Male Infertility from Varicocele (Part Two)

During puberty, the testicles experience a rapid growth and the blood that goes towards them is in greater quantity, but if the valves of the veins cannot return all the incoming blood to the testicles, conditions are created for a portion of the blood to remain in the scrotal area, creating varicose enlargements in the scrotal area, thus a varicocele is formed. It can appear in both testicles, but it is worth noting that in a larger percentage it affects the left side of the scrotum, because in this part there is a greater blood flow.

DIAGNOSIS

From the anamnesis, the information that can be obtained is limited, due to the minimal clinical concerns and that can be neglected by the patients. Often, patients turn to the doctor for the couple's reproductive incapacity. Thus, they will undergo further examinations.

OBJECTIVE EXAMINATION: in most cases, the specialist's visit confirms the diagnosis. In the lying or standing position of the patient, with or without the Valsalva maneuver, if it is observed with the naked eye or by touch, in the upper part of the testicle, the enlarged venous plexus, then we can say that the patient presents a varicocele.

CLINICAL CLASSIFICATION OF VARICOCELE ACCORDING TO DUBIN:

Grade One: Varicocele palpable only with the Valsalva maneuver.

Grade Two: Varicocele palpable even without the Valsalva test.

Grade Three: Varicocele visible even by simple inspection.

Often, a reduction in the size of the affected testicle can be observed, compared to the testicle of the other side. The volume of the testicles is better measured by ultrasound. If in the echodoppler, abnormalities of the testicles or of the epididymis and the presence of varicocele are observed, this is the cause of 30% of male infertility.

Or varicocele may manifest only with disorders in the production of spermatozoa. In these cases, laboratory examinations should be conducted, to determine the condition. The echodoppler is the main instrumental examination for the assessment of varicocele, to measure the volume of the testicles, to highlight the expansions of the pathological venous plexus, to evaluate the blood flow inside the enlarged veins in different positions, etc.

Also, the patient should undergo a laboratory evaluation of the sperm, through which the number of spermatozoa, mobility, as well as their condition. The microbiological examination or sperm culture is used to exclude a bacterial infection, which may impair the quality of the sperm. From the examination of the spermiogram, we can obtain data on the condition of the spermatozoa as well as on the most common causes of male infertility, which can be:

• Oligospermia, when in the seminal fluid the concentration of spermatozoa is less than 20% per milliliter.
• Asthenospermia, when the movement of spermatozoa is less than 50% of the norm.
• Oligo-asthenospermia, is when there are several pathological conditions: fewer spermatozoa in number and less mobile.
• Teratospermia: if more than 40% of the spermatozoa present anomalies.
• Azoospermia: total absence of spermatozoa.
• Necrospermia: presence of dead spermatozoa.
• Pyospermia: spermatozoa infected with pus.
• Polyspermia: when there is a concentration of spermatozoa more than 200 million per milliliter.

For correct spermatogenesis, the scrotal temperature needs to be low. Influencing the rise in temperature are very tight and non-ventilated underwear, exposure to heat sources, sitting in the same position for many hours of the day. Eliminating these factors may favor better production of spermatozoa.

Hormonal examination is also performed.

TREATMENT

The treatment of male infertility can be surgical or conservative. Conservative treatment is based on the use of antibiotics, anti-inflammatories, hormones, or the use of antioxidants, which increase the amount of sperm in subjects who have a poor ejaculation. We must not forget that, often, anxiety, psychological stress, influences the effects of therapy.

The aim of treating male infertility is to improve spermatogenesis and the quality of sperm. For individuals, who suffer from varicocele, currently there are two treatment tactics: surgical treatment, which consists in the elimination of varicocele with a small incision above the inguinal area, to locate the enlarged testicular vein and to perform its ligation, preserving the anatomical elements, that are in its vicinity.

How can the results be predicted?

The intervention results in satisfactory outcomes in 60 - 70% of patients. On the other hand, this intervention is very important, as it stops the damage to the testicular function, to not further damage the hormonal function of the testicles.

The complications of this intervention are minimal. In a small percentage of cases, the spermatic artery stays narrowly connected with the spermatic vein and it becomes difficult to separate the vein with the naked eye. The ligation or damage of the vein together with the artery, may lead to testicular atrophy. In rare cases, hydrocele may form, as a result of the accumulation of fluid in the spermatic cord, which may be followed by hernia.

Another treatment method is the percutaneous scleroembolization of the spermatic vein. This is a minimally invasive method, treated in day surgery. The control of the results of the intervention is done 3 - 4 months after the manipulation.