I. The relationship between varicocele and fertility
It is now recognized that palpable varicocele can affect fertility and is one of the major causes of male infertility. It has been documented that about 40% of primary infertility and 80% of secondary infertility in adult men suffer from varicocele. The factors of varicocele affecting fertility are pathological changes and immunological factors.
1. Histopathological changes of the internal spermatic veins, testes and epididymis
Lesions of the internal spermatic vein reveal degeneration of the endothelial cells of the vessels, hyperplasia of the endothelium, and severe mechanization of the valves by hyperplasia of the mesothelium and smooth muscle of the valves, thus causing blood stagnation. The lesions of testicular injury showed detachment of spermatogenic cells, interstitial edema, and small interstitial vascular lesions. Epididymal lesion manifestation, interstitial edema, epithelial cell degeneration, and disorder of brush border arrangement on the surface of tubular epithelial cells.
2.Immune factors of seminiferous vein, testis and epididymis
In recent years, studies have confirmed that varicocele infertility is related to immune factors. It is found that there are anti-sperm antibodies in peripheral blood and semen of infertile spermatozoa, which enter the testis or epididymis and can interfere with the process of spermatogenesis and sperm maturation, leading to a decrease in the number of sperm or adhesion to the sperm membrane, causing morphological and functional abnormalities of sperm.
Second, the causes of infertility caused by varicocele
The causes of infertility caused by varicocele have not yet been fully elucidated, but may be related to the following factors.
1, blood stagnation in the spermatic vein, which increases the local temperature of the testis and degeneration of the spermatogenic tubules affects the occurrence of spermatozoa.
2, blood retention affecting testicular blood circulation and accumulation in testicular tissues affecting spermatogenesis.
3, left spermatic vein reflux to the renal vein blood, will adrenal and renal secretion of metabolites such as steroids, catecholamines, 5-hydroxytryptamine can cause vasoconstriction, resulting in premature sperm shedding.
4, varicocele on the left side can affect the function of the right testis, because there are rich traffic branches of the veins between the testes bilaterally, and the toxins in the blood of the left spermatic vein can affect the spermatogenesis of the right testis.
Third, the clinical manifestation
Most of the patients are found during physical examination without conscious discomfort, or are detected during consultation for infertility. Those who have symptoms mostly show discomfort or pain in the scrotum, and the pain may radiate to the groin area and lower abdomen, which is aggravated when standing and walking, and alleviated after lying down and resting.
Fourth, surgical treatment
The treatment of primary varicocele should be treated differently according to the presence or absence of clinical symptoms, the degree of varicose veins and the presence or absence of complications. For those who are mildly asymptomatic, they may not be treated, and those with mild symptoms and no complications of infertility may be treated by non-surgical methods such as holding up the scrotum, applying local cold compresses and reducing sexual stimulation. For those who have obvious symptoms or have caused testicular atrophy, decreased semen quality and infertility, they should be actively treated surgically. Surgical methods mainly include traditional open surgery, laparoscopic surgery and other methods of treatment.
1. Indications and contraindications for surgery.
Indications for surgery
If a person with infertile varicocele has abnormal semen examination, no other diseases affecting fertility are found in medical history and physical examination, normal endocrine examination and no abnormal findings in female fertility examination, regardless of the severity of varicocele, surgery should be performed as soon as the diagnosis of varicocele is established.
For those who have severe varicocele with obvious symptoms, such as feeling painful scrotal swelling after standing more, and physical examination reveals obvious shrinkage of testicles, surgery can be considered even if there is fertility and the patient has a desire for treatment.
Clinical observation shows that the incidence of prostatitis and seminal vesiculitis in patients with varicocele increases significantly and is twice as high as normal people, so if the above two diseases exist at the same time and prostatitis is not cured for a long time, varicocele surgery can be chosen.
For adolescent varicocele, since it often leads to pathological and progressive changes in the testes, it is now advocated that adolescent varicocele with testicular volume reduction should be treated with surgery as early as possible to help prevent infertility in adulthood.
For patients with mild varicocele, if the semen analysis is normal, they should be followed up regularly (every 1-2 years), and once there is abnormal semen analysis, testicular shrinkage and softening of texture, surgery should be performed promptly.
For patients with varicocele accompanied by oligospermia due to non-obstructive factors, simultaneous testicular biopsy and varicocele surgery is recommended to help perform assisted reproduction.
Contraindications to surgery
A history of abdominal infection and open pelvic surgery with extensive adhesions is a contraindication to high level ligation of the internal spermatic vein.
2.Open surgical treatment.
There are two traditional surgical routes as follows.
transinguinal canal internal spermatic vein high ligation, transperitoneal retroperitoneal high ligation
3, laparoscopic surgery treatment: laparoscopic spermatic vein high ligation has the advantages of reliable effect, small injury, no obvious scar, few complications, bilateral surgery can be performed at the same time, fast recovery, short hospital stay, etc. Therefore, many clinicians believe that laparoscopy is mainly suitable for those who have bilateral transcatheter laparoscopic high ligation, obesity, history of groin surgery and recurrence after open surgery. The various advantages of laparoscopic high ligation of the spermatic veins over open surgery.
4.Other treatment: In addition, there are also microscopic high ligation of spermatic vein, spermatic vein interventional embolization and other treatment methods, which are clinically applied.