Dear Dr G,

My wife and I are both 32 years old and have been married for three years.

We understand we started late and have been trying hard for a baby since we were married with no positive outcome.

We are also anxious during the festive seasons when well-meaning relatives put tremendous pressure on us, especially my poor wife.

She has been shouldering the burden of not being able to have a child in silence, as her tests with the gynaecologist were all normal.

I also went to see fertility specialists, to my horror discovering my sperm count revealed some “shortcoming”.

The doctor told me I have oligospermia caused by varicocele.

Although I often notice painless swellings in my scrotal sacs which resemble a bag of worms, I never imagined this could be the cause of my inability to father a child.

I am hoping to put Dr G on the spot on varicocele and its effects.

Can you please tell me what constitutes a low sperm count?

How does varicocele occur? And how does it impact fertility?

Do I really need an operation? If so, how is the operation done?

What complications may I face? And how successful would the operation be?

Warmest Regards

Warm William

Varicocele is an abnormal enlargement of the veins, known as the pampiniform venous plexus, within the loose bag of skin that holds the testicles.

This plexus of veins drains blood from the testicles back to the body. In other words, it is like the varicose veins of the legs, with an excess amount of blood stagnating in the scrotum.

Varicocele is more common in the left side, unlike the right side, with the venous system in the left draining blood via the renal vein before returning to the inferior vena cava.

Varicocele is often asymptomatic and most men are oblivious to it. However, it may be noticed as soft lumps, usually above the testicle, rather than presenting as heaviness in the scrotum.

A larger varicocele may even be 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 exact aetiology of varicoceles is unknown, but three main theories have been proposed as the anatomical cause.

The first is the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, resulting in the venous dilations.

The second is the venous insufficiency of the valve of the veins, resulting in the constant backflow of blood.

The third is due to excessive pressure in upstream arteries, created by a “nutcracker syndrome”, a rare vein compression disorder.

Varicocele is common as it affects around 15% to 20% of all adult males.

Up to 35% to 40% of men evaluated for infertility are also noted to have varicocele.

The warming impact of the dilated veins may have an adverse impact on sperm creation, resulting in decreased quality and possible infertility.

The goalposts for this “numbers game” have shifted in the last few years. For many decades, low counts were defined as concentrations below than 20 million spermatozoa per millilitre of ejaculate.

The World Health Organization reassessed the criteria and established a lower reference point of 15 million/ml.

Although sperm counts can fluctuate, and oligospermia can be a temporary setback, the causes can be genetic conditions, age, previous mumps infections, sexually transmitted infections, or ejaculatory duct obstruction.

One of the most reversible causes of oligospermia is varicocele.

One in 20 men are affected by decreased fertility.

Oligospermia simply means semen with a low concentration of sperm. The decrease is often associated with poor morphology and motility, a condition known as OAT (Oligo-Astheno-Teratospermia).

However, some men with varicocele are fertile, some have sperm that are normal in shape and move normally but are compromised in function, and some have sperm with abnormal numbers, shapes and motility.

Treatment of varicocele is only necessary if there is discomfort or 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 embolisation.

Varicocele operations are generally safe, however adversities such as infections, fluid collection, recurrence and even damage to the artery have been reported.

Varicocelectomy is known to improve semen quality in 60%-80% of men and the improvement of fertility can range from 43% to 69% over a two-year interval.

The publications revealed the most improvement in semen quality and pregnancy was noted in repairs for more severe cases of varicocele.

However, lifestyle improvement and female factors must also be taken into consideration when interpreting such results.

A healthy lifestyle also ensures improvement in spermatogenesis.

When the pressure is mounting, emotional stress can only have negative impact on the gonads.

When put on the spot for advice, Dr G says: Reversing the warming sac may be the first step towards semen improvement, but a healthy lifestyle and hard work where it matters can bring about the miracle of pregnancy.

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