Dilated veins in the scrotum may cause infertility and pain: Varicocele, explained.

Did you know that 40% of men with infertility have a varicocele and most of them don't even know it? What is exactly a varicocele and why does it happen? A varicocele is a dilation of the veins that bring the blood from the testicle upwards and it does happen for a number of reasons. Most of the times we don't know exactly which is the reason but frequently is because there is an asymmetrical way our body is done. If you think the heart is leaning towards the left, the liver is leaning towards the right and so happens with the veins inside. So the veins on the left hand side have an anatomy that is more keen to create those conditions that are favorable for a dilation of the blood vessels. And if this dilatation occurs, the blood can run in the opposite direction going from upwards to downwards similarly to what happens to the varicose veins of the limbs. If this happens, we have a dilation of the testicular vein most frequently on the left hand side. Dilatation means reflux of toxic material, unoxygenated bloods and increased temperature and the testicles don't like it. How common are varicoceles and who is most likely to be affected? Varicoceles are extremely common. Up to 15% of men in the world suffer from varicocele and obviously most they don't even know about it. However, if we select the population of men that are struggling to conceive. So men affected by male factor infertility that percentage rises up to 40%. What symptoms should men look out for and can varicoceles sometimes be silent?

It is highly likely that most men that have a varicocele don't even know about it. The symptoms can be very subtle, can be completely inexistent, or can be rather bothersome. Most typically, varicocele can be perceived as what is described as a bag of worms within the scrotum just above the testicle. Now I understand this is quite an awkward metaphor because nobody probably ever felt the feeling of a bag of worms, but it means that there are dilated vessels that are soft to the touch and they are all close to one another because they are contained into what is called the spermatic cord. Structure that brings the blood vessels, nerves, vas deference and lymphatic vessels from the abdominal cavity down to the testicle. The other typical symptom is dull ache on the left hand side up to a consistent pain that especially is present after long time in standing position with warmer temperature rather than colder temperature and all those conditions that favor the further dilation of already dilated blood vessels.

The truth is however that it is highly likely that varicocele remain completely silent and you don't even know you might have it. That's why it is important in case you struggle for example to have babies to have a check of your testicle by a good urologist or andologist. Maybe have an ultrasound scan done. Do varicoceles affect fertility or can some men still conceive naturally? Varicocele is known as the most frequent surgically correctable cause of male factor infertility. However, men with varicocele can easily conceive naturally and most of them they don't have problems with fertility. The point is men with varicocele with a problem with fertility may benefit greatly from having the varicocele corrected. What are the treatment options? Once a varicocele is found, it doesn't go away by itself. It's a chronic condition that can remain as such or become worse and worse. As said, not every varicocele needs treatment, but the treatment is reserved for men that have a varicocele and then either pain or problems with fertility with certain typical characteristics, a fertility test showing abnormalities in concentration, motility or morphology or in DNA fragmentation. Lifestyle can help in avoiding the worst of the symptoms. But the truth is varicocele is a condition that can be treated via surgery or interventions. Anyways, there are two types of intervention. The non-surgical procedures like the interventional radiology embolization of the left internal spermatic vein and the surgical procedure that is a constellation of different techniques but they grossly divide into non-microsurgical and microsurgical. The non-microsurgical are the classical ones where there is an incision and there is a ligation somehow at some point depending on the technique or a laparoscopic approach that means with special cameras in the abdomen to visualize the dilated vein and close them from inside. The microsurgical is nowadays the gold standard technique in terms of high effectiveness and low risk of complication and relies on the identification and isolation of the spermatic cord. Opening the spermatic cordon with the microscope manually going to select the dilated veins, tie them and divide them so that there is a high degree of safety for avoiding problems like collection of fluid around the testicle called hydrocele or death of the testicle due to the for example division of the artery. How do you decide which patients will benefit most from treatment? The selection of patient for treatment of varicocele is done either on the symptoms or on the fertility test plus a history of couple infertility. From what concern the pain the patient decide if they are good candidate or not. There is a typical pain that is intermittent is depending on the standing position depending on the temperature is not normally a stabbing pain or an acute pain is a bit of a dull ache and if that becomes quite bothersome for example if the patient has to take some painkiller there is an indication for treating varicocele. Varicocele may or may not be the cause of the pain and that means that correction of the varicocele may or may not induce the resolution of the problem. Instead, for what concerns couples that are struggling to conceive and within the couple, the man has a fertility test showing parameters that are not normal as per number of sperms or motility of sperms or the number of sperms that look morphologically normal. These are the parameters that are most typically affected by varicocele.

And in 60 to 80% of cases when these parameters are abnormal, correcting varicocele induces a significant improvement of the seminal quality. However, there is mounting evidence nowadays that there is a further parameter linked to the presence of a varicocele and that is the DNA fragmentation. That means the amount of the genetic code, the DNA that is intact and not fragmented into pieces in sperms that otherwise they may be looking normal, moving normal and be in a good number. So even if you have a fertility test that is normal and you struggle to have babies, check the DNA fragmentation because that could be the varicocele affecting your fertility.

Is varicocele treatment available in the NHS? Varicocele treatment is promptly available in the NHS for men that suffer from varicocele and testicular pain. However, if you have a varicocele and you suffer from male factor infertility, you might not find it easy. Interestingly, the United Kingdom is the only country in the world that refuses to consider varicocele treatment for improving fertility. In recent careful research I've done about all the available guidelines worldwide, 19 guidelines establish a relationship between varicocele and infertility and recommend to have the varicocele managed to improve fertility. There is only one country that advises completely against this and that is the United Kingdom. So unfortunately if you have varicocele and male factor infertility you might find some barrier in obtaining your treatment within the NHS. What reassurance can you give men to feel anxious about their diagnosis?

First of all, you're certainly not alone. 15% of men at least in the world suffer from the same condition and there is really nothing to be worried about. Clearly if you are reaching out for problems related to varicocele you are likely to be affected either by pain or by infertility. And the important thing is that you know that for one and another of these two problems there is a full network of management that can help you from a multidisciplinary way with pain and fertility. I might be helpful in looking with you if treating of varicocele can be a good option for you.