Nearly 50% of men diagnosed with infertility have abnormal semen analysis. Among these, varicocele is the most common cause and can be treated surgically.
Prevalence of Varicocele
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According to the World Health Organization (WHO), varicocele occurs in 11.7% of men with normal semen analysis and in 25.4% of men with abnormal semen analysis. More than 80% of varicocele cases are not associated with infertility, but 35-40% of men with primary infertility have varicocele, and 69-81% of men with secondary infertility are affected by this condition. This indicates that varicocele gradually impairs the spermatogenic function of the testes and often occurs on the left side.
Impact of Varicocele on Testicular Function:
– Increased temperature has been confirmed by many studies to reduce testicular function, adversely affecting spermatogenesis.
– Metabolites from the kidneys and adrenal glands. Adrenomedullin, a potent vasodilator normally found only in the adrenal glands, kidneys, lungs, and heart, but not in the testes, is also found in abnormally high concentrations in the spermatic vein due to reflux from the renal vein and adrenal vein into the spermatic vein. Adrenomedullin may contribute to increased scrotal temperature.
– Oxygen deficiency can negatively affect testicular function.
Impact of varicocele on fertility. In 1955, Tulloch noted a patient with azoospermia (absence of sperm) who was able to conceive after undergoing surgery to treat varicocele.
– Semen analysis: In varicocele, the most common finding in semen analysis is reduced motility (90% of cases), followed by low sperm density below 20 million/ml (65% of cases).
– Hormones: Studies have shown that the function of Leydig cells is reduced. Since these are the cells that produce testosterone, testosterone levels in the blood of patients with varicocele are often low, returning to normal after surgery. The function of Sertoli cells is also affected, as evidenced by reduced response to FSH. Therefore, FSH levels in patients with varicocele are often elevated.
Diagnosis
Varicocele is typically classified into three grades:
– Grade 1: Varicocele is only detected during Valsalva maneuver.
– Grade 2: Varicocele is detected in the standing position.
– Grade 3: Varicocele is visible under the skin and palpable when the patient is standing.
Tests that help identify varicocele that may be missed during clinical examination include:
Ultrasound can detect 34% of varicocele cases that clinical examination may miss. Doppler ultrasound has high value in diagnosing varicocele, but its limitation is that it requires blood flow in the vessel to detect it.
Venography is the most accurate test for diagnosing varicocele but is an invasive procedure with potential dangerous complications.
Prognostic Factors
After surgery, the natural pregnancy rate for patients with grade 2 and grade 3 varicocele is higher than for those with grade 1 varicocele.
Individuals with normal testicular volume have a higher natural pregnancy rate after surgery compared to those with testicular atrophy.
Treatment
The goal of treating varicocele is to improve testicular function and semen analysis to enhance fertility.
Interventional radiology to occlude the veins has an overall complication rate of 6%, such as vascular perforation and embolism.
Surgical ligation of the spermatic vein via the retroperitoneal approach (Palomo surgery) has a lower recurrence rate and preserves the spermatic artery. The inguinal approach (Ivanisevic surgery) also has a lower recurrence rate. The subinguinal approach has similar advantages to the inguinal approach and is less painful as it does not involve cutting muscle, although microsurgery is required.
Laparoscopic Surgery.
In summary, subinguinal microsurgery or low inguinal surgery has the highest success rate, fewest complications, and is the most cost-effective.
Most studies show that treating varicocele helps improve semen analysis and pregnancy rates. In couples unable to conceive naturally after surgery, combining intrauterine insemination increases the chances of pregnancy.
