Archive for the ‘Varicocele’ Category

FAQ From My Patients

April 12, 2014

I am frequently asked questions by my patients and the answers may be of interest to you. If you have any questions that you would like me to answer, please write me at nbaum@neilbaum.com. to your good health.

I am a 60 yr. woman with recurrent urinary tract infections. I was told to drink cranberry juice. Is that effective?
Studies have documented that within eight hours of drinking cranberry juice, the juice could help prevent bacteria from developing into an infection in the urinary tract. Previous studies have suggested that the active compounds in cranberry juice work to fight against bacteria, including E. coli. Naturopaths believe in the medicinal value of cranberries. My own experience with hundreds of patients is that cranberry juice helps but you must drink 4-6 glasses a day, which is also a lot of sugar. So I suggest the cranberry juice pills. Anyone who suspects they have an infection should see a doctor, but drinking cranberry juice may be an easy, inexpensive way to help keep E. coli at bay.
I have chronic prostatitis. Is zinc helpful for this condition?
Zinc plays an important role in maintaining and improving prostate health. While zinc is found in every organ, tissue and cell in the human body, in males, the prostate has more zinc than any other tissue except bone.
As men get older, they tend to exercise less and their diets change as well, often causing them to fall short of the recommended daily allowance of zinc. Men who don’t have significant levels of zinc in their diets tend to have higher instances prostatitis. They also have higher prostate cancer rates.
The recommended daily allowance for men is 11 milligrams. Zinc is found in many popular foods, including meat and poultry, as well as oysters, beans, nuts, crab, lobster, whole grains, fortified breakfast cereals and dairy products.

My urologist told me that I have a varicocele. Will this cause me to have a problem with infertility?

Yes it may. Varicoceles are enlarged varicose veins that occur in the scrotum. They are fairly common, affecting 15 out of 100 men overall and one of the most common causes of male infertility because the heat from the dilated veins affect sperm production. Varicoceles occur most often in the left testicle. A varicocele repair is done to improve male fertility and is accomplished on an outpatient basis with improvement in the sperm producing in 3-4 months after the procedure.

I had radiation therapy for prostate cancer and now have a loss of my sex drive. What is the cause?
Men who receive radiation therapy for prostate cancer often receive injections to lower the testosterone level to decrease the growth of the cancer. Testosterone is responsible for the sex drive or libido. Often the testosterone level will return to normal after the medication is discontinued after the radiation therapy. In some instances men can receive testosterone one year after radiation if the PSA level stays at a low level. I suggest you have a discussion with your urologist about the use of testosterone in men with prostate cancer.

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Common Causes of Infertility in Men

August 28, 2013

Sperm making contact with egg

Sperm making contact with egg


About 10 percent of reproductive-age couples in the United States will have difficulty getting pregnant. About 30 percent of cases are due to fertility problems in the man, 30 percent to fertility problems in the woman, and the rest to unexplained causes or multiple factors involving both partners.

If you’ve had regular, unprotected sex for more than a year (or six months if you’re over 35) without conceiving, see your doctor. The National Infertility Association says at least half of those who have an infertility evaluation and treatment will be able to have a successful pregnancy.

A reproductive urologist can identify male fertility issues, recommend treatment options, and help couples decide which options to pursue. You also may want to see a genetic counselor. Sometimes, there’s a genetic reason for male infertility that could be passed down to children. A genetic counselor can help couples understand their options for conceiving.

Read on to learn about the common causes of infertility and available treatments. Keep in mind that success rates may vary because one couple can have multiple fertility problems.

Lifestyle factors. Making healthy choices can improve your fertility. You may be at greater risk of having trouble conceiving if you:

• Smoke;
• Drink alcohol heavily; Use drugs;
• Take anabolic steroids;
• Take certain medications, including testosterone replacement therapy;
• Have been treated for cancer;
• Have poor nutrition;
• Are significantly over- or underweight;
• Are exposed to toxins, such as pesticides or lead.

If you have any of these risk factors, be sure to tell us about it during your consultation.

Blockages. A small percentage of men have a blockage in their ejaculatory duct that prevents sperm from getting into ejaculate fluid. If your vas deferens or epididymis tubes are blocked or damaged, they can prevent your sperm from getting to your partner’s egg. Infection, injury, congenital defects, or a vasectomy could cause this blockage.
• Possible solutions: Surgery to repair an obstruction or reverse the vasectomy, or surgery to remove sperm for in vitro fertilization (IVF).
• Varicocele. Varicoceles (enlarged veins, similar to varicose veins, in the scrotum) raise the temperature in the testes, which may affect sperm production.
Possible symptoms: Some men have scrotal pain, and others have no symptoms. (The problem can be detected through a physical exam or ultrasound.)
Possible solutions: Surgery to repair the varicocele, artificial insemination, or IVF.

Irregular sperm. If you have little to no sperm, poor sperm motility (ability to move), or abnormally shaped sperm, your sperm may not be able to fertilize your partner’s eggs.
Possible solutions: fertility drugs; artificial insemination with donor sperm (or with your own if your count, shape, and motility are not too abnormal), or intracytoplasmic sperm injection (ICSI).

Fertility-Steps To Improve Your Chances

August 21, 2013

Common Causes of Infertility in Men

Hoping for a child

Hoping for a child


About 10 percent of reproductive-age couples in the United States will have difficulty getting pregnant. About 30 percent of cases are due to fertility problems in the man, 30 percent to fertility problems in the woman, and the rest to unexplained causes or multiple factors involving both partners.

If you’ve had regular, unprotected sex for more than a year (or six months if you’re over 35) without conceiving, see your doctor. The National Infertility Association says at least half of those who have an infertility evaluation and treatment will be able to have a successful pregnancy.

A reproductive urologist can identify male fertility issues, recommend treatment options, and help couples decide which options to pursue. You also may want to see a genetic counselor. Sometimes, there’s a genetic reason for male infertility that could be passed down to children. A genetic counselor can help couples understand their options for conceiving.

Read on to learn about the common causes of infertility and available treatments. Keep in mind that success rates may vary because one couple can have multiple fertility problems.

Lifestyle factors. Making healthy choices can improve your fertility. You may be at greater risk of having trouble conceiving if you:

Smoking can be deleterious to your fertility

Smoking can be deleterious to your fertility

• Smoke;
• Drink alcohol heavily; Use drugs;
• Take anabolic steroids;
• Take certain medications, including testosterone replacement therapy;
• Have been treated for cancer;
• Have poor nutrition;
• Are significantly over- or underweight;
• Are exposed to toxins, such as pesticides or lead.

If you have any of these risk factors, be sure to tell us about it during your consultation.

Blockages. A small percentage of men have a blockage in their ejaculatory duct that prevents sperm from getting into ejaculate fluid. If your vas deferens or epididymis tubes are blocked or damaged, they can prevent your sperm from getting to your partner’s egg. Infection, injury, congenital defects, or a vasectomy could cause this blockage.
• Possible solutions: Surgery to repair an obstruction or reverse the vasectomy, or surgery to remove sperm for in vitro fertilization (IVF).

Varicocele. Varicoceles (enlarged veins, similar to varicose veins, in the scrotum) raise the temperature in the testes, which may affect sperm production.
Possible symptoms: Some men have scrotal pain, and others have no symptoms. (The problem can be detected through a physical exam or ultrasound.)
Possible solutions: Surgery to repair the varicocele, artificial insemination, or IVF.

Sperm making contact with egg

Sperm making contact with egg


Irregular sperm. If you have little to no sperm, poor sperm motility (ability to move), or abnormally shaped sperm, your sperm may not be able to fertilize your partner’s eggs.
Possible solutions: fertility drugs; artificial insemination with donor sperm (or with your own if your count, shape, and motility are not too abnormal), or intracytoplasmic sperm injection (ICSI).

No Sperm, No Baby, No Problem

March 29, 2013

Screen shot 2013-03-29 at 1.51.57 PM

 

Women have received a bad rap.  The assumption that most problems associated with the difficulty to conceive and have a baby is the fault of the female partner.  However, let the truth be told, 1\3 are a result of female problems, 1\3 are a male issue, and 1\3 are linked to both male and female problems. 

That’s the bad news.  The good news is that two-thirds of couples treated are ultimately able to conceive.

Part of the issue today is that many women are waiting much later in life to have children.  As women get older they’re going to see more problems trying to conceive. Men are capable of fathering children later in life, certainly into their 40s and 50s. They don’t have the same fertility issues that women have at that age.  That is, the biologic clock of men ticks longer than for women.

Common causes of men’s infertility can be hormonal problems, injuries, illness, medications, or a previous vasectomy. Lifestyle issues like smoking and alcohol use may affect sperm production, but are secondary factors.

A common cause of infertility in men is varicocele, an enlargement of the veins in the scrotum that heats the testicles, affecting the number and shape of sperm.  A varicocle is a common problem and up to 30 percent of all men have a varicocele.

Varicocele can develop in adolescence, and may be discovered by a pediatrician. Because of the long-term effects that can lead to infertility, a pediatric surgeon or urologist may recommend a procedure to correct the problem, depending on the severity. The purpose of the surgery is to seal off the affected vein and route blood flow into normal veins.

Another cause of male infertility is vasectomy.  Men are having a vasectomy, which is a reasonably permanent form of sterilization at an earlier age, and then have a change of heart when they get divorced and then marry a younger partner and want to have children and start a second family.  A vasectomy reversal is now quite successful and can be done as an outpatient in an ambulatory treatment center.

More recently, the public has been bombarded with advertisements for medications aimed at correcting low testosterone or low T. These popular medications for hormone replacement for low testosterone may affect a man’s future fertility.  Men should talk with their doctors about medications if they are trying or may be planning to achieve a pregnancy in the future.

Bottom line: Infertility is just as much a man’s problem as it is for the woman.  Help is available and the place to start is a semen examination to be sure that the man has all the ammunition he needs to father a child. 

When There’s a Problem In the Jewel Sack-Scrotal Pain

September 1, 2012

Every man has taken one in the jewel box that bends him over in excruciating pain and discomfort. Fortunately, most of the pain goes away in a few minutes. However, the scrotum and its contents are very vulnerable to injury and disease. This blog will describe the most common conditions affecting men “down there”.

The scrotum is located outside the rest of the body in order to keep the testicles a few degrees cooler than the rest of the body. This is intended to keep the testicles which contain the sperm factories just the right temperature for sperm production.

Normal Anatomy of the Scrotum

The testicles have two functions: 1) sperm production and 2) testosterone production. Testosterone is the male hormone responsible for developing male characteristics like a deep voice, a beard, and the all-important sex drive.

Evaluation of the painful scrotum
Your doctor will take a careful history and find out how long the pain or swelling has been present. The doctor will want to know if the pain is associated with trauma like a soccer ball or someone’s foot to the “vital parts.” The association of pain and swelling with a fever is a sign of infection and inflammation. A physical exam will be conducted and a light may be used to see if there is excess fluid in the scrotum. This is followed by a urine exam and an ultrasound of the scrotum. This makes use of high frequency sound waves that are sent from a transducer and then reflected back to the transducer to be processed by a computer and then projected onto a computer screen. This test will usually diagnose most of the conditions that cause pain and swelling the scrotum.

Torsion

torsion of the testicle

This occurs when the testicle twists and inside the scrotum and cuts off the blood supply to the testicle. Although torsion of the testicle can occur at any age, it is most common in young boys and young men between the ages of 12 and 18. The chief compliant is the sudden onset severe pain in one testicle. It usually begins after exercise but can occur when the boy is at rest or even awaken the boy from sleep. The physical exam reveals that the testicle is painful to touch and drawn up high in the scrotum. The diagnosis is confirmed by the ultrasound exam. Immediate surgery is required in order to save the testicle. If surgical treatment is delayed beyond 4 hours, it is less likely that the testicle can be saved. Although torsion only occurs in one testicle, the urologist will always repair the opposite testicle so that torsion cannot occur on the opposite side in the future.

Testicular cancer

Testis Tumor


Most men with scrotal swelling worry about testicular cancer, it is actually relatively uncommon with only 7000 new cases diagnosed each year. The disease usually affects young men between the ages of 15-40. The cause is not known but it is much more common in males who have a testicle that has not descended into the scrotum at the time of birth. The man with testicular cancer usually notices a hard lump on the scrotum. The lump is usually painless. The diagnosis is confirmed with a blood test looking for tumor markers, beta HCG and alpha feto-protein, and a scrotal ultrasound. The treatment is to remove the testicle and the cancer. Testicular cancer has a very high cure rate. All men should learn to do a testicle self exam at least once a month. Any suspicious lumps or bumps should be brought to the attention of a physician.

Orchitis

Orchitis is an inflammation of the testicle that is associated with pain and fever and swelling. Mumps is the most common cause. It is not very common thanks to the use of vaccination in young boys. Mumps orchitis is caused by a virus and there is no treatment except bed rest, anti-inflammatory medication, and pain medication.

Epididymitis

This is a inflammatory condition involving the gland and ducts that are behind the testicle and are responsible for allowing sperm to mature until they are ready to enter the semen. It is usually a bacterial infection that starts in the urine or the prostate and then backs up and goes down the vas to cause an infection in the epididymis. The problem may be accompanied by burning on urination and a urethral discharge. Men may also have a fever.

The diagnosis is made with a physical examination, a urine test which may show evidence of infection. The treatment is bed rest, a scrotal support or tight jockey underwear to support the scrotum, antibiotics and anti-inflammatory medication.

Hydrococele

hydrococele


A hydrococele is a swelling that takes place slowly over time. Usually months or even years. A hydrococele is a collection of fluid around the testicle, which remains entirely normal. A doctor can easily make the diagnosis by simply transilluminating the scrotum with a bright flashlight held up against the scrotum. The diagnosis can be confirmed with an ultrasound examination.

The treatment is usually surgical procedure which is brief operation, done on a one day stay basis and most men can return to all activities two weeks after the operation.

Spermatococele

Spermatococeles are fluid filled cysts in the epididymis. Spermatococeles are usually painless swellings that can also be diagnosed by tranillunination. Surgery is the treatment of choice if the spermatococele causes discomfort because of its size or if it is cosmetically unacceptable.

Varicocele

varicocele


Varicoceles consist of dilated network of veins in the spermatic cord. This problem is common and occurs in 15% of men and occurs most commonly on the left side. It usually causes minimal discomfort but can be associated with infertility. Treatment consists of surgically tying off the abnormal veins or using a coil placed by a radiologist to occlude the abnormal veins.

Bottom Line: A lump or bump down there should get a man’s attention. Most scrotal conditions can be easily diagnosed in the doctor’s office or with a scrotal ultrasound. Most cases are not serious and prompt treatment will nearly always put a man back in action.

When You Have A Tack In Your Sack-Chronic Testicular Pain

June 15, 2012
When It Hurts Down There

Chronic Testicular Pain

Chronic testicular pain is a common malady causing havoc in men with this problem. The pain can be so debilitating that men lose productivity in the work place, have sexual problems and even depression that requires treatment. Men often have anxiety about cancer. Chronic testicular pain is also called orchialgia, orchidynia, chronic pelvic pain syndrome, or chronic scrotal pain syndrome. These are all terms used to describe intermittent or constant testicular pain.

Chronic testicular pain occurs at any age but the majority of the patients are in their mid to late thirties. The pain can involve one or both testicles. The pain can remain localized in the scrotum or radiate to the groin, perineum, back or legs. On clinical examination the testis may be tender but in the majority of men is otherwise unremarkable.

Causes of orchialgia include infection, tumor, testicular torsion, varicocele, hydrocele, spermatocele, trauma and previous surgical procedures such as a vasectomy.

Any organ that shares the same nerve pathway with the scrotal contents can present with pain in this region. Pain arising in the kidney, hip, prostate gland or back pain caused by a herniated disc can present as testicular pain. Injury to nerves following a hernia repair can cause chronic testicular pain. Chronic testicular pain has been recognized as a feature of diabetic. Some men attribute the start of their chronic testicular pain to some form of blunt injury to the testicles. Unfortunately in a large proportion of patients the cause of their pain remains unknown.

Post vasectomy chronic pain syndrome
It is not common but there is a possibility that following a vasectomy an obstruction or congestion of the vas or in the epididymis may be the cause of the pain.
If the man has an injection of local anesthetic, such as xylocaine, prior to cutting the vas, this may reduce both immediate and long term post vasectomy pain.

The formation of spermatic granuloma following a vasectomy has been well documented but its protective or causative role as been controversial.

Testing
Scrotal ultrasonography is usually part of the evaluation of patients with scrotal pain. However, in the absence of significant clinical findings during physical examination and in the presence of negative urinalysis, the only real benefit of scrotal ultrasound is reassurance to the patient worried about cancer

Treatment
Surgery is to be avoided if possible. Even if infection has not been identified a small number of patients may respond to a combination of antibiotics and non-steroidal anti-inflammatory drugs. Tricyclic antidepressants, such as imipramine, sometimes relieve the pain. Those with intractable symptoms may benefit from a multidisciplinary team approach involving a urologist and a pain clinic specialist including a psychologist. Transcutaneous electrical stimulation or TENS analgesia often have favorable results. This works on the principle that transcutaneous electrical stimulation causes release of endorphins in the nerves of the spinal cord that supply the scrotum.

A spermatic cord block with a local anesthetic such as xylocaine can be done in the doctor’s office. The procedure, if successful, can be repeated in regular intervals.

For patients who fail to respond to conservative management and wish to avoid the surgical options that are available in treating chronic orchialgia, a trial with an alpha blocker might be an option.

For patients in whom all medical treatments have failed and testicular pain continues to impair their quality of life, surgical intervention may be indicated as a last resort. A number of surgical strategies have been described.

Microsurgical denervation of the spermatic cord may provide relief of chronic testicular pain. Another technique is to divide the ilioinguinal nerve and its branches.

Removal of the epididmymis or epididymectomy should be performed only if the patient had been counselled regarding the likelihood of poor results.

Vasectomy reversal
Putting the vas back together or a vas reversal has helped a number of men with chronic testicular pain.

Unfortunately a small number of patients who fail to respond to medical or more invasive treatment will ultimately undergo removal of the entire testicle for pain relief. This procedure must be the last resort.

Bottom Line:
Chronic testicular pain remains a challenge to doctor as well as the patient.
Help is usually available with medication, nerve stimulation with TENS, and only surgery as a last resort.

Pain in the Pouch- Scrotal Pain May Be Coming From Somewhere Else

June 9, 2012

By far, most causes of pain in the pouch is from the testicles and the epididymis, the gland behind the testicle where sperm are nurtured and mature. But there are other causes of scrotal pain that must be considered and which have different treatments.

Testicular tumors do not usually cause pain, but it is possible. Since testicular cancer is common in young men (between the ages of 18 and 32) and is often cured if treated early, prompt medical attention to any lump is important. If you feel something down there that is new or is hard, see your doctor right away.

Inguinal hernia—An inguinal hernia is part of the intestines which protrudes through the inguinal canal (passageway connected to the scrotum). Inguinal hernia is suspected if swelling or pain above the scrotum worsens with coughing, sneezing, movement, or lifting. This condition is fairly common, especially in young boys, and it occasionally causes pain in the scrotal area. Premature infant boys have the highest risk for inguinal hernia. This condition usually results from an abdominal wall weakness present at birth, but symptoms may not appear until adulthood.
Hernias do not resolve without treatment and may cause serious complications if not treated. Hernia repair surgery is usually required to treat this condition. Often this surgery can be done through a laparoscope which consists of a several pencil sized openings in the lower abdomen. Most men can go home the same day of the surgery and resume all activities, including heavy lifting in 3-4 weeks after surgery.

Pudendal nerve damage (neuropathy), also called “bicycle seat neuropathy,” may cause numbness or pain. Pudendal nerve damage can result from the pressure of prolonged or excessive bicycle riding (e.g., competitive cycling), especially improper seat position or riding techniques are used. Special bicycle seats have been designed to decrease pressure on the area between the scrotum and the rectum, potentially preventing or resolving this problem. Pudendal neuralgia is the painful type of this nerve damage. Sometimes called “cyclist’s syndrome,” pudendal neuralgia is painful inflammation of the pudendal nerve. The pudendal nerve carries sensations to the genitals, urethra, anus, and perineum (area between the scrotum and anus), so the pain can be felt in any of these areas. Pain can be piercing and is more likely to be noticed while sitting. If untreated, nerve damage can lead to erectile dysfunction or problems with bowel movements or urination, such as involuntary loss of feces or urine (e.g., urinary incontinence).

Pudendal Nerve Damage

Narrow bike seat can cause pudendal nerve injury

Surgery—Temporary testicular pain and swelling can be expected after surgical procedures in the pelvic area, such as hernia repair and vasectomy. Post-surgery pain that lasts longer than expected should be reported to a physician. Chronic or recurring pain may be the result of a surgical complication or an unrelated problem, and may need treatment.
Kidney stones—Stones usually cause abdominal pain, but the pain radiates into the testicular area in some cases. Intense, sudden, and severe pain in the scrotum that cannot be explained by a problem in the scrotum may be caused by kidney stones.

Swelling with mild discomfort—Conditions that cause swelling in the scrotal area also may occasionally result in mild discomfort. These conditions include varicocele, hydrocele, and spermatocele. Many cases are benign (mild and non-threatening), but swelling and discomfort in the scrotal area should be addressed by a doctor. If a hydrocele (an abnormal fluid-filled sac around the testicles) becomes infected, it can lead to epididymitis, which can cause severe pain.
Unrelieved erection—An erection that does not end in ejaculation sometimes can cause a dull ache in the testicles. This minor ache, commonly called “blue balls,” is harmless and usually goes away within a few hours or when ejaculation occurs.

Bottom Line: Scrotal pain is common condition that usually involves the structures in the scrotum. However, there are other conditions that can cause scrotal pain. If your doctor evaluates these other causes of scrotal pain, effective treatment can relieve the discomfort.

OH MY GOSH! ! !! ! ! ! !

May 26, 2010

I opened the paper and who do I see?

None other than The King of Pee.

Peas and Pizza-­Just about the best

And the SI* swimsuit edition would put the patient UP for the test!

As he entertains himself

With SI (and his new plot in life)

He will have to give thought

Of how to appease his wife.

Oh Doctor Whiz you’ve done it again:

Microwaves and vasectomies show you’re the KING PIN!!! !!

*Sports Illustrated

Reprinted with permission by Eugenia Lind

Male Infertility-It’s Not Always the Woman’s Fault

May 9, 2010

Nothing is more devastating to a couple than the inability to conceive and have a child.  Infertility is currently a problem for one out of five couples presently trying to have children.  In one-third of the couples the problem is due to a problem in the man; one-third is due to a female cause; and one third is due to both the man and the woman.  Therefore in nearly 2\3 of the couples, there is a male factor associated with the failure to conceive or for the woman to become pregnant.

Any couple embarking on an infertility work-up does so with some fear and reluctance.  It often helps to know what is ahead, to be informed and aware of how it will feel and what the doctor is hoping to find.

The nature of the infertility work-up necessitates that it become a priority in your daily life.  Suddenly, there are specific days that you must have intercourse.  In certain tests you even have to report to the doctor’s office a specific number of hours after intercourse.  As a result, spontaneous lovemaking becomes difficult.  Vacations and business trips become low priority.  Schedules have to be made to fit the demands of the testing cycle. Many women find it hard to take time off from work, especially if they don’t want it known that they are undergoing an infertility evaluation.  It is a stressful time.  Both husband and wife are being tested and scored.  There is a feeling of “pass or fail” and a real sense of despair if a test comes back showing questionable or negative results.  Women often feel frightened and violated by the infertility tests.  Men often feel helpless.  For the husband, testing is over if the semen analysis is normal.  In contrast, he may see his wife having to go through various tests which can be painful and frightening.  This understandably can upset both members of the couple.  Added to this worry and uncertainty is the lingering fear of what the doctor will find.  What if they indeed find an answer, but a discouraging one?  Suffice it to say that deciding to start an infertility workup is a big decision. (This paragraph could be deleted if you are pressed for space)

The following is an overview of the tests involved.  You may want to use it to understand what may be required medically or as a tool to double-check that you have had all the tests.

Initial Appointment

Some infertility specialists like to see the couple together for the first appointment.  This provides a opportunity for the couple to establish good communication with the doctor.  It also is an opportunity to evaluate what, if anything, has been done and what will be needed in the future.  The doctor will be able to explain tests to the couple and will give them a time frame in which he or she hopes to complete the evaluation.(Could be deleted)

The doctor will take a very careful medical history from the male. The doctor will want to know about the medical history of the immediate family.  Attention will be paid to details concerning previous surgery, infections, chronic illnesses, and hospitalizations.  Background information on smoking, alcohol intakes and medications and exposure to environmental or occupational toxins will be requested.  Of course, a reproductive history from both partners will be needed.  Details about the types of birth control practiced will be obtained.  In addition, any history of previous pregnancies should be discussed. Information about frequency and nature sexual intercourse and previous venereal disease is crucial in the evaluation.

Physical Examination

A physical examination of the male is usually done on the first visit.  The physical exam will include an examination of the genital organs, with the doctor noting size, position and condition of the penis and testes.  A rectal exam is done to determine the size and consistency of the prostate gland and seminal vesicles.  The doctor will also note the development of secondary sex characteristics such as hair and fat distribution.

The Medical Evaluation of the Male

Semen Analysis – This is the first and most informative test done on the male.  An analysis can be done any time because a man is not cyclic as women are.  Abstinence from intercourse for 48 hours before the analysis is suggested.  Abstinence for a longer period than two days is not necessary.  For the semen analysis, the doctor will ask the man to masturbate a specimen into a sterile container.  This can be done at home and kept at body temperature and delivered to the lab for evaluation.   Then the laboratory will examine the specimen under a  microscope looking for the number of sperm present, how fast the sperm are swimming (motility) and the shape of  the sperm (morphology).

A fertile semen specimen should have at least 20 million sperm, with at least 50% of the sperm motile and 50-60% with good morphology.  Normal volume is 2-5 cc.

Several additional tests may be done on the male if the semen analysis is not normal.

Evaluation for a varicocele is done by palpating the scrotum while the man is bearing down or coughing.  The link between the presence of a varicocele and infertility is not clearly understood.  The most common theory is that the presence of a varicocele causes poor circulation which ultimately inhibits normal sperm production.

In the event of a subfertile semen analysis, a small biopsy of both testicles may be done.  This procedure is done in a hospital under local or general anesthesia.  The testicular tissue is examined in the laboratory.  This test can tell the doctor if there is an absolute infertile state with no sperm-producing tissue present, or blockage in the vas deferens indicated by the presence of normal testicular tissue yet little or no sperm in the ejaculate.

Finally, if a blockage in the vas deferens is suspected during a testicular biopsy, a vasography can be done to pinpoint the area of  the blockage.  This is an x-ray study in which dye is injected into the vas deferens and a series of x-rays are taken.

Once an infertility work-up is underway it is  important that the couple get the results of each test as they are done.  Couples should ask  their doctors for explanations if need be.  It is your body and you have a right to know what is being discovered.  Sometimes it is wise to make a consultation appointment with your doctor if you feel confused or upset about the tests end results.  This is especially important if the work-up has been going on for a long time or if there is a male factor  problem as well as a female one, which is being treated by another doctor.  It is easy to feel helpless and powerless during an infertility work-up.  Good communication with your doctor can help alleviate some of these feelings.

If men have a normal semen analysis, then the focus shifts to the female partner.  For men who have decreased sperm counts or abnormal motility, there are medications that can be given to enhance the number of sperm and methods to put the sperm in contact with the egg.

Bottom Line: Infertility is problem that impacts the lives of many young couples hoping to conceive a child.  The man is cause of the problem in 50% of infertile couples.  Help is available and much can be done to help a couple make their dreams come true.

Varicocele-A Cause of Male Infertility

May 9, 2010

Varicocele is a mass of enlarged and dilated veins that develops in the spermatic cord within the scrotal sac. A varicocele can develop in one testicle or both, but in about 85% of cases it develops in the left testicle.

Incidence and Prevalence

Approximately 40% of infertile men have a varicocele and among men with secondary infertility -those who have fathered a child but are no longer able to do so-prevalence may be as high as 80%.

Signs and Symptoms

Most men who have a varicocele have no symptoms. Asymptomatic (i.e., symptom-free) cases are often diagnosed during a routine physical examination. Signs and symptoms include the following:

  • Ache in the testicle
  • Feeling of heaviness in the testicle(s)
  • Infertility-can suppress sperm counts and sperm movement
  • Shrinkage (atrophy) of the testicle(s)
  • Visible veins under the scrotal skin-the veins collapse when the man lies down
  • Recurrent or constant discomfort or pain in the genital region should be reported to a urologist to determine the cause.

Treatment

If the patient with varicocele is asymptomatic and infertility is not an issue, no treatment is warranted. If the discomfort is mild, the condition usually can be managed by wearing an athletic supporter or snug-fitting underwear during strenuous activity or exercise.

Surgery

If the varicocele causes pain or atrophy (rare) or if the condition is causing infertility (most common), surgery may be recommended. Most varicoceles can be corrected through a surgical procedure called varicocelectomy (i.e., surgically “tying off” the affected spermatic veins).

Surgical ligation

This treatment usually requires general or regional anesthesia. In this procedure, a 2- to 3-inch incision is made in the groin or lower abdomen, the affected veins are located visually, and the surgeon cuts the veins and ties them off above the varicocele to reroute the blood through unaffected veins. Surgery can be performed on an in- or outpatient basis. The patient typically can resume light activity within a week and strenuous activity in about 6 weeks.

About 50% of men who undergo varicocelectomy to correct infertility father children within the first year. It takes about 90 days for a sufficient quantity of new sperm to be produced to permit fertilization. Semen analysis usually is done at 3- and 6-month intervals after the operation.

Bottom Line: Varicoceles are very common and can be a cause of male infertility.  Help is available and most men can have improvement in their sperm counts after surgical correction