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The commonest reason for male infertility is a low sperm count, and the commonest reason for this is what doctors call "idiopathic" which simply means, we do not know! This is one of the reasons why the diagnosis of male infertility is so frustrating for both patients and doctors - there are few tests available which allow us to pinpoint the cause of the problem. This also means that there is very little in the form of effective therapy which we can offer these men if we do not know what is wrong, how can we treat it?
However, what about those conditions which we think we do understand? Let's discuss these in detail.
One of the commonest reasons for a low sperm count according to some doctors is a varicocele. A varicocele is a swollen varicose vein in the scrotum - usually on the left side. The condition occurs because blood pools in the varicose testicular veins (pampiniform plexus) since the valves in the veins are leaky and do not close properly. The reasons for infertility associated with a varicocele are unclear. Perhaps the accumulation of blood causes the testes to become hotter and so damage sperm production; or the pooled blood brims over with abnormal hormones which may change the way the testes make sperm. The effect of the varicocele on an individual's sperm count is variable and this may range from no effect whatsoever to causing a decreased sperm count. Varicoceles may also have a progressively damaging effect on sperm production, so that the sperm count may decline with time.
How is a varicocele diagnosed? The doctor examines the patient in the erect position and feels the spermatic cord the cord like structure from which the testis hangs. The patient is also asked to cough at this time. A varicocele feels like a "bunch of worms" and on coughing, this gets transiently engorged. Confirmation of this diagnosis is best done by a Doppler test at the same time. The Doppler is a small pen - like probe which is applied to the cord. It bounces sound waves off the blood vessels and measures blood flow by magnifying the sound of blood flowing through the veins. This can be recorded. Patients with a varicocele have a reflux of blood during coughing which shows up as a large spike on the tracing. Other tests which are done uncommonly to confirm the diagnosis of a varicocele include: Doppler ultrasound; special X-ray studies called venograms; and thermograms.
What are the areas of controversy about a varicocele? Most doctors are still not sure whether a varicocele causes a low sperm count or not! It is possible that the varicocele may be an unrelated finding in infertile men - a "red herring", so to speak. Strangely enough, only a quarter of men with varicoceles have a fertility problem. Thus, many men with large varicoceles have excellent sperm counts which is why correlating cause (varicocele) and effect (low sperm count) is difficult.
This means that surgical correction of the varicocele may be of no use in improving the sperm count - after all, if the varicocele is not the cause of the problem, then how will treating it help? In fact, controlled trials comparing varicocele surgery with no therapy in men who have varicoceles and a low sperm count have shown that the pregnancy rate is the same - so that it does not seem to make a difference whether or not the varicocele is treated!
© Dr. Aniruddha Malpani and Dr. Anjali Malpani www.drmalpani.com
Credits: How to Have a Baby: Overcoming Infertility