Infertility and varicocele.
What is it?
Infertility is the inability of a couple to conceive within 1 year of unprotected intercourse.
It can be divided into :
- Primary infertility, when a patient has never been fertile;
- Secondary infertility, when a previously fertile patient has become infertile. Normally, couples will achieve conception at a rate of 20%–25%/month; 75% will achieve pregnancy after 6 months and more than 90% will achieve pregnancy after 1 year.
The risk factors include varicocele; family history of infertility and miscarriages; history of testicular torsion or cryptorchidism; drug use; urinary tract infection; endocrine disorders; chromosomal abnormalities; radiation and chemotherapy; inguinal, spinal, and retroperitoneal surgery; and cystic fibrosis. Varicocele is the most common cause of both primary and secondary infertility.
VARICOCELE AND MICROSURGICAL VARICOCELECTOMY
What is it?
Varicocele is the most common and correctable cause of both primary and secondary male infertility, its prevalence among the population being estimated at between 21% and 41%. It is present in up to 35% of men with primary infertility and up to 75% of men with secondary infertility. It is defined as a varicose dilatation of the pampiniform plexus veins and for anatomic reasons (angle of insertion of the left testicular vein into the left renal vein) it is more common on the left side than on the right.
Its presence is associated with some andrological implications, such as failure of ipsilateral testicular growth and development, symptoms of pain and discomfort, and male infertility.
Diagnosis and treatment.
In late 1971, Dubin and Amelar published a classification of varicocele based on physical exploration according to which it can be graded as follows:
- grade 1 = palpable during the Valsalva maneuver, but not otherwise;;
- grade 2 = palpable at rest, but not visible;
- grade 3 = visible and palpable at rest. In addition, subclinical varicocele is defined as a varicocele that is not palpable or visible at rest or during the Valsalva maneuver, but can be shown by special tests (Doppler ultrasound studies). So, diagnosis is achieved by physical exploration of the scrotum and confirmed by color Doppler ultrasound.
Several treatments are available for varicocele, including laparoscopic varicocelectomy, vein ligation, embolization, and microsurgery. Current evidence indicates that microsurgery is the most effective and least morbid of these techniques. Despite this, because of its complexity in technical terms and because of the cost of the required materials (microsurgical instruments and microscope for magnification), microsurgical varicocelectomy is not a widely used technique and most surgeons still offer other solutions for varicocele repair.
Among the expert community, microsurgical varicocelectomy is considered the standard for varicocelectomy in both adolescents and adults because, compared with other techniques, it is associated with low rates of recurrence and complications. When a patient is to be submitted to this surgery, it should be clearly explained that the aim is only to improve semen parameters in order to ameliorate male fertility; pain reduction should not be considered an objective of this surgery and other interventions such as denervation of the spermatic cord should be considered if pain reduction is the objective. Varicocelectomy and microsurgical varicocelectomy have the potential to avoid the need for artificial reproductive techniques or may permit use of a less expensive and invasive option, e.g., artificial insemination instead of in vitro fertilization.
The main advantages of microsurgery for varicocele repair are the possibility of preserving lymphatic vessels due to magnification and the lower recurrence rate as compared with other techniques, including sclero-embolization. Microsurgery is performed under local anesthesia on an outpatient basis.
The surgical incision is small and very low (about 3 cm and next to the scrotum). Complications are minimal and local and include inflammation, presence of hematoma, and scrotal pain; all complications are manageable with oral anti-inflammatory drugs, local ice (not in contact with skin), or a scrotal suspensory.
Varicocele surgery: the surgical intervention of varicocele
Varicocele surgery allows to restore semen parameters and to improve fertility if the patient has been submitted to surgery with time. Changes in semen parameters can be documented 3 months after surgery since the cycle of production of a new sperm series needs approximately 84 days. In addition, before submit a patient to varicocele surgery, other possible causes of infertility must be ruled out. Surgery consists of closing the various veins by the help of the microscope that allows a selective ligation of these (this is impossible with embolization, sclerotization and all other surgical and radiological techniques) and, above all, microsurgery avoid accidental ligation of sperm artery and the lymphatic vessels. The ligature of these causes post-operative complications, among them the hydrocele that represents the most frequent complication in the usual techniques. Age of the patient has an important role: after 40 years it is difficult to recover the fertility that has been lost due to varicocele changes, for this reason the patient has to be carefully studied to understand if it is candidates for varicocele’s surgical correction.