VARICOCELE

Among men who are unable to make their partners pregnant, varicocele is one of the most common abnormalities. For many years, varicocele has been considered one of the most frequently blamed causes of infertility. It is useful to examine the relationship between varicocele and infertility from different perspectives. Dilatations in the venous system called the pampiniform plexus, which carries deoxygenated blood from the testes, are called varicocele. Varicocele can be visible to the eye, palpable by hand, or detected by Doppler ultrasound examination. Varicoceles detected by Doppler ultrasound are called subclinical varicoceles. In men with varicocele, apart from infertility, the most prominent complaints are chronic groin pain and a feeling of pressure. Today, it is accepted that only clinical varicocele, that is, varicocele that is visible or palpable, is of importance. Varicocele is found in 20% of men who have previously made their partners pregnant. In infertile couples where the woman is normal, the incidence of varicocele is around 35–40%. In a study conducted in the USA, 25% clinical varicocele was observed in the young age group. In the subsequent long-term follow-up of these men, no difference was found between those with and without varicocele in terms of their partners’ chances of becoming pregnant.

There is no universally accepted theory as to how varicocele causes infertility. Although it has been stated that a pattern called stress pattern, involving sperm morphology and motility disorders, is seen in the semen of men with varicocele, the fact that similar disorders have also been observed in men without varicocele casts doubt on the significance of this finding. Unfortunately, differences in sperm count, motility, and structural characteristics between men with varicocele and those without have not been consistently demonstrated in all studies.

At present, the treatment of varicocele is surgical. In an operation called microsurgical spermatic vein ligation, the veins showing varicose dilatation are tied off. This operation can be performed endoscopically, and radiological embolization techniques can also be used. Since there are no comparative studies between the techniques, there is no clear consensus as to which is superior. The generally accepted view among urologists is that repair of subclinical varicoceles has no benefit. There is also consensus that clinical varicoceles, that is, those that are palpable or visible, especially when accompanied by chronic groin pain or a feeling of pressure, and varicoceles seen in adolescence, should be treated. Although it is widely performed by urologists, a topic approached more cautiously by IVF (In Vitro Fertilization) specialists is whether varicocele repair is beneficial in infertile men with abnormal semen parameters. A collective evaluation of randomized studies shows that there is no change in the chances of the partners of men who undergo varicocele repair, compared with those who do not, becoming pregnant. In particular, in cases of azoospermia or severe oligospermia (men with a sperm count of 0 or less than 1 million per ml), there is no role for varicocele repair. In cases where the sperm count is above 5 million, the woman is young, and the duration of infertility is short, varicocele repair may be considered.

In recurrent varicoceles after surgery, a second operation has no place unless the patient has complaints. In conclusion, today varicocele is a condition that is diagnosed too frequently, especially in infertile couples, and often repaired unnecessarily. Because the relationship between varicocele and infertility has not been fully clarified and the benefit of treatment has not been demonstrated, we currently consider varicoceles as incidental findings encountered during infertility investigations and recommend that the approach be shaped accordingly.

REMEMBER!

In the evaluation and treatment of varicocele cases, an IVF Specialist Obstetrician-Gynecologist and a Urologist should work together to provide support. Varicocele surgery can be performed unnecessarily in many cases. For this reason, the issue becomes even more sensitive. Sometimes an incorrect operation or postoperative complications can affect the sperm status much more negatively.