Fertility treatments

Varicocele

Varicocele is found in 15% of the fertile male population, and 40% in infertile men, and has been described as hereditary in many studies where it has been suggested that siblings and children of men with varicocele are at increased risk.

Varicocele

Table of Contents

definition

What is Varicocele?

It is an anatomoclinical syndrome characterized by dilation and tortuosity of the testicular veins of the pampiniform plexus, caused mainly by venous reflux. It is a high prevalence pathology, with a chronic and progressive course.

Its onset usually occurs in adolescence, but most cases are diagnosed in adulthood. It usually occurs on the left side in 70%-75%, followed by the right side (15%-20%), or bilaterally in 10%.

Dilation of the testicular veins has been related to infertility, presenting a decrease of the spermatozoa, their mobility, morphology and capacity of fecundation, being these changes irreversible or not.

Varicocele is found in 15% of the fertile male population, and 40% in infertile men, and has been described as hereditary in many studies where it has been suggested that siblings and children of men with varicocele are at increased risk.

Testicle anatomy

Varicocele

Treatment Summary

This is short summary of the whole process: from the appointment request, to receiving the medical discharge after the treatment in some our Andromedi centers in Madrid, Seville or Canary islands (Tenerife)

Consultations Needed

Because it is a urological medical emergency and because it has a very particular symptomatology, the diagnosis can be made in a single consultation.

Hospital Stay

The hospital stay is usually very short, about 24 hours to wait for the anesthesia to wear off.

Anesthesia Type

Almost always and with the newest approaches, anesthesia is local with general sedation. The open technique requires general anesthesia.

Operation Time

Varicocele surgery is usually quite fast, in less than an hour the patient can be in and out of the operating room.

Post-operative

Light physical exercise is recommended to encourage recovery and return to sexual activity three weeks after the operation.

Resuming Sex Life

Daily activities can be resumed after 48 and 72 hours after surgery without any problem, without exaggerating.

Frequent causes

Causes

It is considered a multifactorial pathology, whose aetiology is not totally defined, however, the frequency of varicocele is much higher on the left side, in 90% of the total cases, for this reason, it has been correlated with alterations in the venous drainage of the left testicle, finding venous reflux and increased pressure in the drainage of the left spermatic vein to the renal vein on the left side.

Among the possible causes that would explain this dysfunction in patients with varicocele are:

Varicocele e infertilidad

Since 1880 a relationship between the presence of varicocele and infertility was discovered, this could be explained by the modifications at the level of tissue and testicular function that occur in this disease.

For normal sperm development, a temperature of approximately 33°C is required. At this temperature, the DNA suffers less oxidative damage, and therefore there is less chance of genetic mutation; this explains the scrotal location of the testicles. In addition to the strategic anatomical location, the pampiniform plexus helps to cool the blood coming from the testicular artery, thus contributing to the optimal temperature required by the testicles. For this reason, any alteration in the veins and consequently varicocele contributes to the increase of the scrotal temperature and deficiencies in the quality of the sperm.

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The alterations in the microvasculature and in the testicular blood supply seen in varicocele, cause a state of sustained vasoconstriction which alters the supply of oxygen, nutrients and transport of hormones which affects the formation of sperm.

In addition, lower plasma testosterone concentration has been observed in patients with varicocele, which is why this pathology has been related to alterations in the cells that produce this hormone, the Ley dig cells.

Another alteration that occurs in patients with varicocele and is related to infertility, is testicular atrophy, observed in up to 70% of patients with varicocele, the testicle that is ipsilateral to venous dilations has been found decreased, with greater testicular atrophy in varicocele grades 2 and 3, but showing a significant improvement in adolescents who have the diagnosis and surgical treatment made in time.

In most cases, the varicocele grade is directly proportional to the effect on sperm quality, both in sperm count and in sperm quality

· Classification ·

1 Grade 3: Visible and palpable without Valsalva manoeuvres.

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Negative evolution of varicocele. 3rd grade

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Negative evolution of varicocele. Grade 2

2 Grade 2: Visible and palpable with Valsalva maneuvers.

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3 Grade 1: Palpable during Valsalva manoeuvres but not visible.

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Negative evolution of varicocele. Grade 1

4 Grade 0 (subclinical): Not palpable or visible at rest or during Valsalva manoeuvres, but reflux is shown on Doppler examination.

Depending on its location, it is classified as:

Unilateral
Unilateral

When venous dilation occurs in a single testicle.

Bilateral
Bilateral

When there is dilation and tortuosity in the veins of both testicles.

Unilateral
Unilateral

Cuando la dilatación venosa se presenta en un solo testículo.

Bilateral
Bilateral

Cuando se presenta dilatación y tortuosidad en las venas de los dos testículos.

symptomatology

Symptoms

It is generally an asymptomatic pathology, but it may present some symptoms such as testicular pain or weight or mass sensation in the scrotal region. A very significant sign is the decrease in testicular size, which may evolve into testicular atrophy.

There are other testicular pathologies that can cause these same symptoms and the doctor will have to make a differential diagnosis, such as orchiepididymitis, testicular torsion, allergic scrotum, testicular tumour, epididymis cyst or inguinal-scrotal hernia.

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Medical Evaluation

Diagnosis

For the study of the patient with suspected varicocele, a medical and reproductive history, complete physical examination, and seminograms should be taken into account.

Varicocele is diagnosed by physical examination, it is necessary to evaluate the patient in supine position and standing, an observation is made in search of obvious venous dilations in the scrotum, then a bilateral manual testicular examination is performed in supine position, standing and asking the patient to execute the Valsalva manoeuvres, which cause increased abdominal pressure and venous dilation.

For an optimal physical examination, the temperature of the environment should not be cold, since this produce elevation of the testicles, the ideal temperature being above 25 degrees Celsius.

Another important parameter to take into account is the testicular size. Approximate measurement is obtained by means of an orchidometer, the most commonly used being Prader’s, which consists of ovoid figures that vary between 2 cm3 and 25 cm3 and are compared with both testicles and with Tanner’s degree of pubertal development. In fully developed testicles, a difference of more than 2 cm3 between the two testicles is not normal.

Another element to be evaluated is testicular consistency, which is firm in a normal testicle but decreases notably in grade 2 and 3 varicoceles.

If clinical varicocele is not observed on examination, subclinical varicocele must be ruled out, and this is done by using conventional ultrasound, Doppler ultrasound, venography and tomography; Doppler and conventional ultrasound being the most used tests.

Doppler’s ultrasound allows the measurement of testicular volume, resistance index and direction if it is retrograde or anterograde, such measurement is performed with the patient standing, lying down or applying the Valsalva manoeuvre, this test not only helps to confirm the suspected diagnosis, but also corroborates the varicocele grade by allowing the measurement of the diameter of the vein pre and post-Valsalva.

A diagnosis of varicocele can be made when the pampiniform plexus veins are tortuous and a diameter greater than 2-3 mm is observed, increasing when standing, veins with a diameter of less than 2 mm being the norm.

Sperm phlebography: this is a somewhat invasive technique to be used on a regular basis, but it has proved to be of great help in cases of recurrence, as it helps to identify the anatomical position of recurrent or persistent sperm veins that are not occluded following varicocelectomy.

tight pants and fertility
TECHNIQUES AND TREATMENTS

Semen analysis and varicocele.

It has already been proven that any grade of varicocele can considerably affect a man’s fertility. For this reason, whenever a diagnosis of varicocele is made, at least two semen analysis should be indicated, in order to evaluate the functional involvement of the varicocele in fertility and to make a surgical decision.

Among the alterations that can be observed in the semen analysis, we have an increase in the number of dead spermatozoa and abnormal forms with a decrease in their mobility and vitality. The most considerable changes that could occur are a marked decrease in the number and concentration of spermatozoa, which is considered a “stress pattern” in the semen analysis, without presenting alterations in the seminal fluid since the function of the prostate and seminal vesicles is not altered.

Early detection and adequate follow-up are recommended for adolescents with varicoceles,

since alterations have been observed on semen analysis since the early age of 13, such as a decrease in the motility and number of spermatozoa in these patients, versus those adolescents who do not have the disease. It should be taken into account that varicocele is a chronic and progressive pathology, which in adulthood can considerably compromise an individual’s fertility rate.

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Techniques and treatment

Treatment

There are several aspects that must be evaluated in order to consider surgical treatment in a patient with varicocele, among these we have:

The surgical treatment will be done with the objective of recovering the reproductive capacity of the patient, correcting testicular pain, preventing or reversing testicular atrophy in the case of adolescents or young patients and improving the individual’s production of androgens.

The most frequent surgical techniques are:

Inguinal Approach (Ivanissevich)

This technique allows the spermatic cord to be approached along the inguinal canal and in this way the spermatic vein(s) and the collateral cremasteric veins can be ligated. This technique is the most indicated in obese patients and has the advantage that it allows the external sperm vein to be ligated.

Subinguinal Approach

It is considered the one of choice because it has shown less postoperative pain, better recovery, allows arterial preservation and there is no need to open the aponeurosis of the external oblique; also, it serves as a choice when there is a history of previous inguinal surgery. The disadvantage is that the number of veins is greater and the risk of arterial injury ­increases.

Currently, varicocelectomy with subinguinal approach is widely used, but with the use of magnifying glasses, which help the surgeon to see everything four times larger and amplify all the structures, thus achieving a more thorough and effective surgery. With this technique, the testicular artery and lymphatic vessels are easily identified so as not to be damaged and to avoid complications such as hydrocele and hematomas. At the same time, it allows the surgeon to see all the veins clearly, to carefully separate and ligate them to correct varicose dilation. It has a recurrence rate of less than 3% and less than 1% of complications, which makes it an excellent surgical option.

The inguinal and subinguinal approaches have the advantage of allowing access to external sperm veins and even gubernaculum testis veins, which are often involved in recurrences. In addition, in case of need, this approach allows for a testicular biopsy or ­examination of the epididymis.

Retroperitoneal (Palomo) approach.
  • This is an approach used in thin patients who have previously undergone surgery by other means. It has the disadvantage of not including the external spermatic vein, which would lead to a higher probability of recurrence.
Laparoscopic technique
  • It has been considered a very effective, popular and easily performed technique by surgeons specialized in laparoscopic interventions. It has considerable advantages such as a better visualization of the spermatic vessels, as well as the detection of collateral venous branches, few complications and recurrences and a quick return to daily activities.

Although many studies confirm that success and complication rates are similar to open surgery, taking into account that it also requires general anaesthesia.

Microsurgical techniques

Being a highly specialized technique, it provides an excellent vision of the surgical field, by means of magnifying lenses and specific instruments it allows to preserve the spermatic artery, the cremasteric ­artery, the lymphatic vessels and the deferens with its vessels, and to perform with precision the ligation and section of the spermatic vein. It has the advantage of having a low rate of post-operative complications

Venous embolization

Is a minimally invasive technique, which does not require general anaesthesia and has a short period of hospitalization. With radiological assistance an introductory device is placed in the right common femoral vein through which the guide and catheter will be inserted, which will be guided to the left spermatic vein, where some metallic coils will be placed at different levels of the spermatic vein. 6-8 coils can be used, choosing them according to the diameter of the vein, the objective of this technique is the occlusion of the collateral veins and trying to decrease the recurrence rate.

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"In our centres in Madrid, Seville or the Canary Islands (Tenerife), we carry out the techniques and treatments with the most modern facilities and the best specialists and equipment to guarantee an effective solution".

Complications

Although this surgery has a low risk and complication rate, some cases may occur such as:

Frequently asked questions at the Andromedi centres in Madrid, Seville and Tenerife

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¿El varicocele predispone al cáncer testicular?

No hay estudios que demuestren que la presencia de varicocele contribuya como causa directa en el cáncer testicular, sin embargo, las dos condiciones pueden coexistir en un individuo

¿Qué resultados puedo esperar luego de una varicocelectomía?
Cuando la varicocelectomía se realiza en paciente joven, con un abordaje quirúrgico adecuado y un equipo médico-quirúrgico óptimo se pueden observar resultados muy favorables, como:
  • Mejora la calidad del semen en el 50-70% de los casos operados.
  • Hay una gran tasa de embarazos después de la operación, oscila entre un 30 y un 60%, por lo general el embarazo se logra luego de 8 meses al año de la varicocelectomía.
  • Se detiene el deterioro de la función y el tejido testicular además hay mejoría en los niveles de testosterona.
  • Puede revertirse la disminución del tamaño del testículo si se realiza al momento de hacer el diagnóstico. En la mayoría de los adolescentes y jóvenes, tras la cirugía del varicocele el testículo aumenta de tamaño.
¿Cómo es la recuperación y los cuidados postoperatorios que se deben tener?

Es una operación de corta duración, aproximadamente menos de una hora, el tiempo de hospitalización es por lo general son 24 horas, para evaluar la presencia de complicaciones inmediatas.

Se pueden retomar las actividades diarias luego de las 48- 72 horas, siempre y cuando la persona no tenga una rutina que implique grandes esfuerzos físicos,
Se recomienda realizar ejercicio físico leve y retomar la actividad sexual posterior a las 3 semanas de operado, luego de que el cirujano haya comprobado que la herida quirúrgica está cicatrizando bien y que no se desarrolló ningún tipo de complicaciones.

Dentro de los cuidados, es muy importante realizar limpieza de la herida quirúrgica con soluciones antisépticas, cambiando los vendajes diariamente. Para la inflamación y molestias que se puede presentar en los testículos, se recomienda el uso de analgésicos antiinflamatorios recetados por el médico tratante y colocación de frío local.

¿Hay relación entre el varicocele y la infertilidad?

Se ha demostrado que la presencia de varicocele influye directamente en la fertilidad del hombre, las cifras nos muestran que un 30 a 40% de los hombres que presentan infertilidad poseen esta patología. 

El varicocele genera mayor estrés oxidativo y alteraciones en la carga genética de los espermatozoides, producto del reflujo venoso y la elevación de la temperatura escrotal que lleva a la disfunción testicular.

¿Un hombre que presente varicocele puede generar un embarazo natural?

Esto va a depender del grado de varicocele que presente el hombre, si este padece de un grado leve, de corta tiempo de evolución el cual no ha afectado su calidad espermática sin problemas podrá lograr el embarazo de la pareja.
Es importante tener en cuenta que mientras mayor sea el grado y el tiempo de evolución de la enfermedad, se verá mucho más comprometida la fertilidad del individuo.

¿El varicocele puede disminuir la libido?
No hay una causa directa para que los hombres que padecen de varicocele tengan disminución del deseo sexual, sin embargo, en las formas graves de la enfermedad hay descenso de los niveles de testosterona, lo que podría originar la disminución de la libido, en casos severos podría ser un motivo de impotencia sexual.
¿Se pueden tener relaciones sexuales si se tiene varicocele?
Si, en caso de que el dolor o malestar en los testículos no represente un problema para llevar a cabo el acto sexual.

 

Author

Dr. Natalio Cruz


Natalio Cruz MD, with 25 years of medical experience, has been until 2016 Head of the Andrology Unit in the Urology Service of the Virgen del Rocío Hospital in Seville, National Coordinator of Andrology in the Spanish Association of Urology (AEU) and General Secretary in the ESSM, positions that he has narrowed to focus squarely on this exciting project of offering a high-level private medical consultation in Seville, Madrid and Tenerife.

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Andromedi Clinic of Urology and Sexual Medicine

Thank you all for your comments and suggestions, we are happy to be of use in the medical and scientific dissemination around Urology and Sexual Medicine.

We try to answer as much as possible all the doubts that you raise here in the comments section. In a limited channel such as this, we cannot (and should not) respond in depth to personal or particular cases, but we can delve into general information.

For all those who want a more in-depth and individualized assessment, they can request a face-to-face appointment at our Spanish centers in Madrid, Seville, or Tenerife through our contact page: https://www.andromedi.com/en/contact

For those who do not reside in Spain, they can also have one with our Clinic without leaving home, through the Internet by video call. It’s very simple, more info at: https://www.andromedi.com/en/online-urologist/

SHAW

Are you going through AZOOSPERMIA, LOW SPERM COUNT OR PREMATURE EJACULATION? Contact Dr. for a lifetime solution to your problem. I was once a victim of azoospermia which almost ruined my life & marriage for 18 years of childlessness, I used different kinds of medicine it was all to no avail. Until I read from someone who got treated/cured by the doctor, I reached out to him and I was able to impregnate my wife after 18 years of marriage, and am now a father. Your case will be corrected by Dr.

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