Common and mostly mild, varicocele can affect men of any age. Because its incidence is even higher in men with fertility problems, it could have an impact on fertility.

Varicocele is characterized by the dilation of a vein (varicose vein) in the spermatic cord, a fibrous cord located in the bursae above each testicle, and connecting each to the scrotum.

Varicocele usually affects only one side, mostly the left due to the anatomy of the venous network of the male genitals. On the left side, blood from the testis is drained to the renal vein, while on the right it is drained to the vena cava, where the pressure is lower than in the renal vein.

Causes

We do not know exactly the pathophysiology of varicocele, other than a malfunction of the unidirectional valves that allow the flow of blood from the testes to the heart. In the case of varicocele, for reasons still unknown, one of the valves does not work properly. Venous blood flows back, accumulates and causes dilation of the veins located in the spermatic cord.

Prevalence

With 15% of the adult male population affected, varicocele is a relatively common condition that can occur at any age.

Evolution and possible complications

Varicocele has no effect on erectile function and sexuality, and in some men, it does not cause any discomfort or complications.

When it is large in size, it can cause a feeling of heaviness, or even pain, which may worsen over time. It can also affect the development and function of the testis with testicular atrophy and, presumably, fertility problems. The figures do indeed suggest an impact of varicocele on fertility: 35% of men affected by primary infertility have varicocele, 80% in the case of secondary infertility, against only 15% in the general population. (2). However, the link between varicocele and infertility has not been confirmed and the possible mechanisms involved have not been elucidated. Several hypotheses have been put forward, however: varicose veins could cause, by blood stagnation, a warming of the testicle harmful to spermatogenesis. Poor venous return could also cause stagnation of toxic substances, such as tobacco, in the bloodstream, with an impact on spermatogenesis. The reflux of adrenal and renal metabolites could also interfere with sperm production.

Note, however, that a man with a varicocele may also have no fertility problem.

Most often, varicocele is asymptomatic and does not cause any discomfort. It then remains unrecognized, or is discovered accidentally or during a fertility check-up.

Sometimes varicocele is manifested by an increase in the size of the testicle, a feeling of heaviness in the bursa, even accentuated pain when standing for prolonged periods, during physical exertion or in hot weather.

The diagnosis is clinical: by palpation and visual examination, the urologist looks for varicose dilations above the testicles. In case of doubt, an ultrasound is performed to confirm the presence of the varicocele and rule out any other pathology (inguinal hernia, cyst of the spermatic cord, effusion of fluid in the bursa, tumor of the testis, etc.). The images will show abnormally large veins and blood stagnation.

In a couple having difficulty having a baby, during the male infertility assessment, the doctor systematically performs a clinical examination to detect a possible varicocele.

If the varicocele is poorly developed and does not cause any discomfort, therapeutic abstention is recommended.

In the event of fertility disorders, the links between varicoceles and subfertility not being confirmed, there is debate on the need to treat varicocele or not. However, there seems to be a consensus: in the event of a clear varicocele associated with abnormalities in the spermogram, treatment of the varicocele is recommended.

This treatment consists of occluding the dilated spermatic vein, generally by embolization: under local anesthesia and under ultrasound control, a small catheter is introduced into the femoral artery to the dilated spermatic veins. Substances are then injected in order to permanently block the vein. They may be obstructing products by sclerosis and / or small metal springs. The operation can be performed on an outpatient basis. Surgical treatment is much rarer today.

In more than half of the cases, this intervention would improve the quality of the sperm. Sometimes no improvement is seen, but treatment never results in sperm degradation (3). In the event of a major alteration of the spermogram, conservation of the sperm at CECOS may be recommended before the operation, however, the French Association of Urology reminds us (4).

To date, no treatment or precaution can prevent the appearance of a varicocele.