When things get too hot down below

Dear Dr G,

My wife and I are both in our early thirties.

We have been trying for a baby since we got married three years ago but there has been no positive outcome.

I recently went to see a urologist, who requested for a semen analysis to be done.

To my dismay, the doctor said it revealed I have a low sperm count, with many non-active and deformed sperm.

He examined my scrotum and said it was warmer than normal.

The doctor diagnosed me with varicocele – when veins in the scrotal sac become enlarged – and the solution to this is to operate, reversing the warming effect of the dilated veins.

What exactly is varicocele and why does it cause poor quality sperm?

Do I really need an operation? If so, how is it done and what complications might I face?

Warmest Regards

Warm William

 

A varicocele is the abnormal enlargement of the veins within the loose bag of skin that holds the testicles, mainly with unknown etiology. A varicocele is similar to the varicose veins in the legs. It is often described as "a bag of worms in the sac" and leads to an excess amount of blood – and heat – in the scrotum. Its severity can be graded from 1 to 3. Grade 1 is generally visible only on straining, while grade 3 is clearly visible when standing.

The warming caused by the dilated veins may have an adverse impact in spermatogenesis, resulting in decrease in sperm quality and male infertility. Many men will be oblivious they have this condition unless they encounter a "dragging" sensation or fertility issues.

Not all infertility issues are due to female etiology – in fact, one in twenty men are affected by decreased fertility and low sperm counts is a common source.

Oligospermia simply means semen with a low concentration of sperm. The "goal posts for this numbers game" have shifted in the last few years. For many decades, a low count was defined as concentrations less than 20 million sperm per millilitre of ejaculate. The World Health Organization reassessed the criteria and established a lower reference point of 15 million sperm per millilitre, consistent with the 5th percentile of ejaculates for normal men. The decrease in number is often associated with poor morphology and motility, a condition known as OAT (Oligo-Astheno-Teratospermia).

Although the sperm count can fluctuate (with oligospermia a temporary setback), the causes of low sperm counts can be due to genetic conditions, age, previous mumps infections, sexually transmitted infections or ejaculatory duct obstruction. The severity of oligospermia can also be further classified as mild, moderate and severe, ranging from 10 to 20 million, 5 to 10 million and less than 5 million, respectively. The severity of oligospermia helps clinicians to determine the mode of treatment, varied from lifestyle changes to the test tube babies. One of the most reversible causes of oligospermia is varicocele. This can affect up to 15% of sub-fertile men.

The treatment of varicocele is only necessary in men who experience discomfort or inability to father a child. The purpose of treatment is to ligate the dilated vessels and divert blood flow through other channels. Such surgical intervention can be an open operation, laparoscopic intervention, or percutaneous embolisation. Varicocele operations are generally safe, however adversities such as infections, fluid collection, recurrence and even damage to the artery have been reported.

Varicocelectomy is well recognised to improve semen quality in 60%-80% of men and the improvement of fertility can range from 43% to 69% over two-year intervals. The publications revealed most improvement in semen quality and pregnancy are mostly noted in repairs for more severe varicocele. However, lifestyle improvement and female factors must also be taken into consideration when interpreting such results.

A healthy lifestyle ensures improvement in spermatogenesis. When the pressure is mounting, the emotional stress can only have a negative impact on the gonads. When put on the spot, Dr G's view is: "reversing the warming sac may be the first step of semen improvement, but further healthy lifestyle and hard work between the sheets can ensure the miracle of pregnancy".