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What is varicocele?
A varicocele is when veins become enlarged inside your scrotum (the pouch of skin that holds your testicles). About 15 of every 100 males have a varicocele. It is like getting a varicose vein in your leg. Most of the time, varicoceles cause no problems and are asymptomatic. Sometimes varicoceles can cause pain, problems fathering a child, or testis to grow slower or shrink. Varicoceles are the most common cause of both primary (fathering first child) and secondary (fathering a child after their first) infertility.
How are varicoceles diagnosed?
Varicoceles are found through self-exam of the scrotum or during a routine doctor’s exam. They’ve been described as a “bag of worms” because of how they look and feel. Urologists often check for varicoceles with the patient standing. You may be asked to bear down while your urologist feels the scrotum above the testicle. It lets your urologist find any enlarged veins. Your urologist may order a scrotal ultrasound to detect for varicoceles if you have a thick scrotum and physical examination is a challenge.
How are varicoceles treated?
Among the most exciting treatment developments are microsurgical approaches to repair dilated varicose scrotal veins to improve semen quality. You should consider treatment if you meet the following criteria:
- you and your partner are trying to conceive a child, but thus far have been unsuccessful
- you have been diagnosed with a varicocele that can be felt or detected by ultrasound if you had a difficult exam (tight scrotum)
- your semen analysis or sperm function tests are abnormal
- your partner has normal fertility or treatable infertility
- you are an adolescent male with a varicocele and reduced testicle size
Cited by many specialists as their preferred approach, this operation uses the optical magnification of a high-powered microscope to provide direct visual access to veins and arteries. Through a mini-incision in the groin, the doctor can reliably separate and preserve testicular arteries, while identifying and ligating both large and small veins that could dilate in the future. Also, while technically demanding, microsurgical varicocelectomy virtually eliminates the risk of developing a hydrocele, the most common varicocele repair complications. In fact, microsurgical techniques have significantly reduced recurrence rates to less than 2 percent and complications rates to less than 5 percent while significantly increasing fertility. The effectiveness of this procedure has been reported in the scientific literature to be as high as a 43 percent pregnancy rate for couples after one year and 69 percent after two years. Dr. Ramasamy is an active researcher in this area and much of his research has helped to reduce the complication rate and increase the fertility rate for this procedure.
After varicocele repair, your doctor will perform a physical examination to verify that the worm like veins are completely gone. Semen sample will be tested first at THREE months after the operation (because each cycle of sperm production takes approximately 2-3 months) and then for at least one year or until pregnancy. If your varicocele returns, or you remain infertile after the repair, ask your doctor about assisted reproductive techniques (ART). These high-tech procedures are often successful in circumventing the same problem to produce a pregnancy.
Is medical treatment for infertility necessary along with varicocelectomy?
Medical therapies for male infertility generally involve hormonal manipulation. Medications such as clomiphene citrate and anastrazole are used to improve sperm counts in men with abormal hormone levels. Blood tests such as follicle-stimulating hormone (FSH), Leutinizing hormone (LH), total testsoterone and estrogen will need to be evaluated prior to commencing medical therapy. Assessing the impact of medical treatments is very difficult, given variations in patients as well as dosing regimens, treatment durations, and outcome definitions. As such, treatment decisions chosen by individual physicians are often based on hormone levels and goals of the patient. It is important to discuss with your doctor to check whether you qualify for medical therapy. For more information, read Dr. Ramasamy’s manuscript on medical therapy for testicular failure (Ramasamy R, Stahl PJ, Schlegel PN. Medical Therapy for Spermatogenic Failure Asian J Androl. 2012 Jan;14(1):57-60)
Is varicocelectomy necessary even though the couple are planning to undergo IVF?
Varicocelectomy has been shown to improve success rates in couples undergoing IVF compared to men who did not have their varicoceles repaired before IVF (Esteves et al. J Urol. 2010). The exact mechanism for why varicocelectomy improves IVF success rates remains unclear but the most promising hypothesis appears to be improvement in sperm DNA fragmentation following varicocelectomy (Zini et al. Int J Androl. 2011). Improved sperm DNA fragmentation is associated with better success with IVF (Simon L et al. F&S 2011). In addition, even though the couple is undergoing IVF, repairing varicocele may improve future chances of natural conception or even future IVF cycles.
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