Varicocele is the inability of the veins (venules) that carry deoxygenated blood from the testicles to function properly, preventing the blood from being carried back to the heart. Due to the accumulation of deoxygenated blood in these veins, they swell and become varicose. The term “varicocele” refers to the equivalent of varicose veins in the testicles, similar to those that occur in the legs, particularly in women. Varicocele is a congenital condition.
1. Varicocele is one of the most common and correctable causes of male infertility, occurring in 15% of adult men.
2. Despite not using contraception, 15% of couples are unable to conceive within a year.
3. One in eight couples (12.5%) experience problems with conceiving their first child, while one in six couples (16.7%) have difficulties with conceiving a second child.
4. Despite no cause being found in either partner, 25% of couples cannot conceive.
5. Among those who seek help for primary infertility, 40% have varicocele, and among those seeking help for secondary infertility, 63% have varicocele.
VARICOCELE IS RESPONSIBLE FOR 15% OF MALE INFERTILITY.
Negative Effects of Varicocele:
1. Inability to conceive.
2. Underdevelopment and smaller size of the testicle on the affected side.
3. Pain and discomfort.
4. Decreased production of male hormones (hypogonadism).
Mechanisms by which Varicocele Affects Sperm Quality:
1. It causes an increase in temperature in the testicles.
2. Enlarged veins (venules) put pressure on the arteries, disrupting the blood supply to the testicles.
3. It prevents the testicular venules from eliminating waste products.
Diagnosis:
The most important method for diagnosis is the examination performed by an experienced Urology Specialist. The examination should be conducted while standing. According to the examination, varicocele is classified into three grades:
1. Grade I: The mildest form, where varicose veins can only be felt by hand during situations that increase intra-abdominal pressure, such as coughing or straining.
2. Grade II: Varicose veins can be felt by hand without the need to increase intra-abdominal pressure.
3. Grade III: The most severe type, where varicose veins are visible while standing.
Second Step in Diagnosis:
Scrotal Color Doppler Ultrasonography is used to determine the diameter of the affected veins, whether there is a reflux of deoxygenated blood, and whether there is a loss of volume in the testicles.
Semen Analysis (Spermiogram):
Varicocele can cause a decrease in sperm count, motility, and morphology. Ideally, two separate semen analyses should be conducted, with at least 7 days but no more than 3 weeks between the two tests.
If Sperm Count is Less Than 5 Million:
Genetic tests (karyotyping and Y chromosome analysis) should be performed. If a genetic abnormality is found, the varicocele is likely coincidental, and treatment for varicocele may not be beneficial.
Subclinical Varicocele:
Varicocele that is not detected during a physical examination but is revealed through Scrotal Color Doppler Ultrasonography. Surgical outcomes for this type of varicocele are significantly lower than those for high-grade varicoceles.
Normal Semen Analysis:
1. Volume should be at least 1.4 milliliters (ml).
2. Total sperm count should be at least 16 million.
3. Total sperm motility should be at least 42%.
4. Progressive sperm motility should be at least 30%.
5. Vitality should be at least 54%.
6. Normal morphology should be at least 4%.
Definitions:
– Azoospermia: No sperm observed in the semen analysis.
– Oligozoospermia: Insufficient sperm motility.
– Teratospermia: Abnormal sperm morphology.
Varicocele surgery must be performed using microsurgical techniques.
Benefits of Varicocele Surgery:
1. 70% improvement in pain post-treatment.
2. 25% improvement in unexplained infertility.
3. Correction of male hormone deficiency.
4. In 44% of patients with azoospermia, sperm can be detected in semen analysis post-surgery.
5. Varicocele surgery improves sperm DNA integrity, preventing recurrent miscarriages and increasing the success rate of IVF treatments.
6. Significant benefits are observed in patients with arrested sperm development detected in testicular biopsy.
Recurrence Rate After Varicocele Surgery:
Embolization Technique by Radiologists:
– Recurrence rate: 7%
– Hydrocele (fluid accumulation in the testicle) rate: 10%
– High Ligation Technique:
Recurrence rate: 23%
Testicular swelling rate: 8%
Subinguinal Microsurgical Technique Recurrence rate: 0.4% Hydrocele rate: 0.44%
The “Subinguinal Microsurgery” technique, which has the lowest recurrence and hydrocele rates, is applied by Prof. Dr. Tahir Karadeniz for varicocele surgeries. Using the “Microsurgical Doppler Device” during surgery to protect the testicular arteries is an important detail.
During surgery, we tie off the diseased veins at the groin level and extend them to the testicle. If the testicular veins are not addressed, there is a 10% risk of recurrence (this answers the frequently asked question of whether we remove veins during surgery).
This article has been updated according to the November 2024 guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA).