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Varicocoeles: Father at last

Updated: Jun 21, 2019

He had noticed a slight swelling on the left side of his scrotum for a year. It happened insidiously and he had not thought much about it. He felt an occasional dull pulling pain which was aggravated when he carried a heavy load. Lying flat relieved the pain.

C, a 35-year-old engineer, had been married for five years. He and his wife had been trying for a baby without success. Abnormal sperm count was the cause.

His sperm count was low (less than 10 million per ml) and they were mainly defective and unable to move and swim effectively.

Normal sperm count should be at least 20 million per ml with more than 50 per cent of the sperm swimming actively and 15 per cent having a normal shape.

When I examined C, the swelling on his scrotum felt like a bag of worms with dilated veins on the skin. The testes were soft and slightly small. Ultrasound examination with Doppler colour flow confirmed the presence of dilated veins which were more prominent when C was asked to bear down (Valsalva manoeuvre).

I told C he had varicocoeles of the testes.

For normal sperm production, the testes require a temperature a few degrees lower than the core body temperature. This is done by a network of veins that surrounds the testes and drains blood back to the heart – effectively cooling that area.

When the valves within these veins are incompetent or defective, blood accumulates and the veins expand and become dilated, forming a venous lump in the scrotum. The pooling of blood around the area raises the testes’ temperature, resulting in poor and abnormal sperm production.

Metabolic waste products may also accumulate in the testes. This diminishes the amount of oxygen and nutrients required for sperm development. In addition, the abnormal blood flow interferes with testosterone (male hormone) concentration, which in turn causes a reduction in sperm production.

Over time, such compromised circulation may result in a disruption of normal male hormone production.

Varicocoele is more common on the left side of the scrotum, as in C’s case. This is related to the anatomical position of the veins. Someone who has varicocoele will usually have it from early childhood but it only becomes larger and more noticeable during adolescence when there is increased blood flow to the testes.

It is also more common in tall and thin men and can run in families. Occasionally, a varicocoele can develop suddenly due to a cancerous growth in the kidney which obstructs the veins. This usually happens in elderly men.

Many patients do not have symptoms. It tends to be found in infertile men – accounting for about 40 per cent of men with primary infertility (never fathered a child) and about 40 to 70 per cent with secondary infertility (have fathered children in the past but are now unable to do so).

The occasional pulling pain that C felt is not common and is usually due to prolonged physical exertion.

“What should I do to improve the quality of my sperm? Could it be cured by taking medicine?” C asked.

Medication does not improve the quality of the sperm as it does not remove the cause. However, a painkiller may be prescribed if there is discomfort. For some patients, wearing snug, supportive underpants may help ease any discomfort.

As for treatment, there are two approaches: surgical repair and percutaneous embolisation.

In surgical correction (varicocoelectomy), all the abnormal veins are tied off (ligation). Two different surgical techniques have been used. They are open incision on the groin or scrotum and laparoscopic (key-hole) surgery using a telescope through the abdominal wall.

These can be done on a day-stay basis under general anaesthesia. Post- operative pain and complications are few.

In percutaneous embolisation, which is performed by a specialist X-ray doctor (radiologist), a special tube (catheter) is inserted into a vein in the groin. Under X-ray guidance, a small metal coil is threaded through the tube into the affected vein. It is then released to block the blood flow to the affected vein and to redirect it to healthy ones.

C opted for the surgical repair as he was afraid of having metallic coils in his body. His sperm count and quality recovered dramatically. Six months after surgery, his wife conceived. He is now the proud father of three children.

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