Dear Dr. G,

My wife and I have been trying for a baby since we married three years ago and although we both understand that such a miracle takes time, we are anxious as there has been no positive outcome despite trying hard.

We recently went to see fertility specialists and while the test results were completely normal for my wife, my sperm count revealed some shortcomings.

The doctor said I have a low sperm count, and this is apparently due to some “warming worms” in my scrotal sacs

The doctor said the diagnosis is oligospermia caused by varicocele, and the way forward is to operate and reverse the warming effect of the dilated veins.

That said, although I have often noticed the painless swellings in the scrotal sacs which resemble a bag of worms, I have never imagined that this is the cause of my inability to father a child.

I am hoping to put Dr. G on the spot on the topic related to varicocele.

Can you please tell me what constitutes a low sperm count? How does a varicocele occur, and how does it impact on fertility?

Also, do I need an operation, and if so, how is it done? Additionally, what complications may I face and how successful would the operation be?

Thank you for helping me to debunk the mystery of the warming worms in my sac.

Warmest Regards
Warm William

One in twenty men are affected by decreased fertility, and a low sperm count is a common source of such a shortcoming. Basically oligospermia simply mean semen with a low concentration of sperm. The decrease in the number is often associated with poor morphology and motility, which is a condition known as OAT (Oligo-Astheno-Teratospermia).

The goalposts for this numbers game have shifted in the last few years. For many decades, the low count was defined as a concentration of less than 20 million sperm per ml of ejaculate. The World Health Organization then reassessed the criteria and established a lower reference point of 15 million sperm per ml, which is consistent with the 5th percentile of ejaculate for normal men. I guess this is a sign of the times.

The severity of oligospermia can also be further classified as mild, moderate and severe, ranging from 10 to 20 million, 5 to 10 million and less than 5 million, respectively. The severity of oligospermia helps clinicians to determine the mode of treatment, which can vary from lifestyle changes to test tube babies.

That said, although the sperm counts can fluctuate, and oligospermia can be a temporary setback, the causes of low sperm count could also be due to genetic conditions, age, previous mumps infections, sexually transmitted infections or ejaculatory duct obstruction and with that said, one of the most reversible causes of oligospermia is varicocele. This can affect up to 15% of sub-fertile men.

A varicocele is an abnormal enlargement of the veins within the loose bag of skin that holds the testicles, mainly with an unknown etiology. A varicocele is like the varicose veins of the legs, with the excess amount of blood in the scrotum being often described as a bag of worms in the sac. The severity of varicocele can be graded from 1 to 3.

Grade 1 is generally visible only on straining, while grade 3 is clearly visible when standing. The warming impact of the dilated veins may have an adverse impact in spermatogenesis, resulting in a decrease in sperm quality and male infertility.

The treatment of varicocele is only necessary in men who experience discomfort or an inability to father a child. The purpose of treatment is to ligate the dilated vessels and divert blood flow through other channels. Such surgical intervention can be an open operation, laparoscopic intervention, or percutaneous embolization. Varicocele operations are generally safe, however adversities such as infections, fluid collection, recurrence and even damage to the artery have been reported.

Varicocelectomy is well recognized to improve semen quality in 60%-80% of men and the improvement of fertility can range from 43% to 69% over two-year intervals. The publications revealed the most improvement in semen quality and pregnancy are mostly noted in repairs for more severe varicoceles. However, lifestyle improvement and female factors must also be taken into considerations when interpreting such results.

An American author and renowned thinker, Arnold H Glasgow once said:

“Improvement begins with I”. In the journey of a man towards fertility, the first step is often acknowledgement. A healthy lifestyle also ensures improvement in spermatogenesis. When the pressure is mounting, the emotional stress can only

have negative impact on the gonads. Infertile men who have recently discovered the “warming worms in his sac” responsible for a dwindling sperm count often put Dr. G on the spot for advice when it comes to contemplating operations.

To that, his view is that “reversing the warming sac may be the first step of semen improvement, but further improvements towards a healthy lifestyle and hard work between the sheets can ensure the miracle of pregnancy”.

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