Dear Dr. G,

My wife and I have been waiting for the Year of the Dragon to have a baby since we married in 2019.

We have been living a healthier life and exercising on a regular basis, and we started having more frequent sexual intercourse since the middle of last year and have been rather surprised at having no outcome.

We both understand the miracle of conception takes time; however, we are both under thirty-years-old and my wife should really conceive easily.

My wife and I recently went to see the fertility specialists and while the tests were completely normal for my wife, there have been some shortcomings in my sperm count.

The doctor said I have a low sperm count, and explained that the diagnosis is OAT Syndrome caused by varicocele, and the way forward is to operate and reverse the warming effect of the dilated veins.

I have often noticed the painless swelling in the scrotal sacks which resemble a bag of worms, but 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 of the varicocele; can you please tell me what constitutes a low sperm count? What exactly is the OAT Syndrome?

Also, how do varicoceles occur and how does it impact fertility?

Finally, do I really need an operation and if so, how is it done? What complications could I face and how successful would the operation be?

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

Warmest Regards

Warm William

The quality of a man’s reproductive ability hinges on the quality of his semen and when it comes to this, the goalposts for this numbers game have shifted in the last few years.

For many decades, a low sperm count was defined as a concentration of less than 20 million sperm per millilitre of ejaculate. The World Health Organization has since reassessed the criteria and established a lower reference point of 15 million sperm per millilitre. This is consistent with the 5th percentile of ejaculate for normal men.

This is generally due to the overall declining amount of sperm in men. The severity of oligospermia is 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; this may vary from lifestyle changes to test-tube babies.

One in twenty men are affected by decreased fertility, and a low sperm count is a common source of such shortcomings. Oligospermia simply means semen with a low concentration of sperm. This decrease is often associated with poor-quality sperm, poor morphology and motility, a condition known as OAT or Oligo-Astheno-Teratospermia. Apart from oligospermia, poor motility of sperm is described as Asthenospermia, while Teratospermia depicts a defective morphology of sperm. OAT syndrome occurs when the overall number, motility and morphology of sperm is compromised.

OAT syndrome can often be a temporary setback, as lifestyle and nutrition can influence the quality of semen. Other causes of low sperm counts are genetic conditions, age, previous mumps infections, sexually transmitted infections or ejaculatory duct obstruction. One of the most reversible causes of oligospermia is varicocele, affecting 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 unknown etiology. A varicocele is like varicose veins of the legs; the excess amount of blood in the scrotum resembles a sac of abnormal lumps in the groin, often described as a bag of worms in the sac. The severity of a 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 on spermatogenesis, resulting in decreasing sperm quality and male infertility.

The treatment of varicocele is only necessary in men who experience discomfort or report 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.

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 most improvement in semen quality and pregnancy are mostly noted in repairs for more severe varicocele. However, lifestyle improvements and female factors must also be taken into consideration when interpreting such results.

Although a healthy lifestyle is necessary to ensure improvement in spermatogenesis, other factors such as varicoceles should be investigated. Infertile men who have discovered the “warming worms” responsible for their dwindling sperm often put Dr G on the spot when it comes to contemplating surgery.

His view is that as improvement begins with I, it is time to embark on the operation to turn warming worms in the sack to cooling dragons in the womb.

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