|
Objective
: To assess the value of varicocoele ligation in improving semen parameters
in cases of male infertility/subfertility.
Methods : The present study analyses 17 cases of varicocoele ligation
done at a major teaching institute in Mumbai. The effect of varicocoelectomy
in terms of improvement in sperm count, motility and morphology was
evaluated.
Results : In 47% of the cases, there was a significant improvement in
the sperm count. In 82% of the cases, sperm motility returned to normal
after the operation.
Conclusion : It can be concluded that varicocoelectomy still remains
a simple, safe and preferred mode of treatment in male infertility with
oligo-terato-astheno-zoospermia.
Introduction
Despite rapid progress in various techniques of assisted reproduction,
infertility still remains a major problem in medicine. Approximately
10% of couples complain of infertility. Male factors account for 25-30%
of all causes of infertility.1,2
Semen analysis is the most commonly done investigation in the evaluation
of infertility. Approximately 25-40% of males investigated for infertility
have an abnormal semen parameter i.e. oligo-terato-astheno-zoospermia.1,2
Amongst the various causes of male infertility, varicocoele remains
one of the commonly encountered and easily manageable causes of male
infertility.1,2 During the past few decades, a number of
documented reports have reviewed the potential detrimental role of varicocoele
on the infertility of man.1-3 Impaired spermatogenesis produced
by the circulatory disturbance is obvious from the demonstrable alteration
in semen quality and abnormal testicular morphology.4 Thus
it is possible to restore normal semen parameters and fertility by ligation
of spermatic vein.
The present study attempts to correlate the association of oligozoospermia
with varicocoele in
cases of male infertility.
Material and Methods
The present study was done at a major tertiary teaching institute.
During the regular infertility out-patient workup, the couple is interviewed
and counselled and complete gynaecological examination of the woman
is done. Baseline infertility investigations, including semen analysis
are advised. In cases with abnormal semen report, analysis is repeated
after 2 weeks. Male partners with persistent abnormal reports in the
form of oligo-terato-astheno zoospermia are then referred to the urosurgery
department for examination, opinion and further evaluation.
Varicocoele can be diagnosed by examination in standing position to
assess visible or palpable varicocoele with impulse on coughing. The
typical feeling in a case of varicocoele is described as a “Bag
of worms”.3 Doppler USG was done in those patients to confirm
the diagnosis.
Males having varicocoele with persistently abnormal semen parameters
were advised surgery for ligation of varicocoele. The surgery was advised
only after excluding female factor for infertility in the couple.
Semen analysis was repeated 3 months after the operation and compared
with preoperative report.
Over a period of 3 years, there were a total of 203 infertility patients,
who had a complete basic workup. Of these 79 males had abnormal semen
parameters (38.9%) and 19 were diagnosed to have significant varicocoele.
Of these 19 cases, 17 cases underwent surgery. This paper presents an
analysis of these 17 cases of significant varicocoele.
Observation and Results
Majority of the cases were in the age group of 30-35. Period of infertility
ranged from 1-8 years. Sixteen patients had left sided varicocoele while
1 had a bilateral one.
Thus varicocoele ligation was done unilaterally in 16 cases and bilaterally
in 1 case. In all patients inguinal approach was used for the operation.
Table 1 shows change in sperm count after the operation. It can be seen
that all 17 cases had counts of less than 20 million/ml before surgery.
In 47% of cases the count escalated above the normal limit after the
operation.
The improvement in sperm motility was more striking (Table 2). Only
11% patients had normal motility as defined by McCleod and WHO grading
i.e. type A (25%) or type III/IV before surgery which rose to 82% after
surgery. Less than 33% sperms with normal morphology is considered as
abnormal. In our study, morphology showed a modest change. Rajan et
al also reported similar findings of persistence of abnormal stress
pattern of sperm after surgery.2
The overall improvement in sperm parameters is shown in Table 3.
Of these 17 cases, 12 patients had regular follow up for 1 year. A year
after surgery, there were 4 pregnancies which included one case of ectopic
pregnancy. The pregnancy rate of 33% was comparable to that reported
by Rajan (1978), Bhide (1970) and Dubin (1970)2,6,7 (Table
4).
 |
Discussion
Varicocoele is one of the commonest causes of male subfertility. 20-40%
of males attending infertility clinic have varicocoele.1
It is more commonly seen in left side. The possible reasons for this
as postulated by Kass3 are
1. Left testicular vein joins left renal vein at right angle while right
testicular vein joins the inferior vena cava.
2. Left testicular vein is longer than right testicular vein as left
testis is at a lower level, hence has to bear a larger column of blood
and therefore more pressure.
3. Loaded pelvic colon compresses left testicular vein causing back
pressure.
4. Left renal vein may be sandwiched between abdominal aorta and trunk
of superior mesenteric vessels.
5. Left testicular artery may arch over left renal vein and cause compression.
6. Close association of left renal veins and left suprarenal veins may
cause adrenaline release from suprarenal vein causing left testicular
vein obstruction.
Though the exact mechanism by which varicocoele causes abnormal sperm
production is not known, rise in temperature, connective tissue hyperplasia
with decreased arterial blood supply causing testicular hypotrophy/atrophy
are likely causes.4
Ever since Tulloch8 performed the first varicocoele ligation to restore
fertility in oligozoospermic male, the operation has got wide acceptance
in the management of male infertility. Currently varicocoelectomy has
become the most simple and effective therapeutic modality in the entire
field of male infertility.
When varicocoele is associated with poor semen quality and when endocrinopathy
and other female factors of infertility are ruled out, ligation of internal
spermatic venous system should be offered to such males after ruling
out infection.
An improvement in semen quality ranging from 60% to 90% and pregnancy
rate ranging from 30% to 60% have been reported by various authors (Table
4).2,6,7 In our study, the sperm count increased by a considerable
extent. But the greatest effect of varicocoele ligation occurs on significant
improvement in sperm motility, which often results in pregnancies even
when sperm count is below normal level. Similar findings were also reported
by Rajan et al.2 Thus it is almost obvious that varicocoele
ligation (varicocoelectomy) promotes fertility by mainly improving sperm
motility than by its effect on other parameters including sperm count.1
The role of testicular biopsy prior to surgery is not established. Etriby
in 1967 documented correlation between testicular histology and improvement
of sperm quality. According to him, premature sloughing with germinal
layer hyperplasia had better prognosis than spermatogenesis arrest.
Though newer modalities like sclerosis of internal spermatic vein, occlusion
with help of gelfoam or transcatheter embolisation using adhesive acrylate
have been tried with some success but these treatment modalities are
very expensive and often unavailable.10-12 Thus varicocoele
ligation still remains simple, safe and the preferred mode of treatment
of the oligozoospermic male.
References
1. WHO, Influence of varicocele on parameters of fertility in a
large group of men presenting to infertility clinics. Fertil Steril
1992; 57 : 1289-93.
2. Rajan R, Thomas M. Varicocelectomy in the management of male infertility.
J Obstet Gynaecol India 1978; 28 : 833-37.
3. Kass EJ, Rietelman C. Adolescent varicocele. Urol Clinic North Am
1995; 22 : 151-9.
4. Meiusset R, Bujan L. Testicular heating and its possible contribution
to male infertility. Int J Androl 1995; 18 : 164-84.
5. McCleod J. Seminal cytology in the presence of varicocele. Fertil
Steril 1965; 16 : 735-9.
6. Dublin L, Amelar RD. Varicocoele and results of varicocelectomy in
selected subfertile men with varicocele. Fertil Steril 1970; 21 : 6060.
7. Bhide A, Rao RV, Sobti M, Bradoo A. The value of varicocele ligation
in the treatment of oligozoospermic infertility. J Obstet Gynaecol India
1991; 41 : 812-5.
8. Tulloch WDS. Varicocele in subfertility; results of treatment. Brit
J Obstet Gyn 1955; 2 : 356-9.
9. Etriby AASE. Subfertility and varicocele. Fertil Steril 1975; 26
: 1013-21.
10. Lima SS, Adderman T, Claude S. A new method of treatment of varicocele.
Andrologia 1978; 10 : 103-7.
11. Riedl P. Selective phlebographic and Katheterthrombosierung der
vena yesticularis bei primarer varikozele. Weinb klin Wochenschr 1979;
91 : 1-8.
12. Zollikofer, modified technique for embolisation of the internal
spermatic vein. Varicocele and male infertility : recent advances in
diagnosis and therapy Berlin.
*Associate Professor;
**Lecturer; ***Registrar; +Honorary Professor; Department of Obstetrics
and Gynaecology, LTMG Hospital, Sion, Mumbai - 400 022.
|
