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Arie Parnham, MBChB, FRCS (Urol)
Consultant Urologist and Andrologist at The Christie NHS Foundation Trust, The Christie NHS Foundation Trust
Category:
Male Factor
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.
Varicocele is in the scrotum and the cord, which supplies blood to and from the testis itself. It’s in the veins that take away the blood from the testis. Why does it happen? Essentially, normal veins have valves that ensure that your blood flow continues in one direction, but in people with varicose veins or varicocele, those valves that ensure that one-way direction do not operate as they should. As a consequence, you get a pooling of blood.
How common are varicose veins? About 1 in 7 men will have a varicocele, and around 1 in 4 men with a varicocele will have some degree of infertility. Therefore, around 40% of infertile men will have a varicocele, so it is something that is associated with infertility.
How do you diagnose a varicocele? There are many ways of checking it, starting with a subclinical examination, they should look at your testes, and they will look for a varicocele. There are lots of different ways to look for varicocele. It’s possible to grade them to some degree. For instance, varicocele can be subclinical, it has to be found during an ultrasound scan. You can have grade 1, and you can feel the varicocele, but only during special manoeuvres called a Valsalva manoeuvre. Then there’s grade 2, and those are the ones that are palpable at rest. The grade is a visible varicocele, and you don’t need to do anything, you can see it without touching it.
The slight problem with examination is that if you go to one doctor, he may say that he feels something and then you might go to another doctor who does the same thing and say that he is not convinced. If it’s visible, then it’s visible, that’s quite easy, but the ones with a grade 1 or maybe even grade 2 where you get a bit of discrepancy, and people struggle. Therefore, the best thing to do is to get an ultrasound scan where the parameters can be measured and checked.
The EAU (European Association of Urology) Guidelines classify as a varicocele a maximum diameter of more than 3 millimetres in the upright position. In other words, standing during the Valsalva manoeuvre with some reflux (the blood is going the wrong way) for more than 2 seconds.
An ultrasound scan is a bit more accurate than an examination. If there’s a suspicion of a varicocele, an ultrasound scan would be advised, and it should be done by someone who’s used to scanning testes and looking for varicocele and would do something similar to what’s described in EAU guidelines.
Varicocele are associated with certain things, for instance, they’re associated with male subfertility or problems with fertility in men. They are also associated with people whose testicles didn’t grow, they go through adolescence or puberty, but their testicles have failed to grow, so they haven’t developed quite as they should. Varicocele can cause some pain and discomfort, and often that pain is kind of a dull, dragging, heavy sensation. It’s also associated with low testosterone levels.
Men who undergo an infertility investigation will have a semen analysis and if you’ve identified to have an abnormal semen analysis and you’ve got a low sperm count, then that may be improved by removing varicocele. There were 15 studies put together, reported in one of the papers, that looked at men who’ve got azoospermia with palpable varicocele. They performed surgery on them to correct their varicocele, and then they looked to see if they can find sperm in the ejaculate whereas previously they didn’t have any actually in this 45% of men or roughly about 43.9% of men, ended up having sperm within the ejaculate at a later date and that sperm could then be used for IVF or ICSI. The success rates for that were around 15%.
Another study looked at men with no sperm when they were ejaculating and had a palpable varicocele. In this study, they compared people who had a varicocele repair versus those that didn’t have a varicocele repair. One group had surgery on their testes that were opened to see if they could pick out sperm, the success rate in finding sperm in these patients was better than in those who hadn’t had a varicocele repair. It was 60% versus 40%, and the live birth rates were better, 75% versus 50%. This shows that a varicocele might help in people who’ve got low sperm counts, and even maybe in those people who have no sperm in the ejaculate.
Another thing worth mentioning is DNA Fragmentation. One of the studies was performed on 41 patients who had high DNA fragmentation, and then they looked at their chances of IVF and ICSI. They found that with IVF those that had high DNA fragmentation had a reduced chance of IVF at 1.92 and those with ICSI less successful at 1.49. Therefore, if you have DNA damage, your chances of IVF or IVF success are reduced. What’s that got to do with varicocele?
Another study compared men who have got varicocele and those that didn’t. They looked at 55 patients with clinical varicocele. They found that those patients who had a clinical varicocele had a higher DNA fragmentation rate than those who didn’t have a varicocele, at 5 to 10% versus 35%. Having a varicocele means that you’re more likely to have a higher DNA fragmentation rate. That suggests that if a varicocele repair is performed, your DNA fragmentation can also be improved.
One more study looked at 37 men who underwent a microsurgical varicocelectomy. They looked at their DNA fragmentation, and they found that it went from around 30% and it improved to about 25%. They had reduced DNA fragmentation after their microsurgical varicocele.
There are 2 options to treat varicocele. The first is to perform surgery, and the other is to have a radiological procedure called embolization. Surgical options involve cutting some way and then using either a camera put into the amp into the tummy to kind of find the veins and tie them off and sometimes using a microscope to identify the dilated veins or the varicocele and then tying those abnormal veins off.
There are also different surgical approaches, there is a scrotal approach which is going through the scrotum, the inguinal approach, which means going in the groin, Open Retroperitoneal high ligation, which goes a bit higher, laparoscopic which is a keyhole and then Microsurgical subinguinal, which is probably a gold standard of surgical options. This has got the best results in terms of the surgical option.
The radiological options are also Antegrade sclerotherapy and Retrograde sclerotherapy and the other option is retrograde Embolisation, which is the gold standard and is most often performed. In a radiological department, they would put a tiny little access port into your neck in the most common circumstance and then feed a tiny wire down into the testicular vein and then block it off with a tiny metal coil which will then cause that vein to shrink away, it’s minimally invasive.
Comparing the rates between a microsurgical subinguinal varicocele repair, the chances of it coming back are somewhere between 1-4%, while with radiological embolization, the chances of it coming back are around about 3-12%. The benefits of the surgery are that the rates of complications are low, it has the lowest recurrence rate, and it probably has the strongest evidence as there were a lot of studies performed on that.
The benefits of Radiological embolization are that your complication rate is low, and you can rapidly return to normal activity, while with surgery, you usually need a couple of weeks off and to take painkillers. With an embolization, you can treat both sides, whereas, with surgery, you would often be very cautious about doing both sides in case something went wrong on one side. With embolization, you have a lower risk of damaging the blood vessels in the testicle. You can repeat it after an embolization as well and it’s also fairly readily available.
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’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.
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.
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.
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.
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.
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.
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.
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.
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