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It is the abnormal enlargement and tortuosity of the veins (veins) that carry dirty blood from the testicles, i.e. varicose veins. This vein dilatation can start at a young age and progress under the influence of gravity. Varicocele is the most common and treatable cause of male infertility.

At mild levels, there may be no clinical signs. It can progress over time and lead to swelling in the scrotum (the bag that surrounds the testicles), pain (in the groin that radiates to the inside of the leg), and impaired sperm count and movement.

What is the Incidence of Varicocele?

Varicocele is generally seen in 15-20% of men after puberty (adolescence) and in approximately 40-50% of men presenting with infertility.

The veins on the left side are connected at a steeper angle to the main vein into which the dirty blood flows, and the veins on the left side are slightly longer. Therefore, varicocele is usually seen on the left side (85%). The incidence in the right testicle is around 15%. It can occur in both testicles. A varicocele on one side can also affect the other testicle.

The Link Between Varicocele and Infertility

It is not known exactly how varicocele causes infertility, but there are some theories. Dirty blood accumulating backwards from varicose veins causes an increase in temperature and pressure inside the testicle. Due to the decrease in oxygen in these dilated vessels and back leakage from the kidney and adrenal gland; the accumulation of certain metabolic products at high rates adversely affects sperm production. As a result, sperm count and movement are reduced.

Symptoms of Varicocele

– Pain in the testicles (pain in the groin and inner leg)

– Swelling and feeling of fullness in the testicles

– Testicular shrinkage

– Infertility

– Visible dilated veins

– Palpable dilated veins

Diagnosis of Varicocele

The diagnosis of varicocele is physical examination. Classically, the diagnosis is made by palpation. Enlarged and tortuous veins (veins) can be felt. It is confirmed by Color Doppler Ultrasonography (USG). Sometimes Color Doppler Ultrasonography can be helpful in cases where physical examination is difficult.

Grading Varicocele

Subclinical varicocele: Not detected by physical examination but detected by ultrasound.

Grade 1 varicocele: Varicocele that is asymptomatic at rest and detected by straining (valsalva+).

Grade 2 varicocele: The collecting veins are palpable on examination (palpable).

Grade 3 varicocele: A varicocele that is noticeable from the outside (visible).

After the diagnosis of varicocele, a spermiogram (semen analysis/ semen analysis/sperm analysis) should be performed. Before the spermiogram, the patient should do a 3-4 day sexual abstinence. If sperm production is damaged, there is a decrease in the movement, number and structure of sperm. More than half of individuals with varicocele have an abnormal spermiogram.

Sometimes the sperm count can be very low. In these cases, some hormones (FSH, LH, testosterone, prolactin…) and other systemic diseases (thyroid, diabetes, cholesterol, etc.) should be checked.

By replacing the missing hormone in patients with hormone disorders; sperm count is increased and infertility can be treated.

Very rarely, there may be sperm production in the testes, but no sperm can be detected in the spermiogram. In this case, obstruction in the seminal ducts is investigated. Using endoscopic or microsurgical methods, this blockage can be opened and a child can be conceived with normal sexual intercourse.

Varicocele Treatment

Varicocele is the most treatable cause of male infertility. The treatment for varicocele is surgery. However, it is wrong to operate on every patient with varicocele. Therefore, varicocele surgery (varicocelectomy) should be performed in appropriate patients, with appropriate time and technique, by experienced specialists.

Who is Varicocele Surgery Performed?

– Men with varicocele complaining of infertility (impaired spermiogram)

– If varicocele causes shrinkage in the testicles; if one testicle is smaller than the other or if there is shrinkage in both testicles

– Patients with very severe pain (not responding to painkillers and scrotal elevation)

Varicocelectomy Surgery

It is an operation lasting approximately 30-60 minutes in which the varicose veins are ligated and the connection is canceled. It can be performed under general, spinal or local anesthesia through a 2 cm incision in the groin area.

The veins (internal, external spermatic veins and cremasteric vein) should be ligated; most importantly, the sperm duct (vas deferens), the testicular arteries (testicular artery) carrying clean blood and the lymph vessels should be protected. If the artery is ligated, complications such as testicular shrinkage may occur; if the lymph vessels are ligated, complications such as hydrocele (swelling of the testicular membranes due to fluid accumulation between them) may occur.

In the light of all this information, the most appropriate method in varicocelectomy surgery is microsurgical varicocelectomy surgery performed with microsurgery (microscopy). The success rate of microsurgical varicocelectomy performed by experienced surgeons is very high and the possibility of postoperative complications is minimal. (Except for some special cases, I almost always perform varicocele surgery with microsurgical technique).

Varicocele does not recur after a successful microsurgical varicocele surgery. After varicocele surgery, the spermiogram should be checked at 3, 6 and 12 months. Sperm production improves in approximately 70-80% of patients. Patients who are infertile due to varicocele have a pregnancy rate of approximately 50-70% after surgery.