Varicocele treatment in Turkey can significantly improve semen parameters and allow for a normal pregnancy or reduce the need for reproductive assistance.
What are varicoceles?
Varicocele or varicocele is a term used to describe abnormally dilated veins (called the "clinic plexus" of the veins) in the scrotum of the testicle.
How is a varicocele formed?
Veins throughout the body carry blood from various organs to the heart. Usually, they have valves that ensure blood moves in the right direction. However, a varicocele is formed as a result of a malfunction of the valves in the testicular vein.
Gravity can make blood pool in the scrotum, causing varicocele. They usually occur in the left testicle, and are likely to be associated with the testicular vein in the abdomen.
How common is varicocele?
Varicoceles are very common and not dangerous. In fact, 15% of adult men have varicocele symptoms. For many men, varicoceles go unnoticed throughout their lives, or won't cause any problems at all. About 20% of teens have varicoceles, so it's possible that some of them will go away on their own.
What are the problems associated with varicocele?
A varicocele can cause three main problems: impaired fertility, decreased testosterone production from the testicle, or discomfort in the scrotum. For this reason, they are usually not treated unless there is reason to be concerned about one of these problems. In some cases, a varicocele can cause a varicocele that causes azoospermia, or a complete lack of sperm in the semen.
Because varicoceles are so common and usually go undetected throughout life, it is possible that about 80% of men with varicoceles are able to become pregnant with their partners without any medical intervention. Also, as mentioned earlier, most men with varicoceles do not have hormonal problems or discomfort.
An important consideration is that large varicoceles appear to have greater adverse effects. See below for a varicocele size classification
How does varicocele affect the testicle?
There are many theories, but most agree that one way is to carry warm blood from the abdomen down toward the testicle in the scrotum. The testicle functions optimally at about 3 degrees below body temperature, so this warmer blood can affect its ability to produce sperm and testosterone. Other theories include the mass's effect on the testicle as well as exposing the testicle to various chemicals from the adrenal gland, which is located near the top of the testicular vein.
Is varicocele dangerous?
A varicocele is not life-threatening, but it can rarely be associated with serious conditions. For example, if a varicocele has formed on the right side rather than the left side, it is important to make sure that there is no mass or other abdominal abnormality that may be causing it.
Also, the varicocele should "reduce" or decrease in fullness when the patient is lying down because gravity no longer fills the varicose plexus in the veins. When a varicocele is not diminished, it also raises the concern that there is an abdominal obstruction such as a lump or tumor that could be causing the lump.
Finally, varicoceles always appear to have effects on testosterone production. However, many men with varicocele will maintain satisfactory levels of testosterone throughout their lives without treatment. However, in rare cases, a varicocele can lead to a severe drop in testosterone, with associated complications including metabolic syndrome and osteoporosis.
What is the grading system for the size of a varicocele?
Varicocele grading systems help determine the size of the varicocele, which then helps guide treatment. Various systems have been created, but below is the one most commonly used today:
Grade 0: seen on ultrasound, but undetectable on clinical examination (also called “subclinical varicocele”)
Grade I: Perceptible on clinical examination when the patient performs a falsalva maneuver ("press down")
Grade II: Tangible even without philosophies
Grade III: A varicocele causes an obvious deformity of the scrotum.
Even in grades two and three, there can be different sizes that are estimated by experienced doctors, and the results can help determine whether or not a varicocele should be treated.
Can a varicocele cause problems later in life?
Data from Johns Hopkins and other institutions indicates that both fertility parameters and testosterone levels can be affected gradually over time. For example, a varicocele is more common in men who have had children previously, but are currently having trouble conceiving. Also, almost all men who have had varicocele repair without surgery notice an increase in testosterone levels after the repair.
How is a varicocele diagnosed?
A “subclinical” varicocele found on ultrasound is not thought to be of clinical significance, since it rarely causes testicular weakness or discomfort. In a few cases, an ultrasound may detect a varicocele when a physical examination is difficult due to the patient's anatomy, or when other findings lead a doctor to order an ultrasound of the scrotum.
A varicocele can often be seen as a varicocele that you can see with the naked eye, or the patient can feel something like a 'bag of worms' in the scrotum. Most commonly, however, a varicocele is not discovered until after an examination by a doctor.
Thus, the best way to detect a varicocele is a thorough physical examination by a urologist. Even seasoned general urologists are often not confident in the diagnosis, so if there is any doubt, one should get an ultrasound and/or see a doctor who specializes in varicocele and other scrotal diseases.
When is the diagnosis usually made?
A varicocele is usually found due to one of the following scenarios:
- Most commonly, in a man who is completely asymptomatic it is evaluated for infertility.
- The patient or doctor may discover a lump in the scrotum during a routine examination.
- A man may see a doctor with pain in the scrotum
What kind of Pain caused by varicocele?
For most patients, a varicocele does not cause any noticeable discomfort. However, mild or severe scrotal pain can result from a varicocele. Patients usually report a sensation of "pain" in the scrotum, usually associated with prolonged standing or activity. The discomfort is usually relieved by lying down (on one's back) and raising one's foot.
A varicocele may cause more severe pain if the veins become infected with thrombophlebitis (blood clotting and inflammation). Evaluation of patients with scrotal pain should include ultrasound of the scrotum to rule out other diseases, and urine examination to rule out infection.
Varicocele repair may be considered when there is no other identifiable cause of the pain and the characteristics of the pain are consistent with the varicocele, but there can be no guarantee that varicocele repair will eliminate the pain.
In modern times, microsurgical removal of the nerve from the spermatic cord at the time of varicocele ligation should also be considered in patients with scrotal pain.
Varicocele and fertility
A varicocele is found on physical examination of approximately one-third of men evaluated for failure to conceive. They are categorized by size (see grading system above) and presence on one or both sides of the scrotum. It is important to know that varicoceles of all sizes may affect fertility. In addition, new evidence shows that sperm function may be affected by varicoceles in ways that are not detected by semen analysis.
A varicocele on one side of the scrotum affects both testicles with respect to function and testicular temperature. As previously mentioned, a varicocele that cannot be felt by a doctor but diagnosed by ultrasound or other imaging studies is not considered clinically significant.
When should varicocele repairs be done?
It is important to have an individualized approach to varicocele management. The decision to treat a varicocele is made based on the size of the varicocele, the patient's fertility goals, symptoms of low testosterone levels or scrotal discomfort, blood tests such as testosterone levels, and/or semen analysis results.
Also, the age and fertility of the patient's partner are very important factors to consider when deciding whether or not to treat a varicocele. The optimal course for each couple should be determined in conjunction with the couple's reproductive endocrinologist when there are female fertility considerations as well. If the partner has not yet been evaluated, she should undergo basic tests to ensure that there are no results that would alter the management of the varicocele.
There is strong evidence to suggest that varicocele repair improves testicular function and may prevent any further damage to the testicle over time, but this is closely related to the size of the varicocele. Thus, testicular function must be assessed directly by semen analysis, testicular volume measurement, and/or blood tests. If there is evidence of testicular damage, varicocele repair may be important to improve testicular function and/or prevent further deterioration.
When a testicle appears unaffected by a varicocele, there are differing opinions about whether or not a varicocele should be treated. If you want to have a varicocele to protect future testicular function, it's important to have a thorough discussion with your surgeon, and have realistic expectations about the chances of any measurable benefit, and the risks of side effects from the procedure. We prefer only treating a patient for any condition when the "risk-benefit ratio" is favourable.
An alternative treatment is to monitor patients with varicocele over time by examining semen analyzes and/or blood tests, and to treat only if there is evidence that the varicocele impairs testicular function.
Varicocele repair in the male partner of an infertile couple is indicated when:
- There is objective evidence of a male factor (eg abnormal semen analysis),
- The wife's fertility is healthy or treatable, and
- There are no other obvious causes of male infertility (eg obstruction, malignancy, or genetic abnormality).
How is a varicocele repaired?
There are three classes of styles:
With varicocele embolization, small coils are inserted through a vein in the groin area and used to block the veins in the abdomen that supply the varicocele. Long-term success rates appear to be slightly lower compared to the open surgical approach, and treatment can take more than one procedure. However, there is no incision, so we often think highly of this approach for children. In addition, it is sometimes used in patients with previous surgical failure, pain as a primary indication for surgery, and body characteristics that increase the risks of surgery such as morbid obesity.
In laparoscopic varicocele ligation, a camera and small instruments are inserted into the abdomen, where the veins that supply the varicocele are cut. This procedure also has lower long-term success rates. In addition, although complications are rare, when they do occur they can be much more serious than other methods. Finally, the rate of hydrocele (a collection of fluid around the testicle) after surgery is higher with this approach.
Finally, there are several open surgical approaches. For most patients, we perform a microsurgical ligation of the varicocele under the inguinal ligament. This approach results in the highest success rates, lowest complication rates, lowest cost, and essentially eliminates the risk of serious intra-abdominal infections
How is it made? Connecting varicocele under the inguinal ligament microsurgery?
In this procedure, the patient is asleep under general anesthesia. An incision is made in the lower thigh area and the spermatic cord is isolated. All veins feeding the varicocele are identified and isolated, while preserving structures important for testicular function.
What are the complications of varicocele that is repaired?
Possible complications of varicocele repair include persistent/recurring varicocele, bruising, infection, and testicular pain. A hydrocele, a collection of water around the testicle, occurs in a very small number of men. For those patients undergoing non-surgical repair, there is an additional risk of a reaction to the contrast agent used in the procedure. Finally, there is a very low risk of losing a testicle.
How does varicocele repair positively affect fertility?
In 540 infertile men with palpable clinical varicoceles who underwent microsurgical varicocelectomy and were followed over 1 year and 2 years after surgery for changes in semen quality and pregnancy, respectively:
- A 50% increase in the total motile sperm count was observed in 271 patients (50%).
- An overall spontaneous pregnancy rate of 36.6% was achieved after varicocelectomy with a median time to gestation of 7 months (range 1 to 19).
- Of the preoperative candidates for in vitro fertilization/intracytoplasmic sperm injection (IVF and ICSI), 31% became candidates for intrauterine insemination (IUI).
- Of all the candidates for an IUI procedure, 42% gained the possibility of spontaneous pregnancy.
- Microsurgical varicocelectomy has great potential not only to avoid the need for assisted reproductive technology, but also to reduce or change the level of assisted reproductive technology needed to bypass male factor infertility.
This means that repair of a clinically significant varicocele can significantly improve semen parameters and allow for a normal pregnancy or reduce the need for reproductive assistance.