Milestone in Urology

VARICOCELE IN SUBFERTILITYRESULTS OF TREATMENT

W. SELBY TULLOCH, F.R.C.S.Ed.Surgeon, Urological Unit, Western General Hospital, Edinburgh

(Br Med J, pp. 356–358, August 6, 1955, reprinted with permission)

During recent years considerable interest has been di-rected to the subject of fertility in the male. It is becomingmore fully appreciated that in the barren marriage the maleshould be examined, and that such an examination shouldprecede the examination of the female.

When a subfertile state is found, attention is focused on theaetiology and the treatment. Recognized aetiological factorsare inflammatory conditions of the urethra, prostate, seminalvesicles, and epididymis; endocrine disturbances; the failureof testicular development; traumatic and other conditions.Much has been written about methods of treatment: vita-mins, hormonal therapy, operative intervention for mechan-ical obstruction have all been recommended. These methodshave their supporters and opponents, and there is consider-able variation of opinion regarding the value of treatment.

During examination of subfertile males, and in some cases ster-ile males, it has been found that the incidence of varicocele is veryhigh. The term “varicocele” may be defined as elongation, dilata-tion, and tortuosity of the veins of the pampiniform plexus. It wasobserved in the physical examination of males who had a varico-cele—far more common on the left side than the right—that thetestis was sometimes smaller than normal and showed evidence ofsoftening in varying degree. Often the testis on the opposite sideshowed a tendency towards softening. In many cases seminalanalysis of the male who had a varicocele demonstrated variationfrom moderate degrees of subfertility to gross depression of thequality of the seminal fluid, even in some cases to azoospermia.

Dr. J. K. Russell (1954), in a careful study of the relation-ship of varicocele to subfertility in the male, has no doubtthat the incidence of varicocele is higher in men with poor-quality seminal fluid. He concludes: “The purpose of thispaper is not to plead for more active treatment (indeed,attention has been drawn to the dangers of active surgicaltreatment), but rather to challenge the traditional attitudethat varicocele is an innocuous condition and to stress theneed for more extensive investigation into the natural historyof varicocele and the effect which it may have upon fertility.”

It has been stated by such an authoritative worker in the fieldof subfertility as Hotchkiss (1944) that “the surgical correctionof a varicocele is probably only effective as a prophylactic meas-ure against damage which might ensue with passing years. It isunlikely that the operation has other than cosmetic value inlong-standing cases with small soft testes.” The purpose of thiscommunication is to stress the value of operative intervention,provided the correct operative technique is used.

It was considered that venous stasis could have two effectson the germinal epithelium:

(a) Lack of Nutrition of the Germinal Epithelium.—Because ofvenous stasis and congestion it seemed possible that the germinalepithelium was not receiving adequate nutrition and oxygenation.It is well known that upsets of nutrition to tissue can occur in othersites of the body where varicose veins commonly occur.

(b) Upset of Temperature Balance.—For adequate maturation ofspermatozoa a very delicate temperature balance in the scrotummust be maintained. Is it likely that with venous stasis tempera-

ture balance is upset? From a nutritional point of view it is hard toexplain how a male with unilateral varicocele would not producean adequate specimen of seminal fluid from the other testis, and itseems more than likely that the cause is an upset of temperature.Davidson (1954) believes this to be the reason.

ILLUSTRATIVE CASE

Some years ago a male aged 27 reported for examination.On two occasions seminal examination confirmed azoosper-mia to be present. Physical examination showed that there

FIG. 1. Testicular biopsy prior to operation for varicocele. Notefailure of normal spermatogenesis.

FIG. 2. Biopsy from same testis as in Fig. 1 after radical cure ofvaricocele. Note return to normal spermatogenesis.

0022-5347/01/1666-2032/0THE JOURNAL OF UROLOGY® Vol. 166, 2032–2033, December 2001Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.

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was bilateral varicocele, with testes slightly smaller thannormal and of soft consistence. Testicular biopsy proved ofinterest. The primary germ cells—the spermatogonia—werepresent. The lumina of the seminiferous tubules were filledwith considerable cell debris, and spermatozoa were notpresent anywhere in the section (Fig. 1). In view of thesefindings, it was decided to carry out radical cure of thevaricocele. Within three months of operation spermatozoawere found in the seminal fluid. Within nine months thispatient’s wife had become pregnant. The sperm count was27,000,000 per ml. Pregnancy terminated normally. By thesimple cure of a bilateral varicocele a state of azoospermiahad been reversed and a normal pregnancy had taken place.

This patient was most co-operative, and after the pregnancy heallowed a further testicular biopsy. This was taken from the sametesticle as the original biopsy. It was seen, by comparison of thetwo sections, that the germinal pattern of the spermatogenesis inthe seminiferous tubules had returned to normal (Fig. 2).

This successful result stimulated interest in the treatmentof varicocele in the subfertile male. Unfortunately, only asmall proportion of patients agree to operative intervention.

OPERATION

The operation recommended is direct ligation of the sper-matic vessels as described by Mr. W. A. T. Robb at p. 355. Withthis operation there are no dangers of testicular atrophy. Theresults of treatment are classified into three groups (see Table).

Group 1. Return to Normal Fertility with Successful Preg-nancy.—In this group are two patients who reported withazoospermia and whose wives became pregnant. In somecases there is no doubt that with the considerable improve-ment in the sperm count a pregnancy has occurred. In onepatient (Case 10) there was practically no improvement inthe count. This man had been married for six years and apregnancy was initiated within four months of the operation.

Group 2. Considerable Improvement in Sperm Count.—This group includes patients whose sperm count has shownsignificant improvement, but pregnancy has not yet oc-curred. The most striking result is in Case 11; but, unfortu-nately, this man’s wife refuses to be examined. With a spermcount as that in Case 15 operation would not normally beconsidered, but the motility rate after repeated examinationswas 20%. Even with an improvement of count the motilityrate was 25%. It is hoped that many patients in this groupmay yet initiate a pregnancy.

Group 3. Failure.—Although in this series there are tworeversals from sterility to subfertility, the group must gen-erally be regarded as failures. In some patients the poorsperm count has even deteriorated. It may be that the pro-cess of destruction of the germinal epithelium had caused somuch damage that it was not reversible.

SUMMARY

A group of subfertile patients with associated varicocele isdiscussed.

The operation used in all patients was high ligation of themain spermatic vessels. This operation is simple, effective,and without danger to the testicle.

The number of cases presented is small, but it is someyears since the first operation was done, and to collect a largeseries is a slow procedure.

From the results obtained it seems justifiable that where avaricocele is associated with subfertility the varicocele should becured.

REFERENCES

1. Davidson, H. A. (1954). Practitioner, 173, 703.2. Hotchkiss, R. S. (1944). Fertility in Men. Heinemann, London.3. Russell, J. K. (1954). British Medical Journal, 1, 1231.

Results of Treatment

Case Age YearsMarried

Unilateral orBilateral

Varicocele

Highest Sperm Count Time After Operationof Initiation of

PregnancyPre-Op. Post-Op.

Group 1

1 28 2 B Azoospermia 27,000,000 9 months2 29 3 U � 29,500,000 4 �3 30 9 U 3,500,000 66,000,000 4 �4 25 2 U 1,300,000 43,000,000 4 �5 32 4 U 3,500,000 97,000,000 8 �6 27 3 U 1,000,000 29,000,000 9 �7 33 3 U 8,000,000 52,000,000 15 �8 29 4 U 20,000,000 29,000,000 5 �9 30 5 U 25,000,000 43,000,000 25 �10 27 6 B 11,400,000 12,000,000 5 �

Group 2

11 28 4 B 1,450,000 85,000,00012 27 2 U 15,000,000 89,000,00013 31 9 U 15,000,000 74,000,00014 23 3 U 12,000,000 44,000,00015 28 3 U 55,000,000 80,000,000

20% (poor motility) 25% (poor motility)16 32 9 U 28,000,000 44,000,00017 33 4 U 2,000,000 18,500,00018 29 5 U 1,500,000 13,000,00019 28 3 U 23,000,000 32,500,00020 27 4 U 50,000 8,000,000

Group 3

21 29 8 U 19,000,000 23,000,00022 26 31/2⁄ U 3,200,000 5,000,00023 29 4 U 6,000,000 7,000,00024 34 9 U 185,000 690,00025 28 3 U Azoospermia 80,00026 28 2 B � 40,00027 37 4 B 8,500,000 2,250,00028 22 2 U Azoospermia Azoospermia29 36 7 U � �30 26 3 U � �

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