Dr Richa Sharma & Dr Amit Basnotra
Infertility is considered one of the main public health issues, as it affects about 15% of the couples of reproductive age. The male factor is involved in 40% – 50% of infertility cases.
The most common type of male infertility is idiopathic infertility, which is characterized by the presence of one or more abnormal semen parameters with no identifiable cause3. Another common cause of male infertility is varicocele
What is Varicocele ?
A varicocele is an abnormal enlargement of the pampiniform venous plexus in the scrotum. This plexus of veins drains the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the testicular veins near the testis, leading to the formation of a varicocele. Varicocele is known as one of the main causes for male infertility and can be treated by a surgery or non-surgical treatments
Signs and Symptooms
Visible or palpable (able to be felt) enlarged vein
Dragging-like or aching pain within scrotum
Feeling of heaviness in the testicle(s)
Atrophy (shrinking) of the testicle(s)
Alteration of testosterone levels
Benign prostatic hyperplasia (BPH) and related urinary problems
Causes
Idiopathic
Lifestyle factors such as activity type, diet, bowel health,testicular temperature, smoking, and alcohol moderation can affect both the occurrence rate and varicocele symptoms severity.
Diagnosis- By Clinical Local examination and By Ultrasound
Treatment Options
Surgery
Embolization
As per latest updates, Role and choice of surgery has to be very precise weighing the risk benefits ratio as it may add to more harm so be more clinical and result oriented following latest evidence from reliable sources
Varicocele and ICSI
The development of ICSI as the method of choice in cases of severe male factor infertility triggered scientists to modify their diagnostic and therapeutic approach. Thus, a frequent question regarding the therapeutic approach of infertile couples with varicocele is whether to treat this condition first or apply directly TESE / ICSI. The advantage of treating varicocele first is that, if it is successful, it provides a good opportunity for natural conception. In addition, it is more cost-effective, especially if future pregnancies are planned.
In order to repair a varicocele the following criteria should be fulfilled-
Involuntary infertility of at least one year.
Presence of a palpable varicocele at the upright position and during a Valsalva manoeuver.
No detectable or at least no irreversible cause of female infertility.
Normal testicular size (> 15 cm3) or small reduction of the ipsilateral testis.
Evaluation of at least two semen analyses at three months interval. The presence of normal semen analyses excludes varicocele as the cause of infertility. The usual effects of varicocele on sperm parameters include mild and moderate asthenospermia, teratospermia or astheno- teratospermia. Initially, sperm concentration is not seriously affected, though later all three semen parameters can gradually deteriorate, resulting in azoospermia in very few cases.
Normal values or slight increase (less than the double of the upper normal range) of serum FSH levels, as very high levels of serum FSH denote primary testicular failure.
Additional factors that must be considered before deciding the therapeutic approach of varicocele in an infertile couple include-
The advanced age of the wife (older than 35 years) and high serum FSH levels should drive the decision towards the ICSI solution rather than repair of varicocele.
In case of chronic presence of varicocele and advanced male age, surgery should be avoided.
Surgical repair of varicocele is recommended in case of secondary male infertility, On the other hand, if the patient has primary infertility, azoospermia, small testicular size and high serum FSH levels, the presence of varicocele should be ignored and surgery should be avoided, as the diagnosis in this case pleads towards primary testicular failure.
Conclusion
Varicocele is one of the most debatable issues in the field of male infertility mainly with regard to surgical intervention. Many scientists believe that the surgical repair of varicocele should include a very narrow group of infertile men. Nevertheless, there are no widely accepted criteria regarding the selection of this group of men. With the development of the ICSI technique during the last few years, research should focus mainly on the effectiveness of surgical repair of varicocele taking under consideration the pregnancy rates of the methods, their cost-effectiveness as well as the couples preferences.
(The authors are senior IVF Consultant, and senior Gastroentrologist)
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