1. Hassan Jamshidian MD Imam Khomeini Hospital
In the name of God
Hassan Jamshidian MD
Imam Khomeini Hospital

2. Varicocele Is found in: 15% of the general population
35% of men with primary infertility
70-81% of men with the secondary infertility

3. Definition
Abn. Tortuosity and dilatation of the testicular veins within the spermatic cord

6. varicocele The most correctable cause of male infertility
Approximately 90% left sided
10% bilateral,some reports more

7. Why is predominant in Lt. side?
1-Difference in the venous drainage
2-Absence of the venous valves is more common on the Lt side
3- The left renal vein may be compressed between the superior mesenteric artery and the aorta

8. Varicocele & Infertility
1-Temperature
2-Reflux of the renal and adrenal metabolites from the renal vein & hypoxia
Decreased motility in 90% & count in 20%
Stress pattern

9. Varicocele-Grading
Grade 1
Grade 2
Grade 3
Grade sub clinical

11. varicocele Majoity of men with varicocele are fertile
Normal gonadotropin and testosterone level
Some elevated FSH
Abn. GnRH are often present in adolescent and subfertile men with varicocele

12. Whom should be repaired?
1-in infertility with any grade
2-Adolescents with grade 2 or 3 with ipsilateral testicular growth retardation
The presence of a varicocele alone is not an indication for varicocele repair,because the majority of men with varicocele are fertile

13. Repair of varicocele will halt any further damage to testicular function
In large percentage of men ,results in improved spermatogenesis(70%), as well as enhanced Leydig cell function
Conception rate 40-50%

14. Techniques of Varicocelectomy
Technique artery p Hydc Failure
Retropr No % %
Inguinal No % %
Laparoscopic Yes % %
Microcopical Yes %

15. Hydrocele

16. Hydrocele-Definition
The accumulation of fluid within the tunica vaginalis

18. Hydrocele
1-Communicating
2-Simple

19. Communicating hydrocele
-Persistence of the processus vaginalis
Smaller in the morning
Frequently bluish hue in thin scrotal skin
Easy transillumination
Same anatomic defect in hernia
Congenital in origin
All should be explored through an inguinal incision

22. Simple hydrocele Caused by: 1-After varicocelectomy 2-Radiation
3-Testicular tumors
4-Orchio-epididymites
5-Trauma
6-Idiopathic(The most common)

23. Ultasonography is the best method for diagnosis of the hydrocele

24. DD of Hydrocele
Cord cyst
Spermatocele
Tumor of the testis
Hernia

25. Hydrocelectomy 1-Excisional Technique 2-Plication Technique
3- Window operation
4-Dartos Pouch Technique
5-Scleroplasty(Tetracycline derivatives)

26. Comlications of hydrocelectomy
Hematoma (the most common)
Injury to the epididymis or the vas deferens

27. Undescended Testis

28. UDT classification
Cryptorchid
Ectopic

30. Cryptorchid Intra-abdominal(retroperitoneal) Intracanalicular
Extracanalicular(suprapubic or infrapubic)the most common

31. Ectopic testis Superficial inguinal (the most common)
Misdiracted outside the normal path of descent
Superficial inguinal (the most common)
Transverse scrotal
Femoral
Perineal
Prepenile

32. UDT incidence 3% of full term at birth
Unilateral is more common than bilateral
30% in premature infants
Prevalent among small for age, low birth weight, twin neonates
70-77% descend spontaneously by 3 months of age
By age 1 year ,incidence is 1% ,and remains constant throughout adulthood

33. In order for normal spermatogenesis to occur ,it is necessary for the normal testes to descend into the scrotum, a specialized, low temp. environment that maintains a temp. 2 to 3 F lower than core body temp.

34. Theories of Descent and Maldescent
Endocrine factors
Gubernaculum
Intra-abdominal pressure

35. Consequences of UDT 1-Infertility 2-Neoplasia 3-Hernia
4-Testicular torsion

36. UDT-neoplasia
Incidence of test. Tumor in general population is 1 in 100,000,but in UDT is 1 in 2,550(40 times more)
Orchiopexy does not reduce the cancer rate ,but can help in early diagnosis
The most common type in UDT is Seminoma
The prevalence of carcinoma in situ is 1.7% in UDT

37. Diagnosis-UDT Laparoscopy CT MRI Ultrasonography
Testicular angiography or venography

38. management-UDT Orchiopexy before or at 1 year of age
Hormonal therapy(HCG, GnRH)

39. UDT-surgical treatment

40. Torsion of the spermatic cord and testis

42. Torsion
Intravaginal
Extravaginal
Gold standard time 6 hours