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Should the indications for the treatment of varicocele be widened?

Χωρίς κατηγορία 2055

kirsokili1A varicocele is a pathological cirsoid dilatation of the spermatic venous plexus of the testicle. It is due to a reflux of blood in the internal spermatic vein, which is the principal drainage vein of the testes, due to the insufficiency of valves that exist normally in the veins and allow the one-way blood flow towards the main vein that drains blood from the testicle, which is the renal vein. The insufficiency of these valves is usually congenital and the reflux of the blood increases with standing and severe fatigue, causing thus the dilatation of the veins.

 

 

The incidence of varicocele in the general population ranges between 4.4-22.6%; in subfertile men it ranges between 21-41% regarding primary infertility (that is when these men have no children at all) and 75-81% regarding secondary infertility. In the majority of cases (90%) the varicocele occurs on the left side, in 30-50% of the cases bilaterally and in 2% of the cases only on the right side.

The venous plexus, which exists around each testicle, as it has a winding form, acts as a heat exchanger with the environment, like the radiator of a car, so that the testicles can maintain a temperature that is at least one degree Celsius lower than the one of the abdomen. It is for this reason that the testicles are located outside the abdomen, in the scrotum. The formation of a varicocele, even in one testicle only, is harmful to this thermoregulatory mechanism, resulting to a sperm production disorder and therefore a fertility disorder. Furtermore, in patients with varicocele, due to the stasis of blood in the veins, free oxygen radicals are generated, which are particularly harmful to the sperm.

 


 

 

kirsokili2The diagnosis of varicocele takes place by the palpation of the dilated veins of the scrotum with the patient in standing position. In case of a varicocele of a small degree, where the veins are not easily palpable and visible, the patient is asked to strain himself with his mouth shut (the Valsalva maneuver), in order for the veins to fill with blood so that they can be palpable.

In the subclinical forms of the disease (non palpable even after the aforementioned maneuver), a diagnostic tool is the ultrasound of the scrotum and the color Doppler ultrasound (triplex). A dilatation of the spermatic veins which is greater than 3.5mm, with the simultaneous reversal of the venous flow during the Valsalva test, delimit the diagnosis. This examination must be also performed in the varicoceles that are palpable, so that the diagnosis can be verified.

 

 

The main indication regarding the treatment of varicocele is infertility. At this point the patients can feel a great anxiety and confusion for the following reason: The indication, which is set by the European and the American Association of Urology for the treatment of varicocele, regards men in couples that have not been able to have a child, despite their regular sexual intrecourses for a year and the man has a clinical (palpable) varicocele and an abnormal spermiogram. However, even then, the couple should be aware that the fact that the possibility of having a child seems to increase, that does not mean that this couple will certainly have a child, which is of course what they desire, although the spermiogram has improved, which does not mean in its turn that it will certainly happen: all this does not mean that the treatment has not been properly performed. It is therefore obvious that, when the diagnosis of varicocele is made after a medical control which the patient desired to be performed, usually after a search on the Internet or the disorded has been diagnosed accidentally during a regular examination by a urologist, who was visited by the patient for some other reason, the question that arises is whether the disease should be immediately treated or not, as the issue of having a child has never been set forth. A normal spermiogram somewhat reassures the patient, but the doubts if a disorder occurs in the future, or if there is a possibility, despite the normal spermiogram, that there is a difficulty in having a child in the future, exist as tormenting questions on the patient’s mind, and sometimes on the doctor’s mind, as they cannot be answered for the time being. All this occurs from the fact that the issue is having a child and nothing else.
 

Another important question, that occurs for varicocele is that, if the only treatment indication of varicocele is the one that has been mentioned and is included in the instructions of the European and the American Association of Urology or if there are indications that its treatment helps other fields. It seems that such indications indeed exist, and although they have not been yet adequately documented, so that they could be included in the instructions of the two scientific associations, the research towards this direction still goes on. However, this documentation does not regard the safety of the treatment anyway, since its safety is granted, but only its effectiveness. Therefore, since the treatment of varicocele is simple, fast, easy, and without complications and without risk of relapsing, it could be applied in addition to the classical indication, in order to prevent or to improve the following conditions:

 

1Azoospermia

By this term we mean the absence of sperm in the semen, a diagnosis that can be made by a spermiogram. This condition is the only one that is related to the complete male infertility and, consequently, with the full incapacity to have a child in a normal way. All other sperm weaknesses, as they can be reflected in the spermiogram, do not exclude having a child in a normal way, they do just reduce the possibilities, depending on their gravity.

The prevailing opinion until today is that, since, in cases of azoospermia, the couple will either way follow the solution of in vitro fertilization, there is no need to treat a possible coexisting varicocele in the man. However, there is evidence today that the treatment of varicocele in the man before the in vitro fertilization increases the chance of finding sperm by a testicle biopsy, increases the pregnancy and birth rates and reduces the spontaneous abortion rates.

 


 

2Progressive testicular damage

The far greater frequency of presence of varicocele in patients with secondary infertility, compared to the ones with primary infertility, supports the view of the progressive testicular damage. There are reports regarding the progressive worsening of the spermiogram image and of the testosterone levels in the blood of patients with varicocele, who have not undergone a surgical repair of the disease.

New data show that 87.5% of the patients with testicular dysfunction and 20% of nomospermic men with varicocele presented a progressive deterioration of the spermiogram, within a period of 63.2 months.

 


 

3Pain

The effect of testicular pain in patients with varicocele ranges between 2-14%. Predisposing factors to the presence of testicular pain in patients with varicocele with a normal spermiogram are:

-the temperature of the scrotum

-the frequency of the reflux

-low body mass

-the distance of the renal sinus from the scrotum

It must be mentioned that the three last factors are statistically greater in patients with intense pain, than in patients with mild and moderate pain. The repair of the varicocele relieves testicular pain in 75% of the cases.

 


 

4Reduction of the testosterone production

There are contradictory opinions regarding how much the repair of varicocele improves the production of testosterone in the testicles, which has already been reduced.

 


 

5Damage to the genetic material (DNA) of the sperm

The damage to the DNA of the sperm is related with lower natural pregnancy rates, after artificial insemination, intracytoplastic sperm injection (ICSI) and classical in vitro fertilization (IVF).

The varicocele is related with a damage to the DNA of the sperm, which is possibly due to oxidative stress. The varicocele causes the generation of oxidative stress even in fertile men with normal sperm. Thus, it is well understood that there is a threshold of oxidative stress beyond which the fertility is affected. The repair of varicocele improves significantly the percentage of sperm with damage to its DNA.

 


 

6Infertility in a normal couple

There are cases of couples with infertility, where the woman is perfectly normal and the man has a varicocele and his spermiograms are quite normal. In these cases, on the basis of what has been mentioned before, it is possible that the varicocele affets the microenvironment of the sperm, without altering the parameters of the spermiogram. Thus, its treatment could reverse these abnormalities and allow a pregnancy.

The treatment of varicocele is only surgical. There are various techniques with almost similar effectiveness. They all aim at stopping the abnormal reflux of blood to the venous network of the testicle, by interrupting the venous drainage of the organ by the ligature and incision of the internal spermatic vein and/or its branches. Attention must be paid to the fact that some of them are particularly overestimated (for example laparoscopic surgery), and they are not optimal regarding their advantages. The complications are either way minor in the hands of an experienced surgeon. The varicocele is not a relapsing disease. There may be a presence of dilated veins in the postoperative ultrasound, but this is not a sign of relapse or of an unsuccessful operation, because it is possible that there is no regression of the dilatation, but the reflux of the blood stops, which is the aim of the treatment. Respectively, the spermiogram needs 3 months after the operation in order to start improving, which improvement can continue for another 9 months. However, there is a chance that this does not happen, but this again does not mean that the operation has failed. Furthermore, even if the spermiogram does not improve, it is not impossible that a pregnancy is achieved.

 


 

Conclusions

The repair of the varicocele improves qualitatively and quantitatively the sperm, even in men over 40 years old and, the sooner it is treated, the better are the results. It inhibits the progressive deterioration of the sperm. It increases the chance of spontaneous pregnancy in patients with weak sperm, regarding the sperm count and/or motility. It increases the possibility of presence of sperm in the semen and the possibility of pregnancy in patients with azoospermia. It improves the outcomes of in vitro fertilization and reduces the rate of miscarriage after it. It increases the serum levels of testosterone, even in men over 40 years old. It eliminates or improves substantially a possible disturbing chronic testicular pain. Finally, it reduces the oxidating stress of the sperm and improves the percentage of the sperm with normal intact DNA, which is theoretically related with the improvement of fertility.

Consequently, given the fact that there is a low morbidity, a low rate of complications and a low cost, in contrast with the assisted reproduction method, particularly in couples where the woman also has infertility problems, should varicocele be operated more frequently than the classical indication of the European and the American Association of Urology?