For many women, varicose veins are an annoying companion. Most women have varicose veins in their legs, but men often have them in the scrotum. These varicoceles, also known as varicose hernias, are more common than you might think. About 20% of men have varicose veins in the scrotum. They usually develop during puberty. The degree of severity varies, which is why most men have no problems with varicose veins. However, a striking number of men who are prone to infertility also have varicocele. This link has not yet been clearly established.

Blood supply to the testes

Of course, in order for all the sperm maturation processes to take place, the tissue needs to be supplied with sufficient nutrients. This supply is provided by the bloodstream. Oxygen-rich blood is transported directly from the abdominal aorta via the testicular artery to the testes and epididymis. This artery branches off at the level of the kidneys. As there is a testicle and an epididymis on the left and right, there is also a testicular artery on the left and right. On the way back, the blood is first collected in a venous plexus in the scrotum. This is the pampiniform plexus. Then there is a testicular vein on the left and right, which corresponds to the arteries. Unfortunately, the anatomy of the abdominal cavity is not symmetrical, so the left and right testicular veins also open at different points into the great veins, which then lead to the heart. The right vein can drain directly into the inferior vena cava, which is usually not a problem. The left vein, however, drains into the renal vein at almost a right angle. This angle alone makes venous drainage more difficult. This is also seen in varicose vein hernias, 95% of which are on the left side.

What is a varicocele?

As mentioned above, a varicocele is basically a varicose vein. These are small veins that collect blood because they cannot drain properly. There are many reasons for this. In general, it is important to remember that most veins in the body have to work against gravity. The veins carry oxygen-poor blood to the heart. But the heart is in the chest. So when you stand upright, all the blood from your legs, pelvis and abdomen has to get up somehow. The veins are not very muscular. But they do have valves. These valves only let blood flow in one direction, towards the heart. This prevents the blood from flowing back into the legs due to gravity. A varicose vein hernia often disrupts the function of these valves, making it difficult for the blood to flow back. In the case of the testicles, this is compounded by the fact that the venous outflow is already somewhat poorer due to the anatomy of the vessels.

The reflux causes the veins to dilate and the typical varicose veins can be seen on the surface of the skin. This does not mean that there is no reflux at all, but that it is usually slowed down. It is often the case that varicose veins in the scrotum disappear when the person lies down.

Classifications and severity

Varicoceles are divided into two groups according to their cause. The first group is called symptomatic varicoceles. This means that they are just a symptom of another condition. For example, if a tumour is squeezing the testicular vein, the blood can no longer flow back. In this case, the veins are still visible when you lie down. The other group is called idiopathic. This includes venous valve insufficiency, vascular weakness or altered pressure conditions. If the pressure in the veins changes when you lie down, the varicose veins usually disappear.

As well as being classified by cause, varicose veins can also be divided into three degrees of severity. However, the classification varies somewhat in the literature. The first grade is when the veins can only be palpated by provocation. This is called the Valsalva manoeuvre. The doctor asks you to breathe out against the closed epiglottis, which increases the pressure in the body. In the second degree, the veins are palpable even without this increase in pressure, and in the third degree they are also visible.

Diagnostic methods

To make a diagnosis, the scrotum is first examined and palpated. The Valsalva manoeuvre described above may also be performed. If a varicocele is found, an ultrasound scan will be done. This can rule out tumours and other problems.

In 25% of cases, the varicocele is accompanied by a fertility problem. These patients may have additional tests done on the sperm itself. These include spermiograms or TUNEL tests. You will read more about this here in the coming weeks.

Next steps

In most cases, varicocele does not cause any symptoms. In this case, no treatment is usually needed. However, it can sometimes cause pain or an uncomfortable feeling of heaviness. In addition, many patients come to the doctor with this condition as a result of failed IVF attempts. In the first case, surgery can certainly help. As far as IVF is concerned, the effect of surgery is not yet completely clear. It is thought that the varicocele is not the only cause of infertility, as it does not seem to affect many men. However, it is possible that varicose veins can make sperm that are already of poor quality even worse. In some cases, the quality of the sperm improves after the defective veins have been removed, but this is only true for some patients.

The operation is generally relatively straightforward. The dilated vein can either be removed or sclerosed, and the treatment is usually carried out on an outpatient basis.

However, as surgery is always a risk factor, it should be carefully considered. If IVF continues to fail, you should both be examined. If you are sure that the problem is with the quality of the sperm, you may consider surgery. Before you do this, you can have a spermiogram and a DNA fragmentation test. This will help you weigh up the risks and benefits of surgery. Maybe you'll get lucky and the varicocele really does affect the quality of your sperm. Then you may not even need IVF after surgery.