Varicocele is a cause of infertility

Author: Urologist-andrologist, Director of the clinic "Andrologist and Me" Ph.D. Rakhmatullaev B.M.

Varicocele - varicocele dilatation of the veins of the spermatic cord, a disease of adolescence, entailing a violation of spermatogenesis and leading to infertility. Signs of varicocele occur in 4.4-30.7% of men aged 15 to 25 years. Usually this is a unilateral process, which is most often localized on the left (80-98%), up to 10% of cases are found on both sides and only up to 2% on the right.

According to military statistics, at military age, varicocele occurs in 10-20% of people. Among the examined boys aged 7-14 years, varicocele was 1.8%, and in the group over 14 years old – 6.2%. It is characteristic that dilatation of the veins of the spermatic cord in boys under 12 years of age was very rare and was much more often detected at the age of 14-20 years. Ages from 15-25 years account for 54.9% of cases of varicocele, from 26 to 35 years – 26%, and older – 18.4% of cases.

It is necessary to note a significant difference between the age of patients in terms of the duration of the disease and hospitalization. Many patients are admitted to hospital treatment 5-10 or more years after the onset of the disease.

The disease occurs at any age and yet, most often between the ages of 15 and 30 years, that is, during the period of intensive growth of the body, puberty and reproductive activity.

The mechanical theory has received the greatest recognition in explaining the cause of the development of varicose veins of the spermatic cord.

Mechanical factors contributing to the development of varicocele include the following: compression of the spermatic veins by the contents of the hernial sacs, frequent excessive abdominal tension, which impedes the outflow of blood through the veins of the spermatic cord, the flow of the left spermatic vein at a right angle into the left renal vein, and the absence or insufficiency of the valves of the left spermatic vein.

The causal connection between varicocele and pathological changes in sperm was established in the early 40s. When examining men with varicocele, pathological changes in sperm were detected in 50% of cases. Among the various causes of male infertility, varicocele accounts for about 39%. Improvement in semen analysis after surgical treatment of varicocele is observed in 50-85% of cases.

There are several hypotheses regarding the negative effect of varicocele on the reproductive function of men. Based on this fact that an increase in temperature leads to damage to the spermatogenic epithelium, a number of authors, having discovered an increase in the temperature of the left testicle with varicocele, suggested that an increase in temperature is a leading factor in the occurrence of infertility. The use of an indirect method for measuring testicular temperature revealed a difference of 0.6-0.8 C between the temperature of the left testicle.

For the normal course of spermatogenesis (the process of producing sperm), a high concentration of testosterone (male hormone) is required, and with varicocele, damage occurs to the cells responsible for the synthesis of sex steroids. It has been suggested that disruption of these cells leads to a decrease in testosterone production and a deterioration in spermatogenesis. In order to verify this position, the level of testosterone in the blood was determined. According to some authors, all or some patients with varicocele had low testosterone levels.

Diagnosis of varicocele is based on the study of patient complaints, anamnestic data, and the results of objective research methods. This makes it possible to determine three stages of the disease.

However, in the absence of varicocele at the time of visual examination, the diagnosis of varicocele is difficult. In these cases, to diagnose the disease and determine the cause of varicocele, it is necessary to resort to various instrumental research methods.

There were reports of ligation of the left spermatic vein in a patient without varicocele, but with a reduced ability to fertilize and low sperm quality, which 6 months after the operation led to the development of pregnancy in the partner. In 1970, scientists reported an improvement in the quality of seminal fluid after surgery and this improvement had nothing to do with the stage of varicocele. These data stimulated the search for the causes of impaired spermatogenesis, which resulted in the emergence of the term “subclinical” varicocele. The diagnosis of subclinical varicocele has become possible, perhaps, thanks to the introduction of instrumental research methods, which today make it possible to choose the most optimal, pathogenetically substantiated method of surgical treatment.

Of the instrumental methods for diagnosing non-palpable(subclinical) varicocele are thermography, phlebography and color Doppler ultrasound.

Currently, pathogenetically based methods of treating varicocele are operations of one form or another.

Today, the most commonly performed operation for varicocele is the Ivanisevich operation, proposed in 1918. This technique is so effective that this method of treatment is still used by most clinics in the world. Despite its apparent simplicity, the incidence of relapse after Ivanisevich's operation is 3-10%.

Thus, varicocele is a disease, mainly of adolescence, leading to impaired spermatogenesis and leading to infertility. The high incidence of morbidity, accompanied in most cases by reproductive dysfunction, determines the relevance of the problem. Under these conditions, the diagnosis of subclinical (non-palpable) varicocele becomes even more relevant.

Urologist-andrologist, Ph.D. Rakhmatullaev B.M.