1. The Varicocele’s Impact over the Masculine Fertility.
Author: Popa Grigore
Research Adviser: University Assistant Dr. Plesca Eduard

2. Varicocele Introduction
A varicocele is an abnormal tortuosity and dilatation of the testicular veins within the spermatic cord.

3. Varicocele General population prevalence 15%-20%
Incidence
General population prevalence 15%-20%
The prevalence in men presenting with infertility 20% to 40%
10% bilateral
90% of varicoceles are left sided
Varicocelele sunt afectiuni frecvente. De altfel, reprezinta principala cauza de infertilitate masculina, fiind responsabile pentru 40% dintre cazuri. Totusi, aceasta afectiune apare la aproximativ 15% dintre barbati si nu determina intotdeauna probleme de fertilitate. Varicocelele au fost identificate la 35-40% dintre barbatii cu infertilitate primara si 81% dintre cei cu infertilitate secundara. Studiile au aratat ca aceasta afectiune determina o lezare progresiva a epiteliului seminal.

4. Varicocele Valsalva (supine and horizontal).
Diagnosis
Valsalva (supine and horizontal).
Testes volumes (bilateral).
Scrotal temperature (thermography).
Doppler ultrasund- reflux.
Scrotal ultrasaund.
Lab tests: sperm analysis, hormon.
Varicocelele se asociaza de obicei cu anomalii ale tuturor parametrilor lichidului seminal. Totusi, pot determina si anomalii izolate in ceea ce priveste numarul spermatozoizilor, motilitate, morfologie si functie.

5. Varicocele
Classification
Grade 0 - Subclinical varicocele; cannot be detected during physical examination; generally identified with ultrasonographic study or venography.
Grade 1 - Detected with palpation with difficulty (< 1 cm); increase in size with Valsalva maneuver
Grade 2 - Easily detected without Valsalva maneuver (1-2 cm)
Grade 3 - Detected visually at a distance (>2 cm)
Scrotal mass/swelling, symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable varicocele, and incidental finding on scrotal US Multiple investigators have directly correlated the degree of testicular atrophy with varicocele grade. Steeno noted that testis volume was reduced by 81% in patients with grade 3 varicoceles and by 34% in patients with grade 2 varicoceles. No patients with grade 1 varicoceles were noted to have testicular atrophy.

6. Varicocele Causes 1) left renal vein Vs. Inferior vena cava.
2) absence of the venous valves: L > R
3) the left renal vein may be compressed between the superior mesenteric
artery and the aorta. "nutcracker phenomenon"
4)Increased length of the left testicular vein: The left vein is cm longer than the right testicular vein.
Unilateral right-sided varicoceles are uncommon and raise the possibility of thrombosis or occlusion of the vena cava (as with a right-sided renal tumor with vena caval thrombosis) or situs inversus.

7. Varicocele
Cause

8. Dilatation of venous plexus Hydrostatic pressure
Varicocele
Pathophysiology
Venous reflux
Dilatation of venous plexus
Hydrostatic pressure
Testicular temperature
Testicular function

9. Increased intracapillary pressure- Interstitial Edema.
Varicocele
Pathophysiology
Increased intracapillary pressure- Interstitial Edema.
Normal Testis Testis with varicocele
H2O
Pc-25mm
H2O
Pc-11mm

10. Varicocele
Pathophysiology
Reasons for altered sperm production, testicular size, and morphologic changes are not clearly understood. Proposed mechanisms for this pathophysiology include the following:
Dilated veins with pooling of venous blood results in increased scrotal and testicular temperature. This is theorized to alter DNA synthesis within the testicle, leading to morphologic changes in sperm and testicular tissue.
Often, in the presence of a varicocele, the ipsilateral testis is abnormally small compared with the contralateral testis. Histologic studies have revealed seminiferous tubule sclerosis, small vessel degenerative changes, and abnormalities of Leydig, Sertoli, and germ cells. These changes have been documented in patients as young as 12 years.

11. Varicocele
Pathophysiology
Low oxygen content in the dilated veins may result in local tissue hypoxia. This could affect both testicular architecture and sperm production.
Renal and adrenal metabolites that reflux into dilated spermatic veins affect testicular tissue damage through undefined mechanisms. Testicular hormone function may be compromised, leading to impaired spermatogenesis.
Effects of a varicocele on semen parameters have been extensively studied in adults. Consistent findings have included decreased sperm motility, lower total sperm counts, and increased number of abnormal sperm forms. A limited number of studies in adolescents with varicoceles have also shown altered seminal parameters in this age group.

12. Varicocele Impact of Varicocele on Sperm Quality Volume 2 ml <
Sperm concentration
mil/ml
Progresiv sperm motiliti
50% <
Sperm morphology
50%<
Sperm DNA
Inactiv mitocondria

13. Varicocele
Methods of surgical treatment

14. Varicocele Surgical treatment
A. Retroperitoneal high ligation of the vein (vein) testicular - Palomo. The original technique involves actually Palomo ligation both testicular vein and artery. Ligtura, including artery, involves the other two sources of pressure as intact testis (a and a deferentiala cremasterica).

15. Varicocele Surgical treatment
Inguinal and sub-inguinal approach is the most commonly used by surgeons. Anatomy familiar, low morbidity and high efficacy of these surgical approaches are ideal. Ligation groin incision is made ​​through the inguinal canal up to external inguinal ring. After isolation of testicular artery is preserved and umbilical cord veins are ligated and sectioned

16. Varicocele Surgical treatment
Microsurgical technique allows a better visualization. Magnification makes anatomical structures easier to identify small anastomotic veins. Iscemie risk of testicular and testicular atrophy by inadequate testicular artery ligation is reduced.

17. Varicocele Surgical treatment High Ligation xx xxx Inguinal
Success
Compl.
High Ligation xx
xxx
Inguinal
Embolisation
Laparoscopic x
Sclerosation
Microsurgical

18. Varicocele Goals and Evidence Scrotal temperature and vein volume Pain
Sperm count
Sperm quality
Testicular growth in adolescence
Hormonal regulation of the testis
Pregnancy rate
Rata barbatilor tratati de inferitilitate la care cauza principala a fost varicocelul este de aproximativ 70 %.

19. Varicocele
Title
The age distribution, disease grading at presentation, treatment strategies and success rate on patients with varicocelle, managed in The 3rd Municipal Hospital, Chișinău and in The 3rd Municipal Pediatric Hospital, Chișinău

20. Varicocele Patients and Method Retrospective study;
Inclusion criteria: male patients ≤19y presenting with varicocelle;
Exclusion criteria: secondary treatment, age > 19y.
Statistic relationship on the results collected concerning the age distribution, disease grading at presentation, treatment strategies and success rate on patients with varicocelle;

21. Varicocele
Goals and Evidence
n = 20p

22. Varicocele
Goals and Evidence
75%
Grading for n
25%

23. Varicocele Goals and Evidence
100% of patients were treated using the Inguinal method (Ivanissech)
Although there are many strategies of tratement for patients with varicocelle, as:
All the patients presented no complications and were fully treated at release from hospital.

24. Varicocele Conclusions
The varicocele is most commonly first diagnosted in young males between 11 and 19 years old and in a quite advanced grade.
Varicocele does not affect erection nor the sexual intercourse, but the treatment delay can cause serious problems of infertility.
The treatment of first choice for all the patients was the Ivanissech method.
The inguinal surgical intervention (Ivanissech) presents a good result at the release from hospital.

25. Varicocele