March 14, 2021 7:35:50 pm
By Dr Ankush Raut
Infertility affects about 8 percent to 12 per cent of couples of reproductive age. Of all infertility cases, approximately 40 per cent to 50 percent is due to “male factor infertility and as many as 2 per cent of all men will exhibit suboptimal sperm parameters. The most common type of male infertility is idiopathic infertility, which is followed by varicocele, which in an European study was found to affect 16.6 percent of men referred for infertility.
Reports regarding the presence of varicocele in the testis dates back to 1st century, when the Greek physician Celsus noted that: “The veins are swollen and twisted over the testicle, which becomes smaller than its fellow, in as much as its nutrition has become defective.” In simple terms, it is an enlargement of the veins within the scrotum. In most cases, it doesn’t show any noticeable symptoms but it is associated with low sperm production, decreased sperm motility, defective sperm morphology leading to male infertility.
The etiology of varicocele is still not well understood. It can be because of either the result of anatomical differences between the right and left spermatic vein (the right internal spermatic vein inserts directly into the inferior vena cava at an acute angle, while the left internal spermatic vein inserts into the left renal vein at a right angle), internal spermatic veins lack functional valves (which can lead to regression of blood) or partial obstruction of the left spermatic vein due to the compression of the left renal vein between the aorta and the upper mesenteric artery (“the nutcracker phenomenon”).
The possibility of varicocele might be related to infertility was first noticed sometime between the end of 19th century and the beginning of 20th century, when surgical repair of varicocele was shown to improve the quality of sperm. Tulloch in 1952 first reported that bilateral surgical repair of varicocele in a man with azoospermia resulted in an increase in sperm concentration (27 x 106 / ml) resulting in spontaneous pregnancy. The prevalence of varicocele among the general population varies from 4 percent to 30 percent, while the prevalence among infertile men varies between 17 percent and 41 percent according to various studies.
The adverse effect of varicocele on spermatogenesis can be attributed to many factors such as increased testicular temperature, increased intratesticular pressure, hypoxia due to attenuation of blood flow, reflux of toxic metabolites from the adrenal glands and hormonal profile abnormalities. An increase in scrotal temperature causes thermal damage of the DNA and proteins in the nucleus of spermatic tubules’ cells and / or Leydig cells. Oxidative stress because of toxic metabolites is known to have adverse effects on sperm structure and function, such as membrane lipid alterations, disruption of sperm metabolism, reduction of its motility, DNA fragmentation and reduced overall sperm quality. Varicocele can also lead to germ cell apoptosis and subsequent oligozoospermia due to increased scrotal temperature, increased intratesticular cadmium concentration and reduced levels of androgens.
The hypothesis that varicocele can cause testicular damage was primarily confirmed in pubertal boys, in which it was shown that a slight reduction in the size of the ipsilateral testis was restored by surgical repair of varicocele. Varicocele progressively affects testicular function in adult men also.
For many years varicocele was considered an important cause of male infertility as numerous studies showed improvement (30 percent to 60 percent) in semen parameters after varicocelectomy, but it is observed that this does not hold true in all cases and there is no significant difference in pregnancy rate even after improvement in semen parameters.
So varicocelectomy should be chosen wisely if the following criteria are fulfilled:
Involuntary infertility of at least one year.
Presence of a palpable Varicocele at the upright position and during a Valsalva manoeuvre.
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 analysis excludes Varicocele as the cause of infertility.
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 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 the case of chronic presence of Varicocele in 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.
The diagnosis of SCOS or maturation arrest in FNA or open testicular biopsy denotes primary testicular failure. Thus, the presence of Varicocele should be ignored. On the contrary, the presence of mild or moderate hypospermatogenesis can be attributed to Varicocele in which case surgery can be a reasonable therapeutic approach.
In conclusion, varicocele is found to be commonly associated with infertile male. It affects sperm quantity, motility and morphology. But Varicocelectomy doesn’t help in every case. With development of ICSI chances of pregnancy has improved. Test tube babies with ICSI are becoming an effective, successful and cost-effective approach in all such cases.
(The writer is Fertility and IVF Consultant, Apollo Fertility Borivali Mumbai)
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