Varicocele Operation Actually Necessary? Varicosele treatment

Varicocele is abnormal enlargement appeared in veins returning from the testicles to the heart.  While no findings appear on mild varicocele cases, it may cause disorders in sperm production and motility by progression during years. 

It is reported that decrease on testicles sizes and disorders on testosterone production may appear in severe cases.  Temperature of the bags called scrotum which protects the testicles is generally lower by several degrees than body temperature.  In other words, a cooler media than the body temperature is required for healthy sperm production. 

By development of blood ponding because of varicose in the bags, the increased temperature may affect sperm production negatively and spoil reproduction function.  Besides the temperature increase, another theory suggested is that harmful wastes  and free radicals from the kidneys and surrenal glands because of increased vascularization and blood building up may accumulate in the testicles.  Thus, it is told that sperm motility and quality may be affected in particular.

 Incidence of varicocele has been detected as 25% in men with defective sperm test and as 12% in men with normal sperm parameters.  Furthermore, 35 to 40% of men who refer due to infertility have varicocele.  However, it should not be forgotten that varicocele may be detected in a significant part of healthy men with children incidentally.   It is generally detected on the left side; the vein on the left is longer and because this vein is connected perpendicularly onto the main vein, the blood can not be discharged completely.  Sometimes it is bilateral and rarely on the right side only. 

How is it diagnosed? 

The most important diagnosis method is physical examination.  It is diagnosed by palpation of the vein and nerve formation entering into the testicles.  Intraabdominal pressure is increased by inducing coughing or straining during the examination and enlarged vascular structure is identified.  Varicocele may be searched with Doppler ultrasonography, however, it is reported that varicocele detected by ultrasonography only is not significant clinically and operation is not required.  Therefore, treatment of non-palpable mild varciocele is not suggested. 

Varicocele treatment is surgical; veins are tied by an operation from the groin area visually or under a microscope.  Use of microscope during the surgery provides clear identification of the veins and preservation of the vessel which feeds the testicle.  Varicocele is most common cause for male infertility which may be treated by microsurgery methods. 

A recovery by 60 to 70% may be achieved in spermiogram values in varicocele cases which are diagnosed correctly and treated by successful application of microsurgery methods (1). 

However, there is conflict on research about how much pregnancy rates are recovered by recovery on the sperm count (2).

In general, cases who can not achieve pregnancy despite the recovery in sperm analysis results within 6 months at least following varicocele operations should pass to intrauterine insemination (IUI) or in-vitro fertilization – microinjection procedures.  Pregnancy may achieve by sperm washing and insemination in mild sperm disorders.  An Urologist is consulted if necessary. 

Insemination is not useful for severe sperm disorders and in-vitro fertilization – microinjection treatment should be applied.  In case of absence of sperm in the sperm sample given, if obstruction is not detected as a cause, in other words, a decrease in sperm production exists, in-vitro fertilization and microinjection should be performed with sperms that will be obtained from parts taken from testicles (microTESE).  Varicocele operation is a waste of time for asoospermic men who have no sperm.  Another important issue is that varicocele detected in young men on adolescent age should be treated even they are not married.  It is suggested that disruption on sperm quality in the future may be prevented. 

In summary; is sperm values are lower for a man in couples whom woman has not any fertility problem and an apparent varicocele which may be detected clinically, not by ultrasonography exists, treatment may be considered.  Otherwise, treatment is not necessary.  Also, varicocele should have spoilt the sperm values to start the treatment.  In other words, if sperm is normal, it may not be treated even varicocele is palpable.  Because insufficient scientific data that varicocele operation facilitates to obtain pregnancy and high achievement rates on in-vitro fertilization, it is more natural for couples to prefer microinjection, in-vitro fertilization rather than to have varicocele operation and wait for 6 months.

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