Varicocele is a pathological phenomenon in which the veins of the spermatic cord become dilated, tortuous, and elongated due to poor reflux or regurgitation of blood caused by damage to the venous valves for various reasons. It belongs to the category of tendon tumor and tendon hernia in Chinese medicine.
The disease develops gradually with puberty, and the incidence is about 5%-20% in adult males and about 35% in infertility. The disease is usually found on the left side, accounting for about 95% of the left side and about 20% of the sides.
Why does varicocele cause male infertility?
It affects sperm quality mainly through the following aspects.
1, testicular temperature increases: testicles like cool and fear heat, by the contraction and diastole of the scrotum to regulate the temperature, generally slightly lower than the body temperature. Varicocele can increase the temperature of the testicles, thus affecting the ability to produce sperm.
2, testicular microcirculation disorders: testicular small arteries, micro-artery contraction, affecting testicular blood supply, will prevent the normal material exchange of spermatogenic tubules, prompting the destruction of spermatogenic epithelium .
3, testicular hypoxia: affect testicular function, sperm quantity and quality decline.
4, oxygen free radical damage: increased lipid peroxidation, resulting in sperm morphological changes, functional and metabolic abnormalities. Causes sperm membrane damage and impaired spermatogenic function
5, vasoactive substances toxic effects: the reflux of blood will be metabolites such as catecholamines, pentazocine, prostaglandins, etc. reflux into the testes. Toxic effects are produced, causing testicular toxicity and damage, affecting the spermatogenic process and killing sperm. Eventually the growth of the testes stagnates and begins to atrophy, and the quality of sperm decreases across the board.
6, nitric oxide mechanism: inhibit energy production, reduce sperm vitality, and affect testosterone synthesis. In addition, it can also produce peroxynitrite toxicity.
7, testosterone secretion disorder: testosterone secretion decreases causing damage to interstitial cells and affecting hypothalamic-pituitary-gonadal axis function.
8, autoimmune effects: damage to the immune barrier of the testicular epididymis and increased levels of anti-sperm antibodies (AsAb).
The rate of AsAb positivity is closely related to the severity of sperm curvature, and the more severe the testicular damage, the more severe the local immune response.
9. Abnormal increase in apoptosis: In the semen of patients with seminiferous varicose veins, many round cells can be seen, most of which belong to immature spermatogonia. Normal apoptosis is about 25% to 75%. Increased apoptosis of spermatogenic cells (primary spermatocytes and round spermatocytes are most sensitive to heat) leads to decreased fertility or infertility.
10.Abnormal acrosome reaction
11.Epididymal injury: Infertility due to seminiferous curvature is not only related to structural and functional abnormalities of the testes, but also may be closely related to pathological changes in the structure and function of the epididymis.
The infertility of men caused by seminal flexure should be the result of a variety of factors acting together, with various factors complementing each other and interconnecting, acting jointly on the organism and eventually leading to abnormal sperm morphology and functional disorders. The effect of one factor alone cannot fully explain the various pathological changes in the testes of male infertility patients caused by seminiferous varicose veins.
What are the discomfort symptoms of spermatozoa?
The main symptom is a feeling of swelling and vague pain in the scrotum, which can radiate to the lower abdomen and waist, and the symptoms are aggravated after standing for a long time or exertion, and reduced after lying down and resting. A significant number of patients have no discomfort or have mild discomfort, which is not brought to the attention of the patient and is often found during physical examination.
How to diagnose and determine varicocele?
Clinical diagnostic criteria There are typical local signs of seminiferous varicoceles in the scrotum and varicose veins in the shape of earthworm masses on palpation, which fill up when standing and disappear after lying down.
Grade I (mild): not obvious on palpation, but may appear on Valsalva test.
Grade II (moderate): dilated veins are extremely palpable on palpation, but not visible.
Grade III (severe): dilated veins can be seen protruding from the scrotal skin when the patient is standing, like a mass of earthworms, and are easily palpable.
Ultrasound is clinically well able to measure the width of the vein and the return of blood, so it is done when seminiferous varicosities are clinically suspected.
Ultrasound diagnosis, classifies varicocele into 4 grades, namely subclinical varicocele, clinical varicocele grade I, grade II and grade III.
Subclinical varicocele: negative clinical palpation and reflux in the spermatic veins on ultrasound, maximum internal diameter of spermatic veins DR: 1.8-2.1 mm, signal reflux duration TR: 0.8-2s.
Clinical type varicocele grade I: positive clinical palpation and DR on ultrasound: 2.2-2.7 mm, TR: 2-4s.
clinical type of varicocele grade II: positive clinical palpation and DR on ultrasound: 2.8-3.1 mm, TR: 4-6s
Clinical varicocele grade III: positive clinical palpation and DR≥3.1mm on ultrasound, TR≥6s.
Treatment of varicocele
1.Surgical treatment
Surgery can improve the semen quality in 65%-70% of patients, but the pregnancy rate is still not high. There is still a lack of observational evidence on the role of seminal varicocele surgery on fertility in a large sample of data. It has been suggested that surgery has not improved fertility in patients with varicocele infertility. It has also been reported that sperm count and motility decreased rather than improved after surgery.
The American Urological Association (AUA) report on varicocele and infertility clearly states that patients with varicocele who have a fertility requirement should be treated only if the following four points are met.
(1) The varicocele is palpable on physical examination of the scrotum.
② The couple is diagnosed as infertile.
③The female partner has normal fertility or there is a treatable cause of infertility.
④The male partner has abnormal semen parameters or abnormal sperm function tests.
Those who are not currently planning to have children but need to have children in the future and can palpate varicocele with abnormal semen also need treatment. Patients who have already had children or do not want to have children, or patients with normal semen parameters are not included in the recommended treatment group.
What are the complications of seminal varicocele surgery?
Scrotal testicular edema (incidence 3%-25%), subcutaneous emphysema, testicular syringomyelia, testicular atrophy (usually not present).
Recurrence rate of spermatocele surgery?
The recurrence rate of surgery has been reported abroad to be 0% ~ 13%, mostly occurring within 3 to 6 months after surgery.
What are the reasons for the failure of surgery to improve the conception rate?
Unsuccessful surgery, still varicocele; no change in semen quality (reasons: late surgery, incomplete ligation, recurrence); semen quality improves but still fails to meet fertility requirements; blood-testis barrier is destroyed, producing AsAb and causing immune infertility.
2.Conservative treatment
Indications: Infertile patients with varicoceles below II°; patients requiring non-surgical treatment and those with poor surgical efficacy requiring herbal treatment; treated infertility patients; infertility patients with severe varicoceles for improving sperm quality after surgery; infertility with severe varicoceles, but one of the sperm density or vitality is still acceptable, may try to treat with herbal medicine first.