1) A 30-year old male presented with a 2-year history of subfertility and a left varicocele on examination. 2) Varicocele is dilated and tortuous veins in the spermatic cord that can impair sperm quality and cause testicular changes through increased oxidative stress and local hormonal imbalances. 3) Treatment options include expectant monitoring, surgery such as high ligation to obliterate the internal spermatic veins, and minimally invasive procedures like embolization. Surgical repair may improve sperm parameters and fertility outcomes.

2. Varicocele &
Infertility
Dr Tasawar Hussain Chatha
PGR Urology

3. History
30 years Male
Resident of Gujrat
Driver by profession
Married
Admitted thorough OPD

4. Chief Complaint
• Subfertility 2 years

5. • Married for 2 years
• No Urinary Complaints
• No history of trauma to genitalia
• No past surgical or Medical history
• Wife workup normal
• Non smoker

6. Examination
• GPE & Abdomen: Unremarkable
• Scrotal examination:
• No visible scar mark, Cough Impulse Negative
• Left hemi scrotal swelling just above the testes
• Non tender, prominent on standing and on valsalva
• And reduced on lying down
• Both testes normal in size and both vas deferens
palpable
• Clinical Diagnosis > Left Varicocele

7. Scrotal Ultrasound

8. Semen Analysis Report

9. Surgical Course
• Patient underwent left high ligation
• Perop there was single dilated spermatic vein in the
retroperitoneum which was ligated and divided.
• Postop recovery was smooth
• Discharged on 1st postop day
• Called for follow up with semen analysis report

10. Varicocele

11. Varicocele
• Definition
• Etiology
• Pathophysiology of testicular changes
• Clinical features
• Investigations
• Treatment –
- Expectant treatment
- Indication of intervention
- Treatment options
- Complication of surgery
• Complication of untreated varicocele

12. Definition
Dilated & tortuous veins of pampaniform plexus of
spermatic cord found in about 15% of male adolescents
with a marked left sided predominance

13. Etiology
Responsible factors
• 8-10 cm longer left testicular Vv. → increased
hydrostatic pressure in upright position
• Entry of left testicular Vv into renal vein at 900
• “Nutcraker phenomenon” due to passage of
left testicular vein between SMA & Aorta
• Congenital absence of valve in left vein in 40%
• Intrinsic ectasia of plexus due to cremaster
atrophy
• Loaded left colon

14. Etiology

15. Pathophysiology of testicular
changes
Adverse effects on spermatogenesis –
• Reflux of renal and adrenal metabolites
• Hyperthermia
• Hypoxia
• Local testicular hormonal imbalance
• Intra testicular hyper perfusion injury
• Increased oxidative stress

16. Clinical features
(Symptoms)
• Asymptomatic - detected during medical
examination or evaluation of infertile male
• Constant dragging pain in Testis aggravated by
standing & relieved by lying down
• Impaired sperm quality
• Cosmetic attention
• Swelling in scrotum
• Failure of affected testis to grow

17. Clinical features (signs)
Examine in warm room, standing & lying position,
with or without valsulva maneuver
• Painless compressible mass with feeling of “Bag of
worms”
• Small sized Testis on affected side

18. Grades of Varicocele
Grade I – Palpable only during valsulva
maneuver
Grade II – Palpable without Valsulva in
standing upright position
Grade III – Visible through scrotal skin
Subclinical – detected during USG

19. Investigation
• Doppler stethoscope (5.3 MHz probe) -audible rush of
blood on valsulva
• Colour Doppler –detects Sub Clinical Varicocele also
• Ultra sound of abdomen
• Semen examination

20. USG & Colour Doppler

21. Treatment
• Expectant treatment – in adolescent males who are
asymptomatic with normal size of testis

22. Indication of
Intervention
• Asymptomatic varicocele with >20% volume loss of
Testis (>2ml)
• Symptomatic varicocele
- Impaired sperm quality
- Pain
- Cosmetic reasons
• Medically unfit

23. Treatment alteratives
(Obliteration of internal spermatic veins)
• Scrotal approach
• Inguinal approach (modified Ivanissevich)
• Retroperitoneal approach (Palomo’s)
• Sub inguinal approach
• Laparoscopic approach
• Per-cutaneous embolization – through trans
femoral/ trans jugular access (Detachable
balloons or steel coils are used)
• Micro Surgery
• Antigrade scrotal sclerotherapy (ASS)

24. Laparoscopic approach

25. Percutaneous
embolization

26. Percutaneous
embolization

27. Microsurgery

28. Antegrade Sclerotherapy

29. Complications of
treatment
• Hydrocele formation – due to ligation of lymphatics
• Recurrence
• Testicular infarction
• Migration of coil to pulmonary artery – usually not
fatal
• Infection & haemorrhage

30. Complication of untreated
varicocele
• Male infertility
• Testicular atrophy