Varicocele is the most common cause of male infertility; fortunately, at this time it is also the most treatable. Between 30 and 40% of all infertile men have a varicocele as their only symptom. Also, 15% of the male population has a varicocele that causes no symptoms and doesn't appear to cause infertility.

Varicose veins, including varicoceles, occur because of an increase in water pressure in the veins. To understand water pressure better, remember that when you dive in water, the deeper you go, the greater the pressure on your ear drums. At the bottom of a column of water, the pressure from the weight of the water above causes an increase in pressure. Varicose veins usually occur in the legs and lower parts of the body where there is the greatest fluid pressure. For the same reason, they also occur in the testicles.

Why then don't all men have varicoceles? Normal testes veins have special valves that reduce the back pressure. These valves allow the blood to travel only in one direction - back to the heart. If the valves are not working or weak, then back pressure can develop as described above. This creates a heavy pool of stagnant blood. The more valve damage, the higher the reservoir of blood, until a point is reached where the vein begins to swell. This is a varicocele, or varicose vein of the testicle.

Most of the time, the varicocele occurs in the left testicle, because of a difference in anatomy between the veins draining the two testicles. (In the left testicle, the spermatic or testicular vein is longer and takes a more roundabout course to return blood to the heart. The left testicular vein enters the left kidney vein, which has generally higher pressures within it. The right testicle vein is shorter and directly enters the vena cava, the main vein returning to the heart, which generally has lower pressure within it.) Rarely does a varicocele occur only on the right side.

Exactly how a varicocele leads to infertility remains a mystery. Of the several theories, one is that the pooled venous blood overheats the sperm production centers of the testicles. Excess heat can kill the sperm. Heat can also speed up sperm production, causing the primary cells to divide so fast that sperm are forced rapidly through development without enough time to mature in each stage. The result is immature and deformed sperm. Another theory suggests that the damaged veins allow chemical toxins normally cleansed through the kidneys to drift down into the testicle.

The only certainty about a varicocele is that if it is surgically tied off, sperm production often improves. Sometimes even patients with zero sperm (azoospermia) or very low counts (oligospermia) can improve when surgery is done.

Diagnosis

A varicocele may be discovered for the first time during a man's physical examination when he is asked to stand up and bear down or cough. Sometimes a man may notice a larger left scrotum or a lumlp in the scrotum. Sometimes men have dull pain as well. If a varicocele is present, the extra pressure will usually make the vein bulge and the specialist can feel it in the scrotum. Sometimes, however, the varicocele is so small or so hidden that it cannot be felt. A scrotal ultrasound can be done to diagnose a varicocele, measure the size of the veins, and detect any other testicle abnormalities if present. It is painless.

If a varicocele is discovered, the specialist will compare the finding with the semen analysis. A varicocele that causes infertility problems usually presents a consistent pattern on the semen analysis, namely, immature sperm, poor motility, low sperm counts, and abnormal sperm shapes.

Treatment

If a varicocele is present and the semen analysis shows a stress pattern and a low sperm count, surgery is usually recommended. Either general or spinal anesthesia can be used in this operation. The surgeon makes an incision in the lower abdomen, locates the bundle of blood vessels, and isolates the veins fromthe artery and the vas deferens. The surgeon ties off the main trunk of the veins above the varicocele. New pathways will open up to carry blood from the testicles. The man may remain in the hospital overnight or go home the same day. He can resume his normal activities, including sex, within a week or two. You can expect pain, swelling, bruising, and stiffness on walking for a week. Ice and analgesics will help. I use optical magnification to identify even the smallest veins. An operating microscope is also used in certain cases.

After surgery, a man must wait three months for new sperm to be produced and find their way into the ejaculate. This is a stressful period, since the first postoperative semen analysis will not be taken for ninety days. Some improvement is usually seen at that time; but maximum recovery of sperm production usually doesn't show up until the next analysis, at the six month mark.

Semen quality and/or sperm count improves in 60% of infertile men who have surgery, but only half of these men go on to impregnate their wives. The number of successful pregnancies is higher for those men whose sperm counts were relatively high (10 - 20 million per cc) before surgery. The pregnancy rate is somewhat lower when the sperm count is under 10 million per cc before surgery. Even so, the overall high success rate makes surgical correction of varicocele the most effective of all fertility treatments available to men.

If the sperm count doesn't improve following surgery, your options are I.U.I. (intrauterine insemination), IVF, or a trial of medication.