It is an indisputable fact that male fertility continues to decline! It has been documented that male sperm quality is declining at a rate of one percent per year, and this is not alarming! This rate is alarming, male fertility has reached the most dangerous moment! Every human life is inextricably linked to a small “tadpole”. However, some diseases can cause these “tadpoles” to lose vitality or even die, varicose veins are one of them. So, what exactly is varicocele? And what causes it? Please read this article carefully, I think most of the questions about varicocele can be found here.
1. Q: What is varicocele? What is the cause of the disease?
As the saying goes: Flies do not bite seamless eggs. A man’s “balls” are wrapped in layers of tissue, so naturally there are no seams and no flies to bite. But this does not mean that your “balls” safe, this is not, something came in. Yes, it’s an earthworm! Of course, this earthworm is not another earthworm, it will not loosen the soil inside your scrotum, nor will it eat your “balls”, in fact it is a strip in the spermatic vein, but it is now thicker and more tortuous, so it looks like an earthworm, and there is a more professional way to call this condition: varicocele. Varicose veins are abnormal dilatation, elongation and tortuosity of the trapezius plexus in the spermatic cord. It is a common condition among men.
The common causes of varicocele are.
(1) People are often in an upright position for their daily activities, and the venous blood in the spermatic cord must overcome its own gravity to flow back upward from below.
(2) Weakness of the vein wall and adjacent connective tissue or underdevelopment of the levator muscle, which weakens the dependency around the intra-seminomatous vein.
(3) Defective or malfunctioning spermatic vein valves leading to blood reflux.
In addition, the incidence of varicose veins on the left side is significantly higher than that on the right side, which is mainly related to the anatomical characteristics of the left spermatic veins and their adjacency.
(1) The left internal spermatic vein has a long stroke, is located behind the sigmoid colon, and enters the renal vein at a right angle, with high reflux resistance.
(2) Proximal clamping phenomenon: the superior mesenteric artery forms an angle with the abdominal aorta or the left renal vein is congenitally malformed after the abdominal aorta, which compresses the left renal vein, thus causing the normal blood return to the left internal spermatic vein to be obstructed to form the proximal clamping phenomenon.
(3) Distal clamping phenomenon: the left common iliac vein is compressed by the right common iliac artery, so that the blood return of the left vas deferens is obstructed to form the so-called distal clamping phenomenon.
2.Q: Why do varicose veins cause infertility?
Varicocele is related to abnormal semen, testicular atrophy, reduced testicular perfusion and testicular spermatogenic dysfunction, etc. The specific mechanisms may be
(1) High temperature. Varicocele can increase testicular temperature and CO2 accumulation in testicular tissues, leading to spermatogenesis disorders and resulting in reduced testosterone synthesis by testicular interstitial cells.
(2) High pressure. Elevated spermatic vein pressure leads to inadequate testicular perfusion and hinders testicular metabolism.
(3) Hypoxia. Poor venous blood return caused by varicocele can lead to testicular stasis and hypoxia, and carbon dioxide accumulation, which interferes with the normal metabolism of the testes and affects spermatogenesis and maturation.
(4) Effects of toxic substances. In varicocele, the blood returning from the adrenal gland may flow backwards along the spermatic vein, bringing the metabolites secreted by the adrenal gland and kidney, such as steroids, catecholamines and 5-hydroxytryptamine, into the internal spermatic vein, leading to the impairment of sperm maturation in the testis.
(5) Damage to the epididymis in varicose veins causes the spermatozoa to gain less power to move forward and their speed decreases.
(6) There are traffic branches between the spermatic veins on both sides, which affect the varicose lesion of the opposite spermatic vein.
3.Q: What is the incidence of varicocele?
Overall, the incidence of varicocele is about 20% in the general male population and about 40% in infertile men. The disease is mostly seen in adult males and relatively rarely in adolescents. Domestic literature reports that the total incidence of varicocele in adolescents aged 6 to 19 years is 10.76%. Varicocele is a vascular lesion, mostly found on the left side, accounting for 85% to 90%, and 10% bilaterally. Varicocele is the first cause of male infertility, accounting for 35% of patients with primary infertility and 50%-80% of patients with secondary infertility.
4.Q: What are the common symptoms of varicocele?
Varicocele is usually asymptomatic and is mostly found during routine physical examinations, or painless worm-like masses in the scrotum are found during self-examinations, or during visits to the doctor for infertility. Varicocele brings men pain mainly with symptoms such as swelling, hidden pain and discomfort, which can be aggravated after standing or walking for a long time and can be relieved or disappeared after lying down. It can be combined with varicose veins of lower limbs, hemorrhoids and other diseases.
5.Q: How to diagnose varicose spermatocele?
Varicocele can be diagnosed basically by physical examination and ultrasound, but there is uncertainty about its relationship with scrotal discomfort, pain, fertility and androgen, so attention should be paid to the combination of varicocele with other diseases that cause the above symptoms, especially psychological disorders manifested by somatic symptoms. At present, varicocele is clinically classified into four levels in China. Subclinical type: The varicocele cannot be found by palpation and when the patient holds the breath to increase the abdominal pressure (Valsalva test), but minor varicocele can be found by color Doppler examination.
Grade I: varicose veins can be palpated only after holding the breath and increasing abdominal pressure (Valsalva test), while the veins cannot be palpated at other times. The internal diameter of the spermatic vein is 2.1-2.7 mm.
Grade II: Can be palpated at rest, but not seen. The internal diameter of the spermatic vein is 2.8-3.0mm.
Grade III: The inner diameter of spermatic vein is ≥3.1mm, which can be felt and seen at rest.
6.Q: Which varicocele needs surgery?
① testicular shrinkage, softened texture, smaller volume of the affected testicle than the opposite side, less than 20% of the volume.
② abnormal semen examination.
③The related symptoms (such as swelling and pain in the perineum or testicles) associated with varicocele are more serious and obviously affect the quality of life, and those who cannot be cured for a long time.
(iv) Ⅱ or Ⅲ degree varicocele with a significant decrease in serum testosterone level, excluding other diseases.
⑤ bilateral varicocele of the spermatic cord.
(6) Juvenile varicocele (10-18 years old): Ⅱ or Ⅲ degree varicocele; those whose testicular volume on the affected side is less than 20% of the healthy side; those whose testicular spermatogenic function has decreased; those with more serious related symptoms caused by varicocele; bilateral varicocele.
7.Q: Is surgery always effective?
Generally, the semen improvement rate after varicocele surgery is about 60-70%, and the pregnancy rate is 30-40%. Most patients improve semen quality six months to a year after surgery, but many take 1-2 years to recover. During this period, one should review regularly to keep track of the post-operative recovery and work closely with the doctor to adjust the treatment plan in a timely manner. For patients in a better financial situation, medication can be used in conjunction with the treatment in order to obtain the best results. Some patients who find the post-operative efficacy is not good and the semen quality is not improved significantly in a short period of time, they lose confidence or turn to assisted reproduction treatment. For example, the cost of IVF is 25,000-30,000 with a success rate of 30-40%), so it should be used with caution in cases where the post-surgical outcome is really unsatisfactory. All this is introduced not to shirk responsibility, but because medicine has stages and limitations and is not a panacea, which is the current state of medicine. We can proudly say that we offer first-class technology at this stage, but not a panacea for everything. Many patients want their doctors to give a straightforward conclusion: to do or not to do? In my opinion, today, with a much higher degree of education for all, it makes the most sense to give patients the right to be fully informed, to fully understand the current state of medicine and its shortcomings, and to make a choice together.
8.Q: Is it better to perform surgery early or late for patients with varicocele?
It is necessary to combine the patient’s will, and to communicate with the patient whether the disease is operated or not. If varicose veins are severe but do not affect fertility, surgery is generally not recommended. However, if the varicocele is severe and the patient already has children and the semen is normal, but if the patient still wants to have children in a few years, he or she should be followed up and if the semen quality is found to be declining, surgery should be performed. In children with varicocele, an evaluation is also performed to rule out some primary disease (e.g. Nutcracker syndrome) causing secondary varicocele, and if necessary, the primary disease needs to be treated. In adolescents with varicocele, it is important to look for other primary diseases in addition to the common causes. Available literature suggests that varicocele progressively impairs testicular function in adolescents, as evidenced by reduced testicular volume and abnormal semen parameters. Conversely, there is a lack of convincing data on whether varicocele also produces progressive damage to testicular function in adults.
9. Q: What are the treatment modalities for varicocele? Advantages and disadvantages?
Since the 1840s, scientists and clinicians have been researching and exploring treatment options for varicocele. Overall, it has gone through the initial conservative treatment, medication, and sclerotherapy to the current embolization and surgical treatment. So far, scientists and clinicians around the world generally agree that surgery is the best treatment method with the best results. In fact, surgery also goes through a long development process. Initially, it was high ligation, which is a very classic surgical method and has cured a large number of patients, however, this procedure is operated under direct vision with the naked eye because it is an open surgery, and the arteries and lymphatic vessels of the spermatic cord are very small, and in most cases it is difficult to identify them with the naked eye, so it is easy to ligate the arteries and lymphatic vessels by mistake, and testicular atrophy and scrotal edema easily occur after surgery. At the end of the 20th century, the use of lumpectomy greatly improved the quality of surgery and reduced the incidence of postoperative complications, but it increased the risk of anesthesia and surgery due to the need for retroperitoneal access and general anesthesia. Also in the 1990s, the development of microscopic techniques improved the quality of varicocele ligation, because this procedure is performed in a lower position with a superficial skin opening, only 2-75px long and 3-100px deep, without entering the abdominal cavity, which generally does not injure the intestine and greatly reduces the surgical risk. This greatly reduces the risk of surgery, and because it is operated under a microscope (magnification 5-10 times), the lymphatic vessels and arteries can be seen very clearly, so that misligation can be avoided, which greatly reduces the complications of surgery, and the surgical results are better than all previous surgical procedures, and the cost is lower than that of laparoscopic surgery, which is basically used abroad.
10.Q: Common complications?
Recurrence, edema and testicular atrophy. However, the recurrence rate of our microsurgery is less than 2%, edema is very rare, and we have not seen any cases of testicular atrophy yet.
11.Q: What do I need to pay attention to after microseminal vein ligation?
①The scrotum should be elevated at the right time for 1-2 weeks after surgery, and ice packs can be applied if necessary (3-4 times a day for 20 minutes each time), all the above strategies can be extended according to your needs. Sports shorts with scrotal support are recommended for 2-3 weeks postoperatively.
② To maximize wound healing and recovery, it is recommended that you allow a week of rest after surgery. Lie down more and stand less – to promote the opening of the lateral circulation and the return of blood and lymphatic fluid to the testicles and epididymis – to reduce the complications of epididymitis and syringomyelia.
③ Abstinence should be 2-4 weeks after surgery, including masturbation and sexual intercourse. Dreams, morning erections and spontaneous erections will not cause any damage, so please do not worry about them and just avoid active stimulation.
④Mild discomfort, pain, swelling and inflammation of the incision after surgery are normal. The scrotum and groin area may swell to the size of a tennis ball, which may resolve within a few weeks. Stiffening of the incision area or formation of localized hard nodules is a common reaction that will resolve over several months as the tissue heals and softens. Slight numbness in the incision and adjacent areas may be experienced and will improve within a few months.
⑤ Contact your doctor promptly if the following occur: pain that persists and pain medication is ineffective; redness and swelling of the incision and scrotum that worsens within a few days; high fever, chills, nausea and vomiting, or pus flowing from the incision.
(6) Do not engage in strenuous sports such as hiking, running, long-distance cycling and motorcycling, ball games and heavy physical labor for three months; do not stand for a long time.
(7) Do not smoke and drink alcohol, eat a light diet, do not eat spicy food, pay attention to the intake of protein, balanced nutrition, often wear tight underwear or scrotal support to prevent the scrotum from falling.
The majority of friends will be relieved or cured of their pre-operative symptoms six months after surgery. At this time, you can increase the amount of exercise or exercise load, such as jogging, playing basketball, etc. It is very important to cheer yourself up and keep optimistic mood, which is good for post-operative recovery.
12.Q: Will varicose veins recur after treatment? How often do I need to have a follow-up examination?
There is a possibility of recurrence after varicocele treatment. The first follow-up can be done 1-2 weeks after surgery, mainly to check for any surgical complications. The second follow-up visit will take place 3 months after the surgery and will focus on semen quality and ultrasound examination of the spermatic veins, and then regular monthly follow-up visits until the woman conceives. The routine follow-up includes.
①History questioning.
②physical examination.
③ Semen routine.
④Ultrasound examination of testicles.
13.Q: Will the quality of semen decrease after surgery? Is it possible that the symptoms of discomfort will worsen?
Theoretically there will be, but it is extremely rare and may be seen in two cases.
① postoperative edema and atrophy, which are related to the surgery.
② varicocele itself is not the cause, while the cause is still present, such as radiation, environmental hormones, other etiologies, etc.
③Seminomegaly is not the etiology of scrotal discomfort.
14.Q: . Conservative treatment of varicose spermatocele?
Patients with asymptomatic or mild symptoms are recommended to take non-surgical treatment. Common methods include scrotal brace, local cold compress, avoiding pelvic and perineal congestion caused by transitional sex, etc. Patients with mild varicocele, if semen analysis is normal, should be followed up regularly (1-2 years) if there is abnormal semen analysis, testicular shrinkage and softening of texture, etc. should be promptly treated surgically. Specifically as follows.
(1) Pay attention to regular life, regular rest and rest, and proper exercise. Avoid heavy physical labor and sports, avoid long standing, long hiking, etc., to achieve a combination of work and rest. Excessive exercise will lead to excessive venous pressure affecting the spermatic veins. Smoking and alcoholism also have some influence on the disease.
(2) Drugs for varicocele.
①heptaosaponins: the representative drug is mai zhi ling, which has the function of anti-inflammatory, anti-exudation, protecting the collagen fiber of the vein wall, gradually restoring the elasticity and contraction function of the vein wall, increasing the venous blood return speed, reducing the venous pressure, thus improving the symptoms caused by varicocele, such as testicular swelling, pain, etc.
②Flavonoids: The representative drug is Avelan 2 tablets divided into two doses at lunch and dinner. It is a micronized purified flavonoid, whose small intestine absorption rate is twice that of non-micronized flavonoids, with anti-inflammatory and antioxidant effects, which can rapidly improve venous tone, reduce capillary permeability, improve lymphatic return rate and reduce edema. It can improve the painful symptoms caused by clinical type of varicocele and delay the development of subclinical varicocele to clinical type.
(3) Other medications to improve symptoms For patients with local pain and discomfort, nonsteroidal anti-inflammatory drugs such as anti-inflammatory pain, ibuprofen, and cinnoxicam can be used. Some studies have shown that such drugs can alleviate to some extent the symptoms associated with varicocele caused by seminal veins and may also improve the quality of their semen for some patients.
(4) Drugs that improve semen quality.
①Carnitine: It consists of L-carnitine and acetyl L-carnitine, both of which are natural substances in human body. They mainly have two physiological functions: one is an important factor in the process of mitochondrial β-oxidation of transporting fatty acids and participate in energy metabolism; the other is to increase cell stability by reducing reactive oxygen species (ROS) and inhibiting apoptosis. The compound carnitine preparation (Borealis) 2 bags (each bag contains L-carnitine 10mg, acetyl L-carnitine 5mg) / time, oral, twice a day, for 4-6 months.
Estrogen receptor antagonist: It is a non-steroidal estrogen receptor antagonist, which can compete with estrogen receptors in the hypothalamus and pituitary gland, thus weakening the negative feedback effect of normal estrogen in the body, resulting in increased secretion of endogenous GnRH, FSH and LH, and then acting on the interstitial cells, supporting cells and spermatogenic cells of the testis to regulate and promote spermatogenic functions; clomiphene can also increase the sensitivity of interstitial cells to LH. Clomiphene can also increase the sensitivity of mesenchymal cells to LH and promote T secretion. Clomiphene can affect the whole hypothalamic-pituitary-testicular axis and correct the hormonal imbalance of the gonadal axis system. Clomiphene 25mg/d, 30d for 1 course, 25d, 5d off, 3 courses in a row.
③Antioxidant drugs: such as vitamin E, can protect the lipid peroxidation of sperm membrane by scavenging oxygen free radicals, and treat weak spermatozoa and sperm dysfunction.
④Human chorionic gonadotropin: Human chorionic gonadotropin 1000 U/dose, intramuscular injection, 3 times a week, total dose 30,000 U. According to the literature, human chorionic gonadotropin can be used to treat infertility after varicocele surgery. It can directly stimulate the production of testosterone in the mesenchymal cells of the testis and can affect the spermatogenic epithelium of the spermatogenic tubules of the testis, thus improving spermatogenic function. Human chorionic gonadotropin can effectively restore the metabolism of the testes and improve the quality of semen.
(5) Botanicals and herbal medicines: Some studies have shown that botanicals and herbal medicines can improve semen quality to some extent, but there is a lack of sufficient evidence-based medical evidence in this regard.
(5) Scrotal support can be used to elevate the scrotum to improve the discomfort of testicular swelling, and some physical cooling methods, such as cold towel compresses, can also be used.
(6) Consume more vitamin-rich vegetables and fruits. These methods also have good effect on preventing varicocele.
(7) It is recommended to go to the hospital to review the testicular ultrasound once in 6 months, and it is recommended to review the semen if you have fertility requirements.
15.Q: How to evaluate the testicular function of varicocele
(1) The size and texture of testicles:Testicles are the production line of sperm, the smaller the testicles, it means the capacity atrophy, which will cause oligospermia, how to estimate by yourself whether the testicle size is normal or not? You can use your hand to make an OK gesture to set your testicles, if the size is about the same as the O-ring, it means that the testicles are of normal size. Testicular size and texture are susceptible to subjective factors. Testicular size can be measured by the Prader testicular measuring device or color Doppler ultrasound, but the former tends to overestimate testicular volume, especially in the case of small testicles. It is generally accepted that the total volume under ultrasound of bilateral testes with normal spermatogenesis is at least 20 mL, while the total volume with the Prader testicular meter is at least 30-35 mL.
(2) Semen examination:Given the fluctuation of semen quality, two consecutive semen examinations within 3 months are recommended. The tests should include: semen volume, liquefaction time, pH, sperm density, and motility rate.
(3) Serum testosterone: serum total testosterone test is recommended, and serum free testosterone or bioactive testosterone test is also feasible in units with conditions.
(4) Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), estrogen (E) (optional), serum inhibin B (optional): serum FSH is a better indicator to evaluate testicular spermatogenic function, and a lower serum FSH level suggests better testicular spermatogenic function, which also predicts better treatment effect.
(5) Testicular biopsy:Not generally recommended, but only used when testicular spermatogenic function cannot be adequately evaluated even after using the above methods.