VARICOCELE AND INFERTILITY IN MEN

Relationship between varicocele and infertility

Varicocele is a disorder that affects the veins of the testicles, namely the veins of the plexus pampiniformis that are inside the scrotum. So that you will see a widened mass and abnormal winding in the veins. Varicocele is a common problem in the practice of reproductive medicine because it is associated with male reproductive potential. The presence of varicocele can cause infertility in men. Varicocele is found to be around 40% in men with primary infertility and 81% with secondary infertility.

This is because the formation of spermatozoa in the testes is very sensitive to the rise in temperature. The presence of varicocele (dilation and winding of veins from the plexus pampiniformis) causes the temperature inside the srotum to increase so that it will disrupt the process of spermatozoa formation (spermatogenesis) so that sperm quality will decrease. The expected temperature for spermatogenesis to run properly is two degrees below body temperature.

Varicocele epidemiology

The epidemiological study states that the prevalence of varicocele in the male population in general is around 15%. Subsequent epidemiological studies have shown that varicoceles develop at puberty. Oster observed that no varicocele was detected in 188 boys aged 6-9 years, but it was detected with an increase in frequency in boys 10-14 years, thus suggesting that varicocele develops at puberty. The Akbay et al. Study evaluated varicocele prevalence in 4052 boys aged 2-19 years. They reported that the prevalence of varicocele was <1% in boys aged 2-10 years, 7.8% in boys aged 11-14 years and 14.1% in boys aged 15-19 years. These epidemiological observations show that the presence of venous inability which is characteristic of varicoceles mainly occurs during testicular development. More recent studies show that the prevalence of varicocele in age-related adult males. Levinger et al., Evaluated the age-related prevalence of varicoceles in men over 30 years of age. Of 504 healthy men, 34.7% were found to have varicoceles on examination. Further analysis, they observed that the prevalence of varicocele increased by around 10% for each decade of life. The prevalence of varicocele is 18% at the age of 30-39 years, 24% at the age of 40-49 years, 33% at the age of 50-59 years, 42% at the age of 60-69 years, 53% at the age of 70-79 years and 75% at the age of 80-89 years.

There is also a relationship between varicocele and varices in the lower limbs. According to Yasim et al., Reported that in 100 patients who underwent varicose surgery, it was found that 72% had varicocele with some degree of severity, probably because the venous valve was incompetent. As suggested by Levinger et al., in their study of age-related increases in the prevalence of varicocele, systemic venous insufficiency may be the cause of both venous inferior inability and inability of testicular veins.

Varicocele symptoms

Varicocele sufferers are often asymptomatic. But in some sufferers feel the discomfort in the scrotum until sometimes there is pain when you move too long in a standing position and will be reduced when sleeping position.

How to diagnose varicocele

To establish the diagnosis of varicocele can be done by physical examination in the form of inspection and palpation of the scrotum. From this examination will get the division of varicocele into grades, i.e.

1. Grade 1 is invisible and palpable venous dilatation with the Valsalva maneuver

2. Grade 2 is easy to detect venous dilatation without the Valsalva maneuver

3. Grade 3 is easily visible through inspection from a distance and on palpable palpation of dilated veins that resemble the appearance of a bag of worms

Valsalva maneuver is an examination in which the doctor will ask the patient to exhale through the mouth and nose closed to clarify the existence of enlarged veins.

The grade of this varicocele correlates with atrophy of the testes. It is said that the volume of the testes will decrease by about 34% in grade 2 and 81% in grade 3. This is also the cause of infertility in patients with varicoceles.

Varicocele is more common in the left testis, but can also occur in both testicles. According to a recent study states in patients with varicocele in the left testis after examination with ultrasound also found in the right testis.

Varicocele Treatment

Most varicocele sufferers do not have complaints or symptoms so treatment does not need to be given. However, if the varicocele causes pain or pain or testicular atrophy or fertility problems, then surgery will be performed. Surgery can also be performed if varicoceles occur in both testes (bilateral varicoceles), grade 2 or 3 varicoceles occur, or abnormal sperm analysis.

The principle of surgery is performed by clamping or binding of dilated and winding veins (varicoceles) in order to inhibit blood flow to these vessels and can flow to other normal veins. Surgery can be done with open surgery or microscopic surgery or laparoscopy or embolization/ sclerotherapy.

The healing process after surgery is 1-2 days. However, sufferers need to rest to avoid strenuous activities or activities for10 to 14 days. In infertile men, sperm analysis can be done after 3-4 months after surgery due to the formation of spermatozoa (spermatogenesis occurs 70 ± 4 days.

REFERENCES:

1.     Ali JI, Weaver DJ, Weinstein SH, Grimes EM. Scrotal temperature and semen quality in men with and without varicocele. Arch Androl 1990; 24: 215–9.

2.     Alsaikhan, B., Alrabeeah, K., Guila Delouya, G., Armand Zini, A.. 2016. Epidemiology of varicocele. Asian Journal of Andrology. 2016; 18, 179–181

3.     Oster J. Varicocele in children and adolescents. An investigation of the incidence among Danish school children. Scand J Urol Nephrol 1971; 5: 27–32.

4.     Akbay E, Cayan S, Doruk E, Duce MN, Bozlu M. The prevalence of varicocele and varicocele‑related testicular atrophy in Turkish children and adolescents. BJU Int 2000; 86: 490–3.

5.     Levinger U, Gornish M, Gat Y, Bachar GN. Is varicocele prevalence increasing with age? Andrologia 2007; 39: 77–80.

6.     Yasim A, Resim S, Sahinkanat T, Eroglu E, Ari M, et al. Clinical and subclinical varicocele incidence in patients with primary varicose veins requiring surgery. Ann Vasc Surg 2013; 27: 758–61.

7.     World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril 1992; 57: 1289–93.