Varicocele is the most common cause of male infertility. Varicocele is detected in 15% of the normal population, and in 35-40% of men (in the 19-35 age group: 24%, over 40: 48%) who apply because we cannot have children. It is treated with surgery. Especially in surgeries performed with microsurgical technique, success rates are higher. In a clinical study I conducted with the couples following their treatment, 38% of the couples had natural pregnancy on average, while this rate was found to be 20% in those who could not have varicocele surgery. Early treatment can help produce healthier sperm and even enlarge a shrunken testicles due to adolescent varicocele.
In a multicenter (meta-analysis) study, it was shown in a study that men with varicocele on examination had approximately three times the chance of having children if they were treated surgically than those who did not. It is known that this rate increases even more as sperm values deteriorate.
What is Varicocele?
Varicocele is the condition in which the venous vessels carrying dirty blood washing the testicles expand abnormally and cannot carry the blood in them, and as a result, the blood flows back. These veins carry blood that is low in oxygen and nutrients from the testicles. The reflux in the enlarged veins causes swelling in the testicles and the expected perfusion and healthy nutrition do not occur. Varicocele is a vasodilation similar to varicose veins in the leg. Varicocele is common in pre-adolescents and adolescents, and is rare in boys younger than 10 years old. It is found in approximately 15% of adult males. It is usually located on the left side, but it can also develop on the right or both sides, although it is rare. In cases of varicocele located on the right side, care should be taken in terms of masses that press on the veins in the abdomen. Varicocele can sometimes appear as a symptom of a tumor (kidney tumor). In this case, they are investigated by ultrasonographic examination, otherwise they are examined in more detail with computerized tomography or MR imaging. Varicocele is usually asymptomatic and painless, and often does not require treatment.
What Causes Varicocele
Although the exact cause of varicoceles is not known. Varicocele is a structural disorder and may have developed for various reasons.
-May be due to insufficient development of the valves in the vein.
– High blood pressure, especially in the left testicular veins, can also do this.
-It may also be due to the compression of the veins coming out of the testis between the larger veins, with a phenomenon we call “Nutcracker”.
– In adolescence, the blood flow to the testis is too high to handle the blood flow out of the testis is also responsible for the development of varicocele. So it may be associated with rapid genital growth in young men.
– But, especially in cases of varicocele seen on the right side, masses that press on the abdomen may also be in question.
Effects of Varicocele on Sperm Quality
Varicocele is detected in 25% of patients with abnormal sperm parameters. It is seen that 35-55% of patients with varicocele have abnormal sperm parameters. The higher the degree of varicocele, the more abnormal sperm parameters are seen. Although the negative effects of varicocele on sperm parameters and infertility are still not very clear, multifactorial mechanisms such as oxidative stress, temperature increase, reflux of harmful substances (metabolites) from the kidney and adrenal gland, hormonal imbalance and hypoxia (oxygen deficiency) are blamed. In the center of these negative effects, oxidative stress does not play a role and takes place. As the degree of varicocele increases, the oxidative stress load increases and this stress disappears after a successful operation. DNA damage is assessed by the DNA fragmentation index. Sperm quality and production may deteriorate as a result of one or more of the following reasons:
1- Stasis due to the pressure of the dirty blood that cannot be drained from the testicle into the testicle and the low oxygen it creates.
2-Dysfunction developing in Leydig cells, which secrete the male hormone testosterone in the testicles.
3- Disruption in the development of sperm cells.
4- Backflow of dirty blood, which contains toxic substances from the kidneys and adrenal gland, together with the blood escaping back to the testicles.
5-Increased temperature in the testicles (normally, the testicles operate at a temperature 2 to 3 degrees lower than the body temperature in the scrotum, if this temperature increases, sperm production may also be impaired).
6- Disturbances in the secretion of gonadotropin and androgen hormones.
7- Communication disorder between sperm cells and the tissue layers surrounding them (lamina propria-extracellular matrix-germinal epithelium).
8-Nitric oxide (NO) accumulating in the enlarged veins can prevent having a child by impairing reproductive functions in men with varicocele.
9-Shrinking (atrophy) of the affected testis. The testis consists of numerous sperm-producing tubules. In varicocele, these tubules are damaged and the testis becomes smaller and softer. Although it is not clear what causes the testicle to shrink, it can be mentioned that the pressure created by the accumulation of venous blood (dirty blood).
Symptoms: There are usually no symptoms in varicoceles. In some cases, there may be a range and degree of pain ranging from blunt to sharp pain. The pain increases with standing and exertion, continues throughout the day, and the patient is relieved when lying on his back.
Varicocele may be noticed by the patient himself or may be noticed by your parents or a doctor during a routine physical examination or during an infertility evaluation at an older age.
Diagnosis and Grading of Varicocele
The gold standard in the diagnosis of varicocele is physical examination. A detailed medical history and symptoms, if any, guide the diagnosis. The diagnosis of varicocele is made by clinical examination. Ultrasound and Doppler, in some cases, especially contribute to the detection and quantification of reflux. Manual examination is performed in an optimal warm environment and the patient is standing. At this time, the unnoticeable enlargement of the vessels is tried to be felt by straining (Valsalva maneuver). According to the examination findings, varicocele is divided into 3 degrees:
Grade 1: Mild varicoceles that can only be recognized by straining.
Grade 2: Moderate varicocele that can be noticed during normal breathing but only on palpation.
Grade 3: Large varicoceles that are palpable at rest and can be noticed even with the eye.
Physical Examination: Varicose veins appearing while standing and/or straining on physical examination make the diagnosis. Swollen veins can feel like a “bag of maggots.” Both testicles should be examined together to compare their sizes. The testis affected by varicocele is usually smaller. While the patient is being examined, the veins are checked first in the supine position. At this time, it is emptied backwards and immediately behind it, the degree of filling of the empty veins with blood is checked by standing up. At this time, the changes that occur in the vessels are graded according to the scale above. The larger the varicocele, the greater the benefit from the treatment.
Doppler Ultrasonographic examination: Varicocele examination with Doppler ultrasound is requested in some cases. It may be needed especially in some men who have a small scrotum or who cannot be evaluated well due to increased adipose tissue, or who have previously had surgery and are now coming for control. However, the main thing in the diagnosis is manual examination. Doppler USG is also used in patients who do not have sufficient improvement in semen parameters after varicocele surgery and who are thought to have failed surgery and repeated (relapse) and in the follow-up of adolescent varicocele.
Doppler USG is also used to confirm the diagnosis of varicocele with vessel diameters (3mm and above) and reflux (reflux more than 2 seconds) at rest or when the patient is straining. Patients with a large vein diameter of 3 mm and reflux for more than 2 seconds benefit from surgery. Patients with reflux (reflux+) showed a greater improvement in postoperative parameters than patients without reflux (136% vs. 61%).
Adolescent varicocele (adolescent varicocele) is a type of varicocele that can lead to infertility as a result of regression in testicular development, atrophy (shrinkage) and deterioration of sperm values in adulthood, as well as findings such as pain in the bags where the testicles are located in the adolescent age (between 11 and 16 years). Most of the varicocele cases in childhood and adolescent age group do not give any symptoms. They are usually detected incidentally by physical examination or noticed by families. When physical examination is performed, volume loss in the testis on the affected side is detected in approximately 10% of the cases. Although the incidence of adolescent varicocele is 15%, it increases with age after 13 years of age, when growth accelerates. While left varicocele is seen in 90% of cases, bilateral varicocele is detected in approximately 10% of cases. Testicular volume is also measured while evaluating adolescent varicocele. Measuring testicular volumes is necessary in terms of the necessity of varicocele treatment and monitoring of testicular volumes after varicocelectomy. Testicular volumes can be measured by ultrasonography as well as by various volume meters (orchidometer). The main purpose of adolescent varicocele is to prevent infertility, to maintain optimal hormone production and to preserve testicular volume. If there is a 20% reduction in testicular volume or a difference of more than 2-3 ml between the two testes and/or worsening in sperm parameters, surgery is recommended. After the surgery, in 50% to 80% of the cases, the testis can regain its normal volume, and serious improvements are achieved in sperm parameters. It has been determined that when adolescent varicocele is treated, the chance of becoming a father in the future is 2-3 times higher than those without treatment. In addition, the rate of miscarriage in future pregnancies in those who were treated in childhood was found to be lower than those who did not.
TREATMENT: Surgery is the only way to treat varicocele, but not all patients may benefit from surgery. Basically, varicocele surgery is recommended in patients with infertility complaints if there is varicocele and if there is deterioration in sperm parameters. Apart from these, if there is pain in a way that affects daily life, there is varicocele in adolescence and more than 20% reduction (2-3 cc) between the two testicles, those who do heavy physical sports or work, patients whose existing varicocele is thought to progress, patients with cosmetic concerns are candidates for varicocele surgery. are patients.
After varicocele surgery, at least a few months are expected to evaluate the results. The reason for this is the development of new sperm and the effects of the surgery appear in about 3 months. After varicocelectomy, sperm parameters increase by an average of 12 million per cubic millimeter, an average of 10% increase in motility, and an increase of 3-5% in morphology (sperm structure). Spontaneous pregnancy rate increases 2.5 times after this surgery, or 30-40% pregnancy can be achieved in those who have had this surgery due to infertility.
In azoospermic patients with no sperm; If varicocele is treated, it has been determined that the probability of finding sperm (2-3 times) and the chance of pregnancy increase (2 times) with the TESE method for in vitro fertilization (microinjection-AVF), and the rate of miscarriage (live birth rate 2 times) decreases in case of pregnancy.
Again, in those with failed IVF attempts and unsuccessful TESE, patients with varicocele who complain of DNA damage (DNA-Fragmentation index over 20%), and low testosterone (hypogonadism) can benefit from varicocele surgery. While the mean total testosterone level causes an increase of about 100ng per ml, there are improvements in sexual desire and other complaints related to low testosterone (hypogonadism).
Surgery: Surgical intervention, these enlarged veins (testicular vein, cremasteric-external testicular veins and partially vasal veins) are tied with a small surgical incision in the groin of the enlarged veins, so that the dirty blood is directed to healthier veins instead of these enlarged veins and over time, these varicose veins are connected. the vessels atrophy and disappear.
Microsurgery: Performing the surgical intervention under the microscope with the microsurgery method; It is a method that should be preferred in terms of obtaining more effective results and minimizing the complications that may occur. In this way, the lymph vessels that cannot be seen with the naked eye are protected, the risk of complications that may occur is reduced, and the lymphatic flow is not blocked.
Laparoscopic: Varicocelectomy can also be performed Laparoscopically, the results are similar.
Angiographic Occlusion: Less commonly, a procedure called angiographic occlusion is used to treat varicocele. A special sclerosing substance is injected into the varicose veins and this substance collapses in the veins and forms a plug. It does not require anesthesia, but there is radiation exposure.
Recurrent Varicocele: As mentioned before, in cases where it is not performed with the appropriate method and meticulousness, and the external and internal spermatic veins are not completely ligated, adequate results cannot be obtained in varicocele surgery, we call it persistent (persistent) or recurrent (recurrent) varicocele. This situation may also be caused by some congenital anatomical vascular variations. When performed according to the technique, the least recurrence (1%) occurs in the microsurgical technique, while this rate is 2-7% in other technicians. For the evaluation of recurrent varicocele, lack of improvement in sperm parameters within 6-10 months after surgery, failure to achieve pregnancy, persistence of testicular growth retardation, persistence of complaints due to pain and low testosterone are the findings that make us think of recurrent varcocele. Physical examination and especially Doppler USG are used in the diagnosis of recurrent varicocele. The expected results with recurrent varicocele surgery are the same as those expected from the first surgery. It is recommended to use microsurgical technique as in primary varicocele.
Complications of the surgery: May recur. But if it is done with microsurgical technique, the recurrence rate is very low; %one. Fluid accumulation around the testis (hydrocele), which we call hydrocele. This, again, has decreased to almost non-existence after surgeries performed with microsurgical technique; 0.4%. Injury to testicular arteries, nerves and lymphatic vessels, resulting testicular loss and decreased testicular function, albeit rare, may occur. These complications are not expected in microsurgical technique. Apart from these, rare problems such as testicular inflammation, bleeding, hematoma, and anesthesia-related complications develop, but they can be corrected with appropriate treatment.
You can return to normal daily activities after 2 days. You can return to more strenuous activities such as exercise after 2-4 weeks as long as you are not uncomfortable. Pain from this surgery is usually mild, but may persist for several days or weeks. Your doctor may prescribe pain medication for a limited time after surgery. After that, your doctor may advise you to take over-the-counter medication such as acetaminophen or ibuprofen. Wearing tight panties or a jockstrap can also help by relieving pressure on the testicles. A healthy and natural diet, exercise, weight control and cessation of smoking, if any, are recommended.
Oxidative stress, which is the main disorder caused by varicocele, improves after the operation, but to correct these conditions more quickly and to increase the antioxidant capacity of the body, it contains some antioxidant mixtures (zinc, phalic acid, L-carnitine, coenzyme-Q10, B12, cysteine and arginine). drugs can be used. It is claimed that additional antioxidant treatment relatively relieves some of the negativities caused by DNA damage. It is recommended to use such empirical mixtures for at least 3 months. Those who take these drugs after varicocele surgery improve their sperm quality more and earlier. There was no difference in pregnancy rate.