I. Definition
Varicocele: It refers to the abnormal elongation, dilatation and tortuosity of the trabecular plexus of the intra-seminomatous veins.
1.Primary varicocele: varicocele caused by anatomical factors and dysplasia.
2.Subclinical varicocele: It refers to the minor varicocele that cannot be detected on physical examination but can be detected by ultrasound, nuclear scan or color Doppler examination. It is generally considered that a vein diameter of more than 2 mm can establish the diagnosis.
(iii) Secondary varicocele: Intra-abdominal or retroperitoneal tumor, hydronephrosis or ectopic vascular compression of the superior spermatic veins may also lead to unilateral or bilateral varicocele, which is called secondary varicocele.
Second, the epidemiological and anatomical factors of varicocele
1.Epidemiology of varicocele
The incidence of varicocele accounts for about 10-15% of the male population and is mostly seen in young adults. Varicocele mostly occurs on the left side, but recently it has been found to occur bilaterally in up to 40% or more. In adolescents, there is a significant correlation between the prevalence of varicocele and age. Recent studies have reported the incidence of varicocele in prepubertal children to be 2%-ll%, in adolescents 9.5%-16.2%, and in late adolescence about 9%-26%. Varicocele occurs less frequently in men before puberty, but after puberty, its incidence gradually increases with age, which may be related to physical growth, increased testicular volume and increased blood supply to the testes.
2, the etiology of varicocele and anatomical factors
Varicocele occurs on the left side of the spermatic cord 90% of the time. The high incidence on the left side is related to the following reasons: 1, the human body usually takes an upright posture, so the blood in the spermatic vein must overcome gravity to return from the bottom up; 2, the weakness of the vein wall and the adjacent connective tissue or the underdevelopment of the levator muscle, which weakens the support role around the spermatic vein; 3, the valve defect or incomplete closure of the spermatic vein on the left side is more than that on the right side; 4, the spermatic vein on the left side is located behind the sigmoid colon. It is easy to be affected by intestinal compression and its patency; 5. The left spermatic vein enters the renal vein at a right angle, with a slightly longer stroke and higher hydrostatic pressure; 6. The left renal vein is located between the aorta and mesenteric artery, and the compression of the renal vein may affect the reflux of the internal spermatic vein, forming the so-called proximal clamp phenomenon; 7. The right common iliac artery may cause the left common iliac vein to be compressed, affecting the reflux of the left vas deferens vein and forming the so-called distal clamp phenomenon.
Varicocele and fertility
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 approximately 40% of primary infertility and 80% of secondary infertility in adult men have varicocele. The factors that affect fertility in varicocele 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 blood 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. colomb et al. found that anti-sperm antibodies (ASA) exist in peripheral blood and semen of varicocele infertility, and ASA enters the testis or epididymis and can interfere with spermatogenesis and sperm maturation process, resulting in a decrease in the number of sperm or adhesion to the sperm membrane, causing morphological and functional abnormalities of sperm.
Causes of infertility due to varicose spermatozoa
The causes of infertility caused by varicocele have not been fully elucidated yet, and may be related to the following factors.
1, blood stagnation in the spermatic vein, so that the local temperature of the testis increases, and the degeneration of spermatogenic tubules affects the occurrence of sperm; 2, blood stagnation affects the blood circulation of the testis, and the accumulation of CO2 in the testicular tissue affects the occurrence of sperm; 3, blood from the renal vein returning from the left spermatic vein, the metabolites secreted by the adrenal glands and kidneys such as steroids, catecholamines, 5-hydroxytryptamine can cause vasoconstriction, resulting in premature sperm 4. varicocele on the left side can affect the function of the right testicle, because there are abundant traffic branches of the veins between the testicles bilaterally, and the toxins in the blood of the left spermatic vein can affect the spermatogenesis of the right testicle.
Treatment of varicocele
Varicocele is a frequent disease in young and middle-aged men. Most of the clinical reports are based on surgical treatment, and some of them are treated with drugs (including Chinese medicine).
Drug treatment
1.Compound carnitine: It consists of L-carnitine and acetyl L-carnitine, both of which are natural substances in human body. They have two main physiological functions: one is an important factor in the process of mitochondrial β-oxidation of fatty acids, and participate in energy metabolism; the other is to increase the stability of cells by reducing reactive oxygen species (ROS) and inhibiting apoptosis. Spermatozoa acquire motility and fertilization ability in the epididymis, and the acquisition of motility and fertilization ability of spermatozoa is not only dependent on androgens, but also related to carnitine, glycerophosphorylcholine (GPC), sialic acid (SA), etc. secreted by the epithelium of the epididymis, and the role of carnitine is crucial, especially the biologically active L-carnitine in the body has a direct impact on the maturation and motility of spermatozoa. In addition, carnitine can increase the concentration of prostaglandin E2 and improve the sperm count. 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.
2, clomiphene: is a non-steroidal estrogen receptor antagonist, can compete with the hypothalamus, the pituitary site of estrogen receptors, thus weakening the negative feedback effect of normal estrogen in the body, resulting in endogenous GnRH, FSH, LH secretion increased, and then act on the testicular interstitial cells, supporting cells, spermatogenic cells, regulation, promote spermatogenic function; clomiphene can also increase the sensitivity of interstitial cells 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. The commonly used dose is 25mg/d orally, with a dose range of 12.5-40mg/d. Doses above 200mg/d significantly inhibit spermatogenesis. The efficacy of combining HCG and clomiphene after inguinal spermatic vein ligation is significantly higher than that of surgical treatment alone. 1000U of human chorionic gonadotropin (HCG) is injected intramuscularly three times a week for a total dose of 30,000U; clomiphene 25mg/d for 30d as a course of treatment, 25d and 5d off for three consecutive courses.
3.Stretching varicose veins to help fertility soup: With the main drugs of made aromatic herb, lychee nucleus, angelica, white peony, red peony, hedgehog, green peel, Chenpi, roasted licorice, etc., it can significantly improve the sperm density, vitality, activity rate, reduce the rate of malformation and shorten the liquefaction time in patients with varicose veins with infertility by combining with high level ligation of spermatozoa. The dose: one dose a day, divided into two doses after meals, 1 month for 1 course, 3 courses of treatment.
4, Tong Gen: Chai Hu, Safflower, Radix Angelicae Sinensis, Wu Jia Pi, Fructus Lycii, Radix et Rhizoma, Huai Shan Yao, Raspberry 10g each, Calcined Dragon Bone, Dan Shen 30g each, Wu Wei Zi 6g, Huang Qi, Chuan Niu Kne 15g each. It can promote testicular blood circulation, improve testicular ischemia and hypoxia, promote testicular sperm production, increase sperm count and sperm activity rate.
5.Other Chinese herbal treatments: there are tonic Chinese medicine and qi soup, kidney and sperm pellets, Chinese medicine sperm production punch, etc., which have certain clinical effect, but more information is needed for further verification.
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. Those with mild symptoms and no complications of infertility can be treated with non-surgical methods such as scrotal support, local cold compresses and reduction of 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.
Laparoscopic surgical treatment: laparoscopic high ligation of spermatic veins has the advantages of reliable results, less damage, fewer complications, simultaneous bilateral surgery, faster recovery and shorter hospital stay compared with traditional open surgery, so many clinicians believe that laparoscopy is mainly suitable for those with bilateral high ligation via laparoscopy, obesity, history of groin surgery and recurrence after open surgery. The various advantages of laparoscopic high ligation of the spermatic veins over open surgery should be for open surgery via the inguinal route or retroperitoneal route, but not for microscopic open surgery via the small incisional route under the external ring. Laparoscopic surgery will entail some intra-abdominal complications, such as bowel, bladder and large vessel injuries. In addition, laparoscopic surgery requires general anesthesia and is difficult to promote in primary care hospitals because of the expensive equipment, high medical costs, and limitations of technical staff.
Other treatments: In addition, there are other treatments such as microscopic spermatic vein ligation and spermatic vein interventional embolization, which are clinically used and have good efficacy.