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Oganes E. Dilanyan
Urologist, MD, PhD
+7(499)344-03-03

Varicocele

In this article

Varicocele is a condition seen in men and adolescent boys, which manifests as varicose veins in the testicles and spermatic cord. Up to 40% of male infertility can be attributed to this condition. In this article I will explain the reasons and the consequences of varicose veins in the testicles and go over the treatment methods. 

I have been treating male infertility for over 20 years. I get visits from 3-4 couples daily with complaints about being unable to have children. Usually there are no other complaints. Typically the wife is tested for infertility first as the pregnancy does not occur. Lots and lots of tests, an array of painful and expensive investigations, hormonal profile, basal temperature monitoring…

And nothing. No detected conditions or other reasons that infertility could be attributed to. Or, even worse, an infection is found and the couple is encouraged to undertake a long and aggressive antibiotics treatment. And still no children. Finally, the husband undergoes semen analysis and the result is severe abnormalities. In milder cases there is a problem with motility or appearance of sperm (morphology). In more severe cases there are no sperm detected in the semen. And surprisingly the male has no symptoms. Only sometimes, after physical exertion there might be some dull pulling pain in the testicle or a feeling of heaviness in the scrotum. Sometimes I hear from patients that Varicocele was diagnosed in childhood.

“A man visits a doctor only after his wife has been thoroughly investigated. Unfortunately such is man’s mentality...”
From a lecture about male infertility.

A Varicocele is an enlargement of veins within the scrotum. During this condition overheating and poisoning of the testicles occurs which in turn leads to disruption of growth and development of sperm. In 50% of all cases male infertility is caused by this condition.

Under normal conditions the blood from the testicles rises to the renal vein. This is helped by the valves in the testicular veins. In a healthy vein blood can only move from the testicle to the renal vein. When the veins are enlarged the valves can’t fully close which leads to the reverse process: blood from the renal vein flows to the testicle. Three testicle damaging factors immediately occur:

 •    Blood pooling in the testicular veins: testicular metabolism products, in other words – poisons, collect and stay near the testicle.

•    Poisons, occurring in the renal vein also poison the testicle once they have got to it. 

•     As the blood in the renal vein is a couple of degrees warmer the testicle overheats.

 

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Здоровая вена яичка с клапанами
Healthy testicular vein with valves
Движение венозной крови
Under normal conditions unoxygenated poison containing blood from the testicle only travels upwards
Расширенные вены при варикоцеле
Testicular vein enlargement during varicocele
Последствия недостаточности клапана
Valve insufficiency leads to reverse blood flow from renal vein
Перегрев и отравление сперматозоидов
Overheating and poisoning of the sperm occurs

So when one has varicocele the testicles overheat and get affected by poisons.

“Nothing special, doctor. This is going to sound weird, but it feels like I have worms in the scrotum".
Patient’s account
What will happen to a human being if they drink a lot of vodka in a sauna? They will be unable to run!”
Overheating and poisoning of the sperm occurs
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Trying to explain the consequences of varicocele to my patients I give the following example: Let’s take a healthy human, place them in a sauna and start giving them vodka to drink. Also, we will lock them in the sauna for a long time and give them a lot of vodka. Then we will take them outside and make them run. Will they run far? Will they be able to run fast? Sperm finds itself in the place of this human. Instead of developing in a cool healthy environment it gets subjected to renal waste products and warm temperatures. Should one really be surprised at the semen analysis abnormalities? Motility is affected – the sperm can’t run after “vodka in the sauna”. Morphology, in other words the shape of the poor sauna and vodka sufferer also gets affected and degenerative forms are seen in the semen analysis.

Infertility and other consequences of varicocele

Due to constant overheating and poisoning of the sperm this condition causes various changes in the semen analysis: most commonly affected are sperm motility (asthenozoospermia) and morphology (teratozoospermia), which in turn leads to male infertility. At the advanced stage of varicocele the production of male hormone testosterone is decreased. Erectile dysfunction also occurs – ranging from mild erectile problems to complete inability to have intercourse.

“Double-sided varicocele? I have read that it only happens on the left side…And only occurs on the right as a result of a tumour!”
Conversation with a patient, who is also a medical student, Moscow

Varicocele on the left... or double-sided?

Վարիկոցելեն լինում է ոչ միայն ձախակողմյան
Thinking that scrotum vein enlargement only happens on the left side is a misconception!

Recently I was present at medical school examination. An all ‘A’s student, future urologist, was answering the exam questions...
— Varicocele is the enlargement of spermatic cord veins, and occurs on the left side in 95% of all cases.
— And what if it occurs on the left and on the right?
— Then we need to look for a kidney or other pelvic organ tumour...
— Well, let’s say there is no tumour, what then?
— Then…Then you are splitting hairs. Varicocele very rarely occurs on the right side. In spite of the student being wrong I gave him an A. He was really trying, it is not his fault that most textbooks in this country postulate left-sided varicocele and do not describe double-sided varicocele at all. The price of such ignorance is often a wrong diagnosis.

There are some western scientists’ articles where it is clearly demonstrated that in fact, in most cases the enlargement of testicular veins it is a double-sided pathology. Therefore the treatment should apply to both sides which will ensure a better result.
The reason for “overlooking” the double-sided varicocele is in the deeply rooted belief in the prevalence of vein enlargement only on the left. Meanwhile this belief is fundamentally wrong, which has been demonstrated in the array of studies using a coloured Doppler ultrasound probe. Unfortunately when the old urology textbooks were written this technology simply did not exist.

What tests and investigations are necessary for a patient with suspected varicocele?

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When investigating a patient with infertility and suspected scrotum varicose veins I carry out an ultrasound scan and coloured Doppler probe of the scrotum on both sides with the patient standing and lying down. Before this I ask the patient to remain standing for a short period of time, and if it is cold outside, to get warm. 
Why do I do this? Because often the filling of the testicular veins only happens when standing up. And cold temperatures can cause blood vessels to constrict which will lead to the lessening of their diameter and I will simply not see the enlarged veins.  
Therefore, if based on the ultrasound scan and a Doppler probe test you have been given the diagnosis on “left-sided varicocele” please think if you have been asked to stand for a short period before the test was carried out. Were both sides of the scrotum checked? Were you cold during, immediately before or after the investigation? Were you examined first in the standing position and then lying down? 
If your answer to at least one of these questions is “no” then there is a possibility of a wrong diagnosis and one should pay close attention to where and how these diagnostics tests are carried out...

“Yes I understand that I have varicocele. But I do not understand what I can do to with it. I apply honey with nuts on my scrotum every day but it does not help!”
Conversation with a patient

How to treat varicocele?

The essence of this condition is the enlargement of the veins of the testicle and reverse flow of warm and poisoned blood to the testicle. The problems that result from this vein enlargement are male infertility, scrotum pain and sometimes prostatitis. Which naturally raises the question about what exactly do I mean talking about varicocele “treatment” and how exactly I am going to do it? 

Varicocele treatment is not limited or entirely defined by surgical removal of varicocele but also aims to cure the patient’s infertility get rid of the pain and prostatitis, in other words it solves the problems caused by the “worms in the scrotum”.

“Doctor, is it at all possible to avoid the operation? It’s a little strange…maybe we could try some stimulation first, or some pills instead of cutting it straight away?”
From a conversation with a patient.

Varicocele surgery

Without surgical intervention the sperm will continue to develop in a poisoned environment therefore any type of stimulation be it with Speman, Spermactine, hormonal medication etc. will simply lead to a greater number of defective sperm with low motility and unable to fertilise an egg.  Is Varicocele treatment at all possible without surgery? Unfortunately all therapeutic, medicinal and traditional home remedies are ineffective at best and in the worst case scenario they waste time and lower the chances for restoring testicular function. 

“IVF/ICSI — is not a panacea. As with any treatment method it has its indications and contraindications”
From a conversation with a fertility specialist.

Would it not be easier to go straight to IVF/ICSI?

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Unfortunately not. Several western studies have shown that in the presence of scrotal veins enlargement the chances for conception to occur and pregnancy continuing with IVF treatment are considerably lower than after the operation. Besides, surgical intervention spikes the chances of the pregnancy occurring naturally. According to some German studies the most effective surgical procedure is the Marmar method operation. In the year following surgery the chance of pregnancy is raised by 52% which after 12 to 18 months rises to 65-7-%.
 

“Five year nightmare is finally over. Thank you Oganes for this precious gift, our baby girl”
Patient feedback

Marmar method surgery is the gold standard in Varicocele treatment

Marmar method surgical intervention
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When suggesting surgical intervention to my patients I tell them about the advantages and disadvantages of all possible methods of treatment. The Marmar microsurgical procedure for treatment of Varicocele is considered to be the best surgical option. Neither the very popular in the past Ivanissevich procedure nor modern laparoscopic surgery or hardening of testicular veins offer the same advantages and effectiveness. 

Marmar operation: What you need to know
Venous outflow after Marmar method surgical intervention.
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Based on years of comparative studies European and American Urology Associations recommend the Marmar method as the gold standard for varicocele treatment. Every patient that I suggest this operation to asks the same question: Why this particular method? Why not laparoscopic surgery? Why not the standard Ivanissevich operation? Why not the testicular vein embolization or microsurgical inosculation? 

Result

First and possibly most important is that Marmar operation leads to great improvement in sperm quality and to pregnancy occurring naturally. This is not just in my experience but also the data from European and American Urology Association. It has been shown that even in really difficult cases of male infertility operated patients have a much higher change of conception.   

Relapses

What is special about the Marmar  method is the use of a very powerful surgical microscope which allows  treatment of the smallest veins. This is why after this particular surgical procedure Varicocele relapse occurrence is no greater than 0,5-1,0%, while laparoscopic surgery results in relapses in 5–10%, and Ivanissevich method up to 40%.

Complications

During most types of surgery testicular artery is damaged in 10 to 40% of cases, which can lead to dramatic fall of nutrients getting to the testicle. In our case we use a surgical microscope, which allows us to save the testicular artery. Applying the European gold standard while preparing the patient for surgery lowers the chances of complications to zero.

Hydrocele

This is a standard complication (up to 30%) of almost all types of surgical procedures. The occurrence of Hydrocele warrants a repeat operation. Microsurgical treatment of Varicocele is an exception. Sevenfold magnification of the operation area allows us to avoid tying of the lymphatic vessels thus avoiding the risk of hydrocele. 

Inflammation and pain

Due to minimal incision (no more than 1,5 cm) pain after microsurgery is practically absent. The patient is discharged the following day. At the same time the Ivanissevich method is characterised by a large incision and up to one week of pain symptoms. Laparoscopy treatment involves entering the abdominal cavity and risk of organ damage.

Radiation

It is known that x-rays damage the testicles, which can lead to an incurable condition of radiation infertility. This is the only reason why I do not recommend embolization or hardening of the testicular vein as the operation is carried out under x-ray and often with high radiation exposure for the patient.

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