Understanding Varicocele: What You Need to Know About Male Fertility

In this episode of "Taco Bout Fertility Tuesday," Dr. Mark Amols dives into the often overlooked topic of varicocele, a common male condition affecting fertility. With a blend of personal experience and professional insight, Dr. Amols explains what varicocele is, how it impacts sperm quality, and the various treatment options available. Learn about the different grades of varicocele, when intervention is necessary, and why early detection is crucial. Whether you're a couple trying to conceive or simply curious about male fertility issues, this episode offers valuable information and practical advice. Don't miss this enlightening discussion on understanding and managing varicocele to improve fertility outcomes. Tune in, and be sure to share this episode with anyone who might benefit from it! 

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Transcript

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Today we talk about varicoseal. It might sound like a spell from a Harry Potter movie, but there's no magic wand need to understand this common male condition. Let's conjure up some facts and dispel the myths. I'm Doctor Mark Amols, and this is taco, about fertility. Tuesday on today's episode, we're going to be talking about varicocele. And this is a condition that, affects men's fertility. What's interesting about this topic is it's something that I personally dealt with. It's actually one of the causes of my infertility. Now, although our, podcast is primarily geared towards women, understanding male fertility issues like Maricocell is crucial for couples when they're trying to conceive. So we're going to discuss what a varicocele is, how it affects fertility, the available treatment options for it, and the success rate of these treatments. We'll also explore when it's recommended to intervene and at what grade of a varicocele intervention is necessary. So, yes, I have low sperm count, and that is due to a varicocele. I have. My varicocele was very severe. Kind of a funny story. I could have prevented this whole thing if I would have seen a doctor when I was younger. Now, again, I'm assuming I may have had problems otherwise, but when I was around 1415, I noticed that on the left side of my testicle, there was this kind of wormy feeling, like a bunch of worms in my testicle. And I didn't know what it was. And the first thing I thought was, I have cancer. I was freaking out. And then I went and I told my dad that I had this weird lumps in my testicle, and I didn't know what to do. And he said, okay, come over here. Come show me it. I can tell you at 1415 years old, one of the things you don't want to do is show your junk to your dad, let alone have your dad fill your junk. So at that point, I stopped worrying about it and never saw a doctor until I was older, when I was around, let's say between 18 and 20. And I was there for another reason and let the doctor know. And he said, oh, yeah, it's a varicocele. Now, he kind of brushed it off. He said to me, well, you can get it fixed, but it's not causing problems. You don't have to do anything about it. And he was partially correct, but I should have done something about it, and I didn't. And unfortunately, that is probably what led me to have severe sperm issues. And so the moral of that story is, one, definitely get it checked out, especially if you're having problems getting pregnant. But two, if your kid ever comes to you and says to you that they have lumps in their testicle, don't tell them that you have to see it or feel it first before they see a doctor. So the first part you have to understand about varicocele is that it is an enlargement of the veins within the scrotum. What's really interesting about the scrotum is that the blood vessels actually have, like, a pampiniform plexus, where it's like a plexus of veins that surround the testicle versus just one vein coming off. There's supposed to be this plexus around the testicles, and the purpose for that is to pull away the warm blood. That way, the testicles are always cooler versus if it was just one vessel, the blood could sit there longer. So by having this plexus, the veins are basically cooling the testicles down all the time. This is one of the reasons why testicles are on the outside of the body. So they can be cooler. Now, when we say cooler, we're not saying significantly colder, but at least not the internal body temperature, which your, women's ovaries are, because they're inside the body. Now, just like women or men can have varicosities on their legs, which is due to the vessels not working well and the blood flow is not going up them. What can happen is they can start swelling and get larger, and then the flow is not good anymore. Well, the same thing can happen in the testicles and usually occurs on the left testicle. And there's a reason for that, which I'll get into a minute, but by having poor flow, the veins now cannot remove the warm blood, and so it starts to pool. Now, that pooling will cause the heat to go up, and eventually that will hurt the sperm, both in count, motility, quality. It can even affect the fragmentation of the DNA in the sperm. So this can cause infertility. A matter of fact, varicoceles affect about 15% of, all men and up to 40% of men who have infertility. Now, there are different grades of varicocele. So although there might be 15% of men with it, it doesnt mean its always causing their infertility. There are some men who have it and have no infertility. Some men can also have pain with it. So as I got older, I actually did develop pain with it. And so one of the reasons I had repaired was not just for fertility, but was really for the pain that I was getting because it causes icky swelling in that area when it filled up. Now, I mentioned the left side is more common. The reason for this is due to the anatomy on the right side. The veins from the testicle go right into the vena cava, which is right next to the pelvis. But the left vein actually goes all the way up, to the renal vein. This distance is significantly longer, and because of that longer distance in gravity, there can be failures in that vein, and that can lead to a varicocele. So it's very common for it to be on the left side. If you were going to feel for these, what you would do is you would feel the testicular sac and usually feel lumped in there, which sometimes will be said like a bag of worms, because there's all these, like, bumpy veins. And you should really compare to your right side, because if you don't have that and the left side does, that tells you there's something different. Now, it's possible you can have bilateral varicoceles, but usually, like I said, it's usually on one side. Now, if you're having discomfort, like an achy pain there, and you end up feeling this, you probably do have a varicocele. Now, what happens is, if you think you have one or if you get tested for one, usually the doctor will do an exam. Exactly, checking for those things we discussed. Usually this is going to be a urologist. Now, there are other ways to also evaluate other than just physical exam. One of the ways you can do it is with an ultrasound. The ultrasound can then measure how wide those vessels are and can determine if it is a mild grade varicocele or if it is, a grade three with the largest type of varicocele. Grade ones are very small and barely palpable, and they can be seen on ultrasounds and measured. Grade two are a little bit more moderate. They're easily palpable, and you don't even have to bear down to feel them. What I mean by that is that when a man bears down, they swell up because the veins have lost a lot of their function to push the blood up. And so they pull blood, and then the large ones are very visible. You can almost see them with your eyes. You look at the testing worm, looks like it has these bumps on it. So usually a urologist will have an ultrasound to help evaluate and really just get a better idea of how bad the reflux is of the blood versus going forward, it's actually refluxing backwards. Now, we talked about earlier how the purpose of these veins were to pull the heat away. So if you affect the flow and the flow is now retro, then what happens is you start getting increased temperatures in the scrotum. This then leads to increased heat, which can affect the sperm quality. It can affect the oxidative stress of the testicle, causing DNA fragmentation. And so you can see how this can really affect your fertility, no different than if you were in the hot tub all the time. So basically, it's like creating a hot tub around your testicles all the time when you have a varicocele. Now, if you're fortunate enough to have, let's say, a grade one varicocele, and you don't have any fertility issues, a lot of times you can just kind of watch and wait. You really don't want to do a surgery at this point. No reason. And even if you are having fertility issues, it likely is not affecting it much. So if you go through the procedure, you're really going to help it. It also depends what your sperm issue is. If we're just worried about morphology, like the shape of the sperm and you have a mild case of varicocele, you're probably not going to get benefit from removing the varicocele, especially because varicoceles really don't help with morphology much. So what are the interventions that you can do to help with a varicocele? So one of the main stage surgeries is going to be a varicocelectomy. This is where you basically ligate the effective vessels by removing them. Now, you can't remove all the vessels or then you wouldn't have any blood flow removed from the testicle. So you're removing those big varicosity ones and leaving the smaller ones. Usually they make an incision up on your abdomen and then they pull the testicle up and then they do the surgery through that, and then they put everything back. The success rate for this is about 60% improvement in the sperm quality. And pregnancy rates will increase with the first year post surgery. Now, again, it also depends where you start with. If you start with really bad sperm, it may be a huge improvement. If you start with just a minor issue in your sperm, you may not notice much. As I mentioned, motility is really helped a lot in this procedure. Just like quality and also sperm DNA fragmentation. Now, there are minimally invasive procedures that you can do as well, which is percutaneous embolization. This is a less invasive option where they can actually go and put, basically, beads that go down to the vessels and shut the blood flow off, shutting in those vessels, without having to cut them out. Now, I can tell you, as someone who has done the procedure, it's quite uncomfortable. Now, when I was happening, I was fine because I was asleep, but when I woke up, ice was my best friend in the world for about a week because everything was swollen. Just even going to the bathroom was very painful. Coughing was painful. So it is uncomfortable, but it does get rid of the problem. And even though I had pain afterwards, I had no pain. Unfortunately, there's more to this story, but we'll get to that in a minute. So anytime you have infertility issues and you have a grade two or three varicocele and the sperm is significantly affected, it's definitely worth moving forward with treatment, especially if you have pain or discomfort, because who wants to deal with that? But another thing should be looking at is the size of the testicle. If that testicle is getting smaller, then it's undergoing atrophy, which means it's actually getting poor blood supply to it and it's dying. And this is really important, because if there's a change in the size of your testicle on the side with a varicocele, if you don't do something soon, it will be too late. That is what happened with me, unfortunately, because it took so long until I did something about it, the effect on the testicle was already so severe that even during the surgery, didn't benefit me much. Now, yes, it did benefit me from the standpoint of not having pain, but from a fertility perspective, it did not prevent us from needing IVF anymore, and we still need to proceed with IVF. The part to the story I was mentioning was that this is the crazy part. It can come back. And so even though I was pain free for many years after having that procedure, unfortunately, the other veins started swelling and it came back. So, unfortunately, it isn't a hundred percent successful. From the standpoint of lasting forever, it may only last for a few years. The main key points to understand are that varicoseals affect 15% of men, and if you have infertility, there is a possible chance they have that you can basically just ask your partner and say, hey, have you ever noticed that the testicle on the left feels different? Or if it feels like there's a bunch of worms in there, then that might be the start of the discussion, if there is any concern or they feel like things might not be completely perfect, they can always see a urologist who can then do a further evaluation, such as with an ultrasound or the physical exam. And then, as we talked about, depending on the grade of it and depending on your circumstances, it may be worth even having surgery, if that's the best thing for you guys. Anytime you have pain, I highly recommend getting it treated. I can tell you that I felt way better after having a surgery. Not right afterwards, obviously, because that was not comfortable. But, over the years, it was really nice to finally not have that pain anymore. Unfortunately, like I said, it can come back. And potentially, if you're trying to have more kids, you might need to do another procedure, or might have to then still go into something like IVF because it came back. When it comes to sperm parameters post varicocelectomy, that will be benefited. Essentially, you increase your sperm concentration, and that's very common to be seen, after the procedure. Same thing with motility. Motility should get better because that's affected by heat. Morphology may occur, but it's generally less pronounced compared to the count and motility. When it comes to sperm DNA fragmentation, there are many studies that indicate a reduction in the sperm DNA fragmentation after varicocele treatment. Other factors you must think about is the extent of existing damage. So, like in my situation, unfortunately, it was done later, the damage was already done, and so the benefit was much smaller because it was too late. On the same token, age. So if you are much, much older, you may not see as much improvement because the sperm is already poor quality because of age, whereas if you're younger, you're going to have a better response to treatment. It also matters what your sperm quality is from the very beginning. Now, this may be more related to how much damage is already being done, but basically, people who have relatively better baseline semen quality tend to have better improvements. Those with severely impaired, semen parameters might experience less benefit than the people who start off with somewhat better numbers. Overall, this is an important parameter to know about and make sure you have your partner tested. If this is something you guys are concerned about in the general infertility evaluation, although we do a semen analysis, most fertility doctors do not evaluate the men physically. And so this is something that's important to bring up if it is suspected in your partner. Hopefully this episode was helpful to someone who maybe is going through fertility, or maybe you have a friend who's going through fertility. Maybe you know a guy who has mentioned a few times that he has kind of some aches in the groin area. Or maybe his dad told him, hey, let me see that first before going to the doctor, and you can tell him, hey, no, don't wait. Just go to the doctor. Either way, if you know someone, please tell me about this episode. And as always, if you liked this show, please give us a five star review on your favorite medium and tell your friends and family about us. As always, I love doing this show, and I always look forward to every week doing it with you. I can't wait again to talk to you next week on talk about fertility Tuesday. Subscribe.