the testicles (ovaries) to the heart in men. While it usually causes no symptoms at mild levels, it may progress over the years and cause sperm production and motility disorders.
It is said that in very advanced cases, it may cause a decrease in testicular size and disorders in testosterone production. The temperature in the bags called the scrotum, which protects the testicles, is usually a few degrees lower than body temperature. In other words, in order to produce sperm in the healthiest way, an environment cooler than normal body temperature is required. With the development of blood pooling due to varicose veins inside the bags, increased heat can negatively affect sperm production and disrupt reproductive function. Another theory put forward, not only the increase in temperature, is that harmful wastes and free radicals from the kidneys and adrenal glands may accumulate in the testicles due to increased vascular structure and blood supply. Thus, it is said that especially the movement and quality of sperm may be affected.
frequency of occurrence
Varicocele was detected in 25% of men with defective sperm test and in 12% of men with normal sperm parameters. Additionally, 35-40% of men complaining of infertility have varicocele. However, it should not be forgotten that varicocele can be detected incidentally in a significant number of healthy men who have children.
It is mostly seen on the left side. The veins on the left side are longer and the blood cannot drain completely because they are connected at a right angle to the main vein from which the blood flows. Sometimes it can occur bilaterally or rarely only on the right side.
How is it diagnosed?
The most important diagnostic method is physical examination. Diagnosis is made by manual examination of the vascular and nerve structure leading to the testicle. During the examination, intra-abdominal pressure is increased by coughing or straining and the dilated vascular structure is recognized.
Varicocele research can be done with Doppler ultrasound, but it has been reported that varicocele detected only by ultrasound has no clinical significance and there is no need for surgery. Therefore, treatment of very mild varicocele that is not palpable is not recommended.
treatment
The treatment of varicocele is surgery; the veins are connected by an operation performed in the groin area, either visually or under the guidance of a microscope. Using a microscope in surgery allows the vessels to be identified more clearly and the vessel feeding the testicle to be carefully protected.
varicocele can be treated using microsurgical methods; It is the most common cause of male infertility. In varicocele cases diagnosed correctly and treated with the successful application of microsurgical methods, a 60-70% improvement in spermiogram values can be achieved (1). However, there are conflicting studies on the extent to which this improvement in sperm improves pregnancy rates (2).
Generally, cases that do not become pregnant despite the improvement in sperm analysis results within 6 months at the latest following varicocele surgery must definitely proceed with intrauterine insemination (IUI) or in vitro fertilization (microinjection). In mild but not extreme sperm disorders, sperm washing process and by vaccination It is possible to achieve pregnancy. If necessary, the opinion of a Urologist is taken. In severe sperm disorders, insemination cannot be beneficial and in vitro fertilization is not recommended.microinjection treatment must be applied.
If there is no sperm in the sperm sample given and if the cause of this is not detected as a blockage, that is, if there is a lack of sperm production, then the sperm obtained from the pieces taken from the testicles (man's ovaries) is used (microTESE). in vitro fertilization treatment and microinjection treatment is required. Varicocele surgery will be a waste of time in azoospermic men who do not have any sperm.
Another important issue is that it would be appropriate to treat varicocele detected in young men in adolescence, even if they are not married. In this way, it is suggested that possible deteriorations in sperm quality that may occur in the future can be prevented.
To put it briefly; In couples where the woman has no problems, if the man's sperm values are low and there is an obvious varicocele that can be detected clinically rather than by ultrasound, treatment may be considered. Otherwise, treatment is not required. Again, in order to undergo treatment, varicocele must have disrupted sperm values. In other words, if his sperm is normal, varicocele may not be treated even if it is palpable.
Today, due to the lack of scientific evidence that varicocele operation facilitates pregnancy and the high success of in vitro fertilization treatments, it is natural that couples prefer direct microinjection, that is, in vitro fertilization treatment, instead of having a varicocele operation and waiting for 6 months.
1. Agarwall A. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach
Urology 2007 Sep;70(3):532-8.