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Varicocele and male infertility – diagnosis and prospects

Arie Parnham, MBChB, FRCS (Urol)
Consultant Urologist and Andrologist at The Christie NHS Foundation Trust, The Christie NHS Foundation Trust

Male Factor

From this video you will find out:
  • What is a varicocele?
  • How common is it?
  • How is a varicocele diagnosed?
  • What causes a varicocele to develop?
  • What methods of treatment are used for varicoceles?
  • What is the effect of varicocele repair for sperm DNA fragmentation?
  • What is the effect of varicocele repair in azoospermic patients?
  • How successful is varicocele surgery?

What is the relationship between varicocele and infertility? 

In this session, Arie Parnham, MBChB, FRCS (Urol), urologist and a national expert in surgery for penile cancer, Consultant Urologist & Andrologist at The Christie NHS Foundation Trust. Mr Parnham has discussed varicocele, diagnosis, symptoms and treatment options.

What is the relationship between varicocele and infertility?  - Questions and Answers

I have had 3 semen analysis in the last 6 months. I had lower motility on the 1st test, 22% DNA fragmentation, higher mortality on the 2nd test, and higher DNA fragmentation 28%. On the 3rd test, lower motility, DNA fragmentation down to 23%. I was just diagnosed with varicocele. Is flip-flop motility DNA unusual?

The answer to that is no, I don’t think it is. One semen analysis to another can vary quite significantly. It depends on so many other different factors. For instance, if you have an illness over some time, then in between those or just before a semen analysis, you can find a significant change in your fertility. You might find that your sperm count goes down, your motility goes down, it might change your DNA fragmentation.

If you look at DNA fragmentation while you get it, that’s still something that’s been worked on, but it’s looking at things like these environmental factors such as heat which is part of varicocele’s contribute to increasing the temporal or poor temperature regulation of the testicles, so it’s not abnormal. When we do semen analysis, we just don’t do one, we do several because then we get a bit of an idea and a trend of what is going on with your fertility. 

I have 4 varicocele on my left testes, but I also have 99% MAR (antibodies), which should be at least 40%. Will removing the varicocele make any difference to this?

I’m not sure if it necessarily would. If you look at what you’ve described there, I’d suggest that you’ve got a varicocele, and you’ve got your antibodies, I couldn’t definitively say that it would make a difference to that level. If you’ve got infertility, and that’s been ongoing, then preparing your varicocele would likely improve your chances going forward.

Can varicocele still go away on its own?

Not usually. The fact is that usually your the veins themselves aren’t working properly, and as a consequence of that, they don’t repair themselves. Most of the time, they don’t. You can do certain things to help mitigate against your varicocele. For instance, some people find that wearing a kind of snug underwear can sometimes help, but then that equally has the opposite effect of heating your testicles which you don’t want. It depends on what your problem with your varicocele is. If it’s fertility-related, then the answer usually is you probably need it correcting.

Can you get this minor surgery on the NHS, or you have to go private?

You can get it on the NHS. I think you have to find certain centres that will do it. If you’re referred to your local fertility unit on the NHS, then they should be able to offer you at least one of those options that we’ve discussed today. Whether that be embolization or Microsurgical varicocelectomy. The answer is yes, you can.

Are varicoceles very common in men?

As I said at the beginning, in men, overall varicoceles occur in around  1 in 7 in men, so they are relatively common and certainly, they’re more common in people who’ve got infertility.

Are varicoceles more common in older men?

They probably are over time, and just as varicoceles in women are more common as you get older, varicoceles will be the same, you would imagine they would be more common in older men as well.

I have received conflicting advice on whether it is safe trying to conceive naturally with DNA fragmentation of 15%. One fertility specialist has said that there is a higher risk of miscarriage. Others say the evidence is not that convincing. If the DNA fragmentation is borderline 22%, they say not to worry. Any advice? Is it better to wait for surgery and hopefully reduce DNA fragmentation or keep trying and go for the procedure?

DNA fragmentation is kind of an evolving area within male infertility. While you’re getting this kind of variation in advice is probably, because it is evolving, and I don’t think there are any definitive answers on this. We know that if you’ve got a higher DNA fragmentation rate, your chances of having successful IVF or ICSI is lower. That would be one reason why you might find that doesn’t work. These studies are small, they’re not like massive studies with hundreds or thousands of patients, so you can’t definitively say that. 

As far as I’m aware, there aren’t large randomized trials looking at it, so I guess it depends on what you’ve got. If you’ve got a varicocele, and you’re having issues with conceiving naturally, then I guess one of the things you might want to consider is a varicocele repair but will it make a massive difference, no one could promise you that if that makes sense.

Do you know how I can reduce my MAR antibodies?

That’s a difficult one, but the short answer is no. There’s not any obvious way to reduce our antibodies. Many people will say dietary supplements and things like that, but there’s no convincing way that I’m aware of.

If we had successful surgery removing varicoceles. Is it possible that they will happen again?

They can, and it depends on what you choose. If you choose surgery, that’s probably your best chance of it not coming back. Based on the data that’s available that somewhere between 0 and 4% of them coming back. So, the answer is yes, they can, that’s the case with any surgery, and nothing’s ever 100%, but that’s probably your most reliable way. The recurrence rates and embolization are between 4% and 11%, so they’re not vastly different. 

Arie Parnham, MBChB, FRCS (Urol)

Arie Parnham, MBChB, FRCS (Urol)

Arie Parnham, MBChB, FRCS (Urol) is a urologist and a national expert in surgery for penile cancer and men’s health issues (including erectile dysfunction, penile implants, penile reconstruction, Peyronie’s disease, Male infertility and sexual dysfunction). He is one of only three surgeons in the North West and North Wales that manages penile cancer in the NHS (all of which are based at The Christie). He also provides support for men dealing with the consequences of their cancer treatments including the insertion of penile implants for erectile dysfunction. He graduated from Birmingham University in 2005 and went on to complete his surgical and urological training in the West Midlands, Oxford and the North West. He has worked at three specialist centres, and completed a prestigious fellowship at Europe’s largest dedicated andrology unit dealing with penile cancer and complex andrological conditions. He has also completed observerships at Weil Cornell (New York) in male infertility and pelvic surgery at Leuven University Hospital, Belgium. He is the only surgeon in the North West and one of only four in the country that has completed the Weil Cornell microsurgical training for male infertility (The surgeons at Weil Cornell were the pioneers and leaders in microsurgical fertility techniques including micro-TESE, vasovasotomy, epididymovasostomy and no scalpel vasectomy) Mr Parnham has published extensively on subjects including penile cancer, erectile dysfunction, Peyronie’s disease, male infertility and other disorders of male sexual health. Consequently he is regularly invited to talk internationally on such subjects. He is currently a member of the European Association of Urologists guideline panel for male sexual dysfunction, developing guidance for the whole of Europe on this subject. He is a reviewer for 4 journals, a subeditor and an invited member of the publication steering committee for the Journal of Sexual Medicine. Mr Parnham currently runs a module for the Royal College of Surgeons on operative skills in urology. He is an invited faculty for six national and international courses on urology and is an honorary lecturer at Edgehill University.
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Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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