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What about treatment? Does it work? There seem to be many opposing views on this.
If the varicocele is truly the cause of the infertility and the man's poor sperm quality (oligo-, astheno- , teratospermia), then it usually will not respond favourably to any other ministrations than operation. A sub-inguinal, microsurgical varicocelectomy is then the treatment of choice. When performed at centers of excellence in carefully selected patients, results are very good, and there is marked improvement in sperm counts and spontaneous pregnancy rates. There is usually no need for any medicines to improve sperm counts. The operation is generally performed as a day care case under epidural, spinal, or local anaesthesia, and the patient is discharged the same day or the next morning.
Microsurgery for varicoceles requires microsurgical training for surgeons, assistants, and staff, special operation theatre infrastructure, and instrumentation. The use of optical loupes (magnifying spectacles) is not microsurgery. Microsurgery requires a special operating microscope (see Figure 5). All urologists, andrologists and other surgeons offering surgery for varicocele are not trained microsurgically. Varicoceles can be operated upon even without a microscope, like it was done in the past, but the results are just not as good as those obtained with microsurgery that is performed by skilled microsurgeons with great experience.
Figure 5: Dr. Sudhakar Krishnamurti performing varicocele microsurgery, and (below), a close-up of the operating microscope
Microsurgery allows selective ligation of the veins and avoids injury to the testicular artery and lymphatic channels in the spermatic cord, thus preventing post-operative complications such as testicular damage, atrophy, azoospermia, hydrocele formation, etc.. Recurrence rates with microsurgery are very low too.
| All urologists, andrologists and other surgeons offering surgery for varicocele are not trained microsurgically. |
Other operative approaches, including laparoscopic varicocelectomy, are much less effective than microsurgery, and carry significantly higher complication rates.
Will patients require IVF (in vitro fertilization) or other ART (Assisted Reproductive Technologies) after varicocele treatment? Or is it better to avoid varicocele surgery altogether and go in for these procedures
instead?
The disrepute that varicocele surgery has achieved is partly deserved, but mostly undeserved. Surgeons who are not specialized in this kind of microsurgery are unable to offer the same results as those who are trained to do this, and this brings varicocele surgery on the whole into disrepute. At the best centers, fertility rates of 50 % at one year and 70 % at two years after operation can be achieved. If the operation works, the man can go on to have many children. Figure 2 shows one such patient.
However, the reason why many men with varicoceles are not offered varicocele microsurgery as an option at all, and are persuaded instead to undergo assisted reproductive technologies (ART) like IUI (intra-uterine insemination), IVF (in vitro fertilization) or ICSI (Intra-Cytoplasmic Sperm Injection), is that many of these men have landed up at infertility clinics where the doctors and staff are only trained in such therapies. Most infertility centers do not have an andrologist or uroandrologist on their staff, and often, the man is not even examined physically. He is only asked to furnish samples of semen on the dates his partner ovulates. It is in the interest of these centers to malign varicocele surgery and persuade the patient to undergo other treatments instead. Also, some of these centers see patients who have failed varicocele surgery performed by regular surgeons, and therefore think that it doesn't work. It must be noted that the high success rates boasted with many assisted technologies at infertility centers is a cumulative success rate after many attempts, and that the success rate per attempt (all technologies across infertile women of all ages combined) is hardly ever greater than ten to twenty per cent at most of these centers. The other point to note here is that if a varicocele operation is performed at a center of microsurgical excellence, the man is able to father many children naturally thereafter (see Figure 2) and usually will not need any further medical assistance whatsoever. By contrast, if the first pregnancy in a varicocele patient has been achieved by treating his semen sample and his partner, rather than by treating his varicocele, these torturous ART processes have to be repeated every time the man wants to father a child, until a pregnancy ensues. Each 'cycle' requires the woman to take medicines and injections to induce ovulation (egg release) for several days mid-cycle each month. The lady is also subjected to serial ultrasound scans to confirm ovulation. And then, of course, there are the pokes to pick up the ova (eggs) and all that. Many of these women are working women and some have to travel to the bigger towns to undergo all this. Not too many doctors explain all this to the patient.
Also, it must not be forgotten that the treatment of a varicocele is not for fertility alone. The varicocele is already harming the testis in an infertile male. If only the semen sample is treated, and not the varicocele, this damage continues and the testicular damage becomes worse. Over time, sperm counts may decline dangerously, and testosterone levels may drop, causing additional problems. Also, on the whole, ARTs like IVF and ICSI (Intra-Cytoplasmic Sperm Injection) carry much higher costs than varicocele microsurgery.
| Most infertility centers do not have an andrologist or uroandrologist on their staff, and often, the man is not even examined physically. |
The surfer must beware of the websites/ specialists that do not address these aspects, and engage instead only in false propaganda that suits their interests more than the patients'.
Lastly but importantly, in male dominated societies, it is common for men to shy away from treatment for their own infertility. Instead, they persuade the partner to seek treatment. This is unfair, unscientific, and, as has been discussed above, is not in the best interests of the couple.
To summarize, it may be quite accurate to state here that if, in an infertile couple, there is a varicocele male factor that is impairing semen quality and causing infertility, that varicocele must be treated microsurgically at a center of excellence. This is especially important if the woman is normal.
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| Sex is Not a Four-Letter Word |
| Publisher: Rupa & Co., India |
| A sex edutainment book by Dr. Sudhakar Krishnamurti... |
| Check with a good bookstore near you!OrBuy online at |
| WWW.SINAFLW.COM |
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