WHAT IS VARICOCELE?
It’s the abnormal dilation, folding, or varicosity of the venes carrying the venous blood from the testicles (venous blood vessels). This dilation might start at a young age and progress due to gravity. Varicocele is the most common and treatable reason of male infertility.

It may be asymptomatic. It might lead to swelling in the scrotum, pain (on the groins) and disorders in sperm number and activity by progressing in time.

What’s the prevalence of varicocele?
Varicocele is typically seen in 15-20% of the males after puberty, and in 40-50% of the males we receive with the complaint of infertility.

Venous blood vessels on the left are connected to the main vessel where the blood is flows more vertically and they are longer. For this reason, varicocele is typically seen on the left side (85%). The rate of being observed on the right venous blood vessel is around 15%. It might be observed in both testicles. Varicocele on one side may also affect the other testicle.

VARICOCELE and INFERTILITY
Although it’s not completely known how the varicocele causes infertility, there are some theories on this subject. Venous blood accumulating on the venous blood vessels with varicosity causes heat increase and increase of pressure in the testicles. Decreasing oxygen level and accumulation of various metabolic substances due to kidneys and adrenal gland might affect sperm production. As a result, sperm amount and activity decrease

Symptoms of Varicocele;
 Pain in testicles (pain affecting groins and the inner part of legs)
 Swelling in the testicles
 Reduction of testicle size
 Infertility
 Observable, dilated vessels
 Dilated vessels that can be felt by hand

Diagnosis of Varicocele:
It’s diagnosed through physical examination. Typically it’s diagnosed through palpation. Dilated and folding vessels (venous blood vessels) are felt. It’s confirmed with Coloured Doppler Ultrasonography (USG). When the physical examination is not possible, Coloured Doppler Ultrasonography might help


(Left grade 3 varicocele)


Grading varicocele:
 Subclinical varicocele: Can’t be diagnosed with PE, however is diagnosed with ultrasonography.
 Grade 1 varicocele:Asymptomatic when resting, diagnosed during straining (valsalva+)
 Grade 2 varicocele: Venous blood vessels can be felt with hand (palpable)
 Grade 3 varicocele: Varicocele that can be seen (observable).

After varicocele is diagnosed, spermiogram should be conducted. Patient should stop his/her sexual activity 3-4 days before the spermiogram. If the sperm production is damaged, a decrease in the activity, amount and structure of the sperm would be observed. More than half of the individuals with varicocele would have disorders diagnosed in the spermiogram.

Sometimes the sperm number might be very low. In these cases, various hormones (fsh, lh, testosterone, prolactin...) and other possible systemic diseases (thyroid, diabetes, cholesterol) should be checked.
Deficient hormones are provided for the patients with hormonal disorders and the infertility can be treated by increasing the sperm number.

Rarely, sperm production might be available, however no sperms might be observed in the spermiogram. Blockage in the seminal ducts would be checked in these cases. This blockage would be opened by using endoscopic or microsurgical methods, and it would be possible to have a child with normal ways.

TREATMENT OF VARICOCELE
Varicocele is the best treatable reason of, male infertility.  The treatment is a surgical operation. However, any patient with varicocele can’t have the operation. Therefore, varicocelectomy should be applied on the right patient on the right time and with the right technique by the specialist surgeons experienced in this area.

                   
WHO CAN HAVE VARICOCELE OPERATION?
 Male individuals with varicocele who has the complaint of infertility (the ones who are diagnosed with a disorder in the spermiogram)
 In the cases where varicocele causes shrinking in the size of testicles, a testicle is smaller than the other or both of them are shrinked
 Patients with severe pain (the ones who don’t respond to pain killer and scrotal elevation)

                          
VARICOCELECTOMY OPERATION
This is an operation that takes between 30-60 minutes where venous blood vessels with varicosity are tied and the connection of these vessels are blocked. It might be conducted through general, spinal or local anaesthesia with a 2 cm section on the groin area.
The venous blood vessels (internal, external spermatic venes and cremasteric venes) should be tied; and last but not least, seminal duct (vas deferens), testicle arteries and lymph ducts should be preserved. Complications such as testicle shrinking in the cases where arteries are tied, and hydrocelle (liquid accumulation between the tunicles of testicle and swelling) in the cases where the lymph ducts are tied might be possible.



In the light of this information, the best technique for the varicocele operation is microsurgery varicocelectomy operation conducted with microsurgery (microscopy). The success rate for the microsurgery varicocelectomy operation conducted by specialist doctors and the possibility of any complications would be minimal. (I always conduct the varicocele operation with microsurgery technique except some specific conditions.)
Varicocele doesn’t repeat itself as a result of a successful varicocele operation.
Spermiogram would be needed on the 3rd, 6th and 12th months following the varicocele operation. Sperm production of around 70-80% of the patients turn back to normal after the operation. Reproduction rate of the patients with infertility due to varicocele is around 50-70% after the operation.

© 2016 - Op. Dr. Cem ÖZLÜK