Dr Margaret answers emailers’ embarrassing problems
in this monthly problem page.

Varicocele

Dear Dr Margaret
My partner has a varicocele. I’ve heard that it can affect fertility. I want to have children one day, so I am quite worried about it. Is there an operation he could have?

A varicocele is swollen veins in the scrotum. When I last discussed varicocele, a couple of years ago, I couldn’t give an absolutely definite answer to the fertility question. Doctors had been arguing for years about whether a varicocele affects fertility and whether an operation would help. Recent research has now provided more information.

Normal testicles
The testicles are easy to feel, especially when standing up after a warm bath or shower. They are firm but not hard, and are smooth with no lumps. (If the testicle feels hard, or you feel a lump, get it checked by a doctor straight away.) Behind and slightly above the testicle, you can feel the ‘epididymis’, a storage tube; it feels soft and maybe slightly tender. You can also feel the ‘spermatic cords’, which lead upwards from the epididymis and behind the testicles. The spermatic cord contains a tube for sperms to reach the penis, arteries, veins and nerves.

Varicocele
The veins of the spermatic cord can become swollen, elongated and looped, similar to varicose veins in the leg – this is a varicocele. If the veins are only slightly swollen they will be unnoticeable, but moderately swollen veins can often be felt. They feel like a bag of worms, most obvious when the man is standing. Varicocele does not usually cause any symptoms, although some men report discomfort or may feel embarrassed if the swollen veins are visible under the skin. About 15% of normal healthy men have a varicocele, usually on the left side.

Varicocele and infertility
The main concern was whether a varicocele damages the development of sperms in the testicle. Developing sperms like to be cool (which is why the scrotum hangs outside the body), and the blood in the swollen veins could act like a hot water bottle, keeping the testicle too warm. A World Health Organization study of men attending infertility clinics found a varicocele in 25% of men with abnormal semen (e.g. a low sperm count). So varicocele is only slightly more common in men with sperm problems than in Mr Average. Experts are still unsure whether a varicocele really does affect sperms. If it does, the effect is small.

Treating varicocele will not improve fertility
A varicocele can be treated by a surgical operation (tying off the veins) or by injecting a special substance into the veins to block them (embolization).

In 2001, the Cochrane Collaboration investigated varicocele treatment for fertility. They are an international network of experts who look at every scrap of scientific evidence about medical problems (www.cochraneconsumer.com). They concluded that routinely treating varicoceles in men who are having fertility problems is ‘ill-advised’, because there is not enough evidence that it does any good.

Now researchers in the Netherlands and Canada have reviewed the very best evidence, and they conclude that treating a varicocele does not improve fertility.

So the main reason for considering surgery is cosmetic, because of embarrassment about a noticeable varicocele.

What if he is not very fertile?
Fertility expert Dr Gillian Lockwood points out that human beings, as a species, are not very fertile. Even young couples with normal fertility have only a 25–30% chance of establishing a pregnancy each month that they try. If you and your partner were to have trouble conceiving, his varicocele is unlikely to be the reason. Subfertility affects 1 in 20 men. If tests showed that his sperms are not high quality (not many sperms, poor swimmers or funny-shaped sperms), there are now very effective fertility techniques that can help. These techniques include placing the sperms directly into the uterus at the time of ovulation (intrauterine insemination), or IVF (in-vitro fertilization), or ICSI (intracytoplasmic sperm injection). ICSI is used when the semen quality is very poor and involves injecting a single sperm directly into the female egg using microscopic instruments. It is a common technique in infertility clinics.

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