Varicocele:Andrological point of view

Varicoceles:
Varicocele has been most controversial topic as to what is significant varicocele,how should it be diagnosed and how should it be operated.The dilemma still persists amongst health care professionals especially Gynecologists whether Varicocele surgery really helps in infertility.Below is a list of common questions cropped up in minds of health care professionals as well as common men and we are trying to give simple and scientific answers as follows..
1. What is varicocele?
2. What are the symptoms?
3. How to diagnose the condition?
4. Does it need surgery?
5. Basis of the treatment
6. What surgery is the best?
7. What should the patient expect post-operatively?
8. Any other modalities for the management?

What is varicocele?:
Varicoceles develop as a result of dilatation and tortuosity of veins of the pampiniform plexus secondary to retrograde flow into the internal spermatic vein (ISV).It may sometimes give feel of bag of worms in the hemiscrotum.
The incidence of varicocele in general population is as high as 15% so surgical selection of the case should be scrupulous.


What are the symptoms:
the common symptoms are dragging sensations in the hemiscrotum,contstant dull pain,testicular atrophy.




How to diagnose:
Clinical Examination in standing position and with Valsalva is all that is necessary although in obese patient sometimes Colour Doppler Ultrasound is needed to prove the diagnosis.


Colour Doppler should only be offered for obese or previously operated groins
Does it need surgery?
• Clinically detectable varicoceles associated with abnormal semen parameters normal female partner or female partner with potentially curable infertility problem. IVF with or without ICSI can be considered to be first-line treatment in the presence of an independent female infertility factor requiring the use of these techniques.
Certain factors predict good outcome like:
 Grade 3 varicocele
 Lack of testiculat atrophy
 Normal FSH
 Motility >60% and motile sperm count >5 ×106


• Palpable varicoceles in adolescent boys when accompanied by ipsilateral testicular atrophy. Adolescents with normal testicular size should be offered follow-up with annual measurement.



REDUCTION IN SIZE OF THE TESTES AS SEEN BY PRADERS ORCHIDOMETER
• Debilitating testicular pain. But unfortunately, 10-15% has either persistent or worsening symptoms.

Basis of the treatment:
• Infertile men with varicocele, were found to have an increased number of abnormal forms, decreased motility and lower mean sperm counts (‘stress pattern'. Varicocelectomy results in significantly improved semen parameters in 60% to 80% of men).
• A multi-center WHO study on the influence of varicocele on fertility parameters demonstrated that the mean Testosterone level of men older than 30 years of age with varicoceles was significantly lower than that of younger patients with varicoceles which was correctable after the surgery.
• Only two randomized, prospective, controlled studies have been performed to show cause and effect relationship between varicocelectomy and improvement in pregnancy rate. Nieschlag et al found that semen parameters improved significantly in the treatment groups but pregnancy rates were no different. Most of the varicoceles in that study were Grade I and a microsurgical; artery sparing technique was not applied. A second study by Madgar, et al. employed a cross over design. In that study, pregnancy rates were 6 times higher in the men undergoing immediate varicocelectomy compared to those in the observation group (60% vs. 10% respectively) over the first year.
• Varicocelectomy can be effective even in men with azoospermia. Matthews and Goldstein recently reported that 55% of azoospermic men had motile sperm observed in their ejaculate after repair.
What is the best modality of treatment:
Surgical repair may be accomplished by various surgical approaches like inguinal (Ivanissevich), subinguinal and retroperitoneal approaches (Palomo), Most experts perform inguinal or subinguinal surgical repair employing loupes or an operating microscope for optical magnification. Techniques using optical magnification help in reliable identification and preservation of the testicular artery or arteries, cremasteric artery and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins reducing the risk of persistence or recurrence of varicocele. The introduction of microsurgical technique to varicocelectomy has resulted in a substantial reduction in the incidence of postoperative hydrocele formation and testicular atrophy. The use of magnification enhances the ability to identify and preserves the 0.5 - 1.5-mm testicular arteries, thus avoiding the complications of azoospermia.
Microsurgery only should be the choice for varicocele patient

Laparoscopy has been used for varicocele repair but this approach carries the risk of major intraperitoneal complications, such as injury to bowel, bladder and major blood vessels and also risk of leaving some tributaries especially above level of L4 vertebra.
In general; laparoscopy should not be assorted for varicocele treatment.
The Gold standard of varicocelectomy is Microsurgical Varicocele Ligation.
What should the patient expect post-operatively?

The semen count will take a while to improve so semen analysis should be repeated after an interval of 3 months. Adjuvant medicines such as L carnitine, CoQ 10,Selenium and zinc may facilitate further recovery of sperm count.

Any other modality of tretament:
Some treatments like applying cold water, Typical Yoga postures like Sarvangasan and sheershasan(relieving pressure off the veins) and avoiding sleeping prone are said to ease the varicocele but yet to be proved.