Varicocele treatment in Turkey can significantly improve semen standards and allow for natural conception or minimize the need for assisted reproduction.
What is varicocele?
Varicocele or varicocele is a term used to describe abnormally dilated veins (called the “tendril plexus” of veins) in the scrotum of the testicle.
Symptoms of varicocele
Some men with varicocele may not have any symptoms.
However, others may experience the following symptoms:
- Pain in one or both testicles: The pain may be dull or sharp, and may be worse after standing or physical activity.
- Heaviness or swelling in the scrotum: The swelling may be more noticeable when standing or after exertion.
- Enlarged veins in the scrotum: The veins may look squiggly or resemble a bag of worms.
- Change in testicle size: The affected testicle may become smaller than a healthy testicle.
- Feeling tired or fatigued: Some men may feel tired or fatigued for no apparent reason.
- Infertility: Varicoceles may affect the quality of sperm, which can lead to difficulty conceiving.
How does a varicocele form?
Veins throughout the body carry blood from various organs to the heart. Normally, they have valves that ensure the blood moves in the right direction. However, varicocele forms as a result of malfunctioning valves in the testicular vein.
Gravity can cause blood to pool in the scrotum, causing varicocele. It usually occurs in the left testicle and is likely related to the abdominal testicular vein tract.
How common is varicocele?
Varicoceles are very common and not dangerous. In fact, 15% of adult men experience symptoms of varicocele. For many men, varicoceles go unnoticed throughout their lives or won’t cause any issues. About 20% of teenagers have varicocele, so it’s likely that a portion of them will go away on their own.
What are the issues associated with varicocele?
Varicoceles can cause three main problems: infertility, decreased testosterone production from the testicles, or discomfort in the scrotum. For this reason, they usually aren’t treated unless there’s cause for concern about one of these problems. In some cases, varicoceles can cause varicoceles, which can cause azoospermia, or a complete lack of sperm in the semen.
Because varicocele is so common and because it usually goes undetected throughout life, about 80% of men with varicocele are likely able to conceive with their partners without any medical intervention. Also, as mentioned earlier, most men with varicocele do not experience hormonal issues or discomfort.
One important consideration is that larger varicoceles seem to have greater adverse effects. See below for a varicocele size rating.
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How does a varicocele affect the testicle?
There are many theories, but most agree that one way is by carrying warm blood from the abdomen down towards 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 effect of mass on the testicle and exposing the testicle to various chemicals from the adrenal gland, which is located near the top of the testicular vein.
Is varicocele dangerous?
Varicoceles are not life-threatening, but rarely, they can be associated with serious conditions. For example, if a varicocele forms on the right side rather than the left, it is important to make sure there is no mass or other abdominal abnormality that could be causing it.
Also, varicocele should “decrease” or decrease in fullness when the patient is lying down because gravity no longer fills the worm plexus in the veins. When varicocele does not decrease, it also raises concern that there is an obstruction in the abdomen such as a mass or a tumor that can cause a mass.
Finally, varicocele always seems 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, varicocele can lead to a severe drop in testosterone, with associated complications including metabolic syndrome and osteoporosis.
Degrees of varicocele in pictures
Varicocele grading systems help determine the size of the varicocele, which then helps guide treatment. Different systems have been created, but below is the scale most commonly used today:
- Grade 0: Seen on ultrasound but undetectable on clinical examination (also called “subclinical varicocele”)
- Grade I: palpable on clinical examination when the patient performs the Valsalva maneuver (“push down”)
- Grade II: Tangible even without Valsalva
- Grade III: Varicocele causes an obvious deformity of the scrotum.
Even in the second and third rows, there can be different sizes estimated by experienced doctors, and the results can help determine whether or not varicocele should be treated
Can varicocele cause issues later in life?
Data from Johns Hopkins and other institutions suggest that both fertility parameters and testosterone levels can be gradually affected over time. For example, varicocele is more common in men who have previously had children but are currently having difficulty conceiving. Also, almost all men who undergo non-surgical varicocele repair notice an increase in testosterone levels after the repair.
How is varicocele diagnosed?
“Subclinical” varicocele found on ultrasound is not thought to be clinically significant, since it rarely causes testicular weakness or discomfort. In a few cases, ultrasound may detect varicocele when physical examination is difficult due to the patient’s anatomy, or when other findings lead the physician to order a scrotal ultrasound.
Varicoceles are often varicose veins that can be seen with the naked eye, or the patient can feel something that looks like a “bag of worms” in the scrotum. Most commonly, however, varicoceles are not detected until after a doctor’s examination.
Thus, the best way to detect varicocele is a careful physical examination by a urologist. Even seasoned general urologists are often not confident of the diagnosis, so if there is any doubt, one should get an ultrasound and/or visit a doctor who specializes in varicocele and other scrotal diseases.
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When is the diagnosis usually made?
Varicoceles are usually found due to one of the following scenarios:
- Most commonly in a completely asymptomatic man who is being evaluated for infertility.
- A patient or doctor may discover a lump in the scrotum during a routine examination.
- A man may see a doctor with scrotal pain
What kind of pain does varicocele cause?
For most patients, varicocele does not cause any noticeable discomfort. However, mild or severe scrotal pain can result from varicocele. Patients typically report an “aching” sensation in the scrotum, usually associated with prolonged standing or activity. The discomfort is usually relieved by lying down (on one’s back) and elevating one’s feet.
Varicoceles may cause more severe pain if the veins become infected with thrombophlebitis (blood clotting and inflammation). Evaluation of patients with scrotal pain should include a scrotum ultrasound to rule out other diseases and a urine test to rule out infection.
Varicocele repair may be considered when there is no other identifiable cause for the pain, and the pain characteristics are consistent with varicocele, but there can be no guarantee that it will eliminate the pain.
In modern times, microsurgical denervation of the spermatic cord should also be considered at the time of varicocele ligation in patients with scrotal pain
Varicoceles and fertility
Varicoceles are found in the physical examination of approximately one-third of men who are evaluated for failure to conceive. They are categorized by size (see grading system above) and their presence on one or both sides of the scrotum. It is important to know that varicocele 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 through semen analysis.
A varicocele on one side of the scrotum affects both testicles in terms of function and testicular temperature. As mentioned earlier, a varicocele that cannot be felt by a doctor but is diagnosed by ultrasound or other imaging studies is not clinically significant.
When should varicocele repairs be done?
It is important to take an individualized approach to varicocele management. The decision to treat a varicocele is based on its size, 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 varicocele. The optimal course for each couple should be determined in conjunction with the couple’s reproductive endocrinologist when there are also female fertility considerations. If the partner has not yet been evaluated, she should undergo baseline testing to ensure no findings would alter the management of varicocele.
There is strong evidence to suggest that varicocele repair improves testicular function and may prevent any additional testicular damage over time, but this is closely related to the size of the varicocele. Thus, testicular function should be assessed directly by semen analysis, testicular volumetry, and/or blood tests. If there is evidence of testicular damage, varicocele repair may be essential to improve testicular function and/or prevent further deterioration.
When the testicle appears to be unaffected by a varicocele, there are varying opinions on whether or not varicocele should be treated. If you want varicocele ligation to protect future testicular function, it is important to have a thorough discussion with your surgeon, and get realistic expectations about the chances of any measurable benefit, and the risks of side effects from the procedure. We only prefer to treat a patient for any condition when the “risk-benefit ratio” is favorable.
The treatment alternative is to monitor patients with varicocele over time by checking semen analyses and/or blood tests and only treat if there is evidence that varicocele is impairing testicular function.
Varicocele repair is indicated in the male partner of an infertile couple when:
- There is objective evidence of a male factor (such as an abnormal semen analysis).
- The wife’s fertility status is intact or treatable, and
- There are no other obvious causes of male infertility (such as obstruction, malignancy, or genetic abnormality).
How is a varicocele repaired?
There are three categories of methods:
With varicocele embolization, small coils are inserted through a vein in the groin area and used to block the veins in the abdomen that feed the varicocele. Long-term success rates appear to be slightly lower compared to an open surgical approach, and treatment can take more than one procedure. However, there is no incision, so we often strongly consider this approach for children. In addition, it is sometimes used in patients with previous surgical failure, pain as the main indication for surgery, and body characteristics that increase the risk of surgery, such as morbid obesity.
In laparoscopic varicocele ligation, a camera and small instruments are inserted into the abdomen, where the veins that feed 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. The rate of hydrocele (fluid collection around the testicle) after surgery is higher with this approach.
Finally, there are several open surgical approaches. For most patients, we perform microsurgical varicocele ligation under the inguinal ligament. This approach results in the highest success rates and lowest complication rates, has the lowest cost, and essentially eliminates the risk of serious intra-abdominal injuries
How is microsurgical varicocele ligation below the inguinal ligament performed?
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 to testicular function.
What are the complications of a repaired varicocele?
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 minimal 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 testicular loss.
How does varicocele repair positively affect fertility?
In 540 infertile men with palpable clinical varicocele who underwent microsurgical varicocelectomy and were followed for more than one year and two years after surgery for changes in semen quality and pregnancy, respectively:
- A 50% increase in total motile sperm count was observed in 271 patients (50%).
- A total spontaneous pregnancy rate of 36.6% was achieved after varicocelectomy with a mean time to pregnancy of 7 months (1 to 19).
- Of the pre-surgical candidates for extracorporeal fertilization/intracytoplasmic sperm injection (IVF and ICSI), 31% became candidates for intrauterine insemination (IUI).
- Of all IUI candidates, 42% gained the possibility of spontaneous conception.
- Microsurgical varicocelectomy has great potential not only to avoid the need for assisted reproductive technology but also to minimize or alter the level of assisted reproductive technology needed to overcome male factor infertility.
This means that repairing clinically significant varicocele can significantly improve semen parameters and allow for natural conception or minimize the need for assisted reproduction.
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