While there are many hormonal, physical, and metabolic causes of male infertility, varicocele is the most common and easily treatable cause of infertility.
A varicocele is the dilation and tortuosity of the testicular veins, causing them to bulge within the scrotum. The patient perceives these bulges as palpable swellings and reports testicular pain when standing for long periods, which eases when lying down. Varicoceles appear after puberty, after the age of 15-16. They are rare before this age. A study conducted at Gazi University in 4,000 primary school boys found a 1% incidence rate. However, the incidence after puberty is 15%. Of these, 50-60% cause infertility. In other words, not every varicocele is infertile.
Varicoceles are 90% on the left side, and 10% are bilateral. When a patient has a varicocele, especially if it's bilateral, an abdominal ultrasound should be performed to confirm that there is no pathology or tumor compressing the veins.
The reason varicoceles are more common on the left side is that the left testicular vein travels a much longer distance through the posterior abdominal wall than the right to drain into the left renal vein, and the valves that prevent blood backflow within the vein are malfunctioning.
The testicles lie within the scrotum (scrotum), at a temperature between 35 and 35.5 degrees Celsius. Therefore, in winter, the scrotum contracts, keeping the testicles close to the body. In summer, the scrotum relaxes, keeping the testicles cooler. In a varicocele, blood backflows into the testicles and pools, causing the testicles to reach a temperature of 37 degrees Celsius. This increased temperature disrupts testicles and negatively impacts sperm production. The pooled blood in the testicles decreases oxygen, and sperm production is impaired due to the lack of oxygen in the sperm-producing cells. Metabolic residue from the left adrenal gland, due to leakage in the left testicular vein, which opens into the left renal vein, negatively impacts the testicles and impairs sperm production. In left varicoceles, the left testicle, and in bilateral varicoceles, both testicles, begin to shrink over time. This reduces sperm count and quality.
Such harmful effects first reduce sperm motility. Then, their number and morphology (normal appearance) decrease, leading to varicose vein infertility.
A significant varicocele is diagnosed by palpation. These are grades 1, 2, and 3. The lowest-grade subclinical varicocele is diagnosed by scrotal color Doppler ultrasound. This ultrasound measures the increased diameter of the testicular veins, the amount of backflow, and the rate and flow of the leak. Based on these findings, the vein is searched for surgically. In the presence of a varicocele, the veins become more visible during the Valsalva maneuver, which is performed with the patient straining while standing.
If pregnancy and childbearing are not achieved despite one year of unprotected intercourse, infertility should be considered and investigations initiated. Infertility occurs in 10% of the population. Men account for one-third of this, women account for one-third, and both account for one-third. In infertile couples, examinations should begin with the man, as examination is easier. Two sperm tests are performed one month apart on the third day after ejaculation, two days before ejaculation. If possible, these should be performed in two different laboratories. If both tests are normal, the woman's tests can be initiated. If sperm counts are abnormal, the man should be treated first. Normally, there should be over 20 million sperm per cc of semen, A motility should be 25%, A+B motility should be 50%, and normal Kruger morphology should be above 4%, especially around 14%. If the sperm count is below 10 million, pituitary and testicular hormone tests should also be performed to determine if there is a hormonal imbalance.
In cases of sperm disorders, a varicocele is first investigated. If present, it is corrected surgically. Because the production of a single sperm cell takes 86-90 days, a three-month wait is required after surgery for sperm to recover. Approximately 40% of patients become pregnant within three months of surgery. If pregnancy does not occur, treatment is supplemented with two or three three-month courses of medication during the waiting period. This results in a further 20-30% success rate. For the remaining patients, treatment is left to obstetricians and in vitro fertilization centers.
We wish you healthy days.
Prof. Dr. İbrahim BOZKIRLI
Urology Specialist
Private Mersin System Surgical Medical Center