Frequent and benign most of the time, a varicocele can affect men of all ages. Because its incidence is even higher in men with fertility problems, it could have an impact on fertility.
What is varicocele?
Varicocele is characterized by the dilation of a vein (varix) in the spermatic cord, a fibrous cord located in the pouches above each testicle, and connecting each to the scrotum.
The varicocele generally affects only one side, mainly the left because of the anatomy of the venous network of the male genitals. On the left side, testicular blood is drained to the renal vein, while to the right it is towards the vena cava, where the pressure is lower than in the renal vein.
Causes of varicocele
The pathophysiology of varicocele is not exactly known, except for a malfunction of the unidirectional valves that allow blood flow from the testicles to the heart. In the case of varicocele, for reasons still unknown, one of the valves does not work properly. Venous blood refluxes accumulates and causes dilation of the veins in the spermatic cord.
With 15% of the adult male population affected, varicocele is a relatively common pathology that can occur at any age.
Evolution and possible complications
Varicocele has no effect on erectile function and sexuality, and in some men, it does not cause any discomfort or complication.
When it is large, it can cause a feeling of heaviness or pain that may increase over time. It can also affect the development and function of the testis with testicular atrophy and, presumably, fertility problems. The figures do indeed suggest an impact of varicocele on fertility: 35% of men affected by primary infertility have a varicocele, 80% when it comes to secondary infertility, against only 15% in the general population. The link between varicocele and infertility is not confirmed, however, and the possible mechanisms at play are unclear. Several hypotheses are however advanced: varicose veins could provoke, by blood stagnation, a warming of the testicle harmful to spermatogenesis. The wrong venous return could also lead to stagnation of toxic substances, such as tobacco, in the bloodstream, with an impact on spermatogenesis. The reflux of adrenal and renal metabolites could also affect sperm production.
Note, however, that a man with a varicocele may also have no fertility problem.
The symptoms of varicocele
Most often, varicocele is asymptomatic and causes no discomfort. It remains unknown or is discovered by chance or during a fertility test.
Sometimes the varicocele is manifested by an increase in the volume of the testicle, a feeling of heaviness in the stock market, or even pains accentuated during prolonged standing, during physical exertion or in hot weather.
The diagnosis of varicocele
The diagnosis is clinical: by palpation and visual examination, the urologist looks for varicose dilatations above the testicles. In case of doubt, an ultrasound is performed to confirm the presence of varicocele and rule out any other pathology (an inguinal hernia, spermatic cord cyst, effusion of liquid in the bursa, a tumor of the testicle …). The images will reveal unusually large veins and blood stagnation.
In a couple having difficulties to have a baby, during the assessment of infertility in humans, the doctor systematically performs a clinical examination to detect a possible varicocele.
Treatment and prevention varicocele
If the varicocele is poorly developed and causes no discomfort, therapeutic abstention is recommended.
In cases of fertility disorders, the links between varicoceles and hypofertility are not confirmed, there is a debate about the need to treat or not varicocele. However, a consensus seems to be reached: in case of net varicocele associated with abnormalities of spermogram, the treatment of varicocele is recommended.
This treatment consists in closing the dilated spermatic vein, usually by embolization: under local anesthesia and under ultrasound control, a small catheter is introduced into the femoral artery to the dilated spermatic veins. Substances are then injected to permanently clog the vein. These may be clogging products with sclerosis and/or small metal springs. The operation can be performed as an outpatient. Surgical treatment is much rarer today.
In more than half of the cases, this intervention would improve sperm quality. Sometimes, no improvement is found, but the treatment never leads to sperm degradation. In the case of major spermogram alteration, sperm preservation at CECOS may be recommended before the procedure, however, the French Urology Association recalls.
To date, no treatment or precaution prevents the appearance of a varicocele.