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Oganes E. Dilanyan
Urologist, MD, PhD
+7(499)344-03-03

Varicocele

In this article

Varicocele is a condition seen in men and adolescent boys, which manifests as varicose veins in the testicles and spermatic cord. Up to 40% of male infertility can be attributed to this condition. In this article I will explain the reasons and the consequences of varicose veins in the testicles and go over the treatment methods. 

Varicocele in adult males

“Doctor, my husband’s semen analysis appears to be abnormal”; “We are trying to get pregnant and so far not succeeding, we have tried everything”; “Disrupted sperm motility and morphology, we have tried everything and nothing worked”; “I don’t drink, don’t smoke, have no hormonal imbalance, my wife has been thoroughly investigated everywhere possible but we have no children” “Semen analysis shows no sperm.” Where does all this come from? Why does a young man spend months or sometimes years undergoing treatment for various infections, prostatitis, “strengthening” with the help of nuts and honey? Why is a reasonably healthy couple deprived of the chance of parenthood? 

Marmar microsurgical procedure

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- Is the most effective way to treat varicocele according to European and American Associations of Urology.
- I use microsurgical equipment and the highest resolution microscope which allows me to carry out surgical procedures to the highest quality and safety standards.  
- Offering Marmar operations in Moscow I guarantee expert level of diagnostics and successful treatment of varicocele as well as follow up.

I have been treating male infertility for over 20 years. I get visits from 3-4 couples daily with complaints about being unable to have children. Usually there are no other complaints. Typically the wife is tested for infertility first as the pregnancy does not occur. Lots and lots of tests, an array of painful and expensive investigations, hormonal profile, basal temperature monitoring…

And nothing. No detected conditions or other reasons that infertility could be attributed to. Or, even worse, an infection is found and the couple is encouraged to undertake a long and aggressive antibiotics treatment. And still no children. Finally, the husband undergoes semen analysis and the result is severe abnormalities. In milder cases there is a problem with motility or appearance of sperm (morphology). In more severe cases there are no sperm detected in the semen. And surprisingly the male has no symptoms. Only sometimes, after physical exertion there might be some dull pulling pain in the testicle or a feeling of heaviness in the scrotum. Sometimes I hear from patients that Varicocele was diagnosed in childhood.

“A man visits a doctor only after his wife has been thoroughly investigated. Unfortunately such is man’s mentality...”
From a lecture about male infertility.

What is Varicocele: Causes and symptoms in adult males

A Varicocele is an enlargement of veins within the scrotum. During this condition overheating and poisoning of the testicles occurs which in turn leads to disruption of growth and development of sperm. In 50% of all cases male infertility is caused by this condition.

Under normal conditions the blood from the testicles rises to the renal vein. This is helped by the valves in the testicular veins. In a healthy vein blood can only move from the testicle to the renal vein. When the veins are enlarged the valves can’t fully close which leads to the reverse process: blood from the renal vein flows to the testicle. Three testicle damaging factors immediately occur:

 •    Blood pooling in the testicular veins: testicular metabolism products, in other words – poisons, collect and stay near the testicle.

•    Poisons, occurring in the renal vein also poison the testicle once they have got to it. 

•     As the blood in the renal vein is a couple of degrees warmer the testicle overheats.

 

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Здоровая вена яичка с клапанами
Healthy testicular vein with valves
Движение венозной крови
Under normal conditions unoxygenated poison containing blood from the testicle only travels upwards
Расширенные вены при варикоцеле
Testicular vein enlargement during varicocele
Последствия недостаточности клапана
Valve insufficiency leads to reverse blood flow from renal vein
Перегрев и отравление сперматозоидов
Overheating and poisoning of the sperm occurs
“Nothing special, doctor. This is going to sound weird, but it feels like I have worms in the scrotum".
Patient’s account

So when one has varicocele the testicles overheat and get affected by poisons.

What will happen to a human being if they drink a lot of vodka in a sauna? They will be unable to run!”
Overheating and poisoning of the sperm occurs
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Trying to explain the consequences of varicocele to my patients I give the following example: Let’s take a healthy human, place them in a sauna and start giving them vodka to drink. Also, we will lock them in the sauna for a long time and give them a lot of vodka. Then we will take them outside and make them run. Will they run far? Will they be able to run fast? Sperm finds itself in the place of this human. Instead of developing in a cool healthy environment it gets subjected to renal waste products and warm temperatures. Should one really be surprised at the semen analysis abnormalities? Motility is affected – the sperm can’t run after “vodka in the sauna”. Morphology, in other words the shape of the poor sauna and vodka sufferer also gets affected and degenerative forms are seen in the semen analysis.

Infertility and other consequences of varicocele

Due to constant overheating and poisoning of the sperm this condition causes various changes in the semen analysis: most commonly affected are sperm motility (asthenozoospermia) and morphology (teratozoospermia), which in turn leads to male infertility. At the advanced stage of varicocele the production of male hormone testosterone is decreased. Erectile dysfunction also occurs – ranging from mild erectile problems to complete inability to have intercourse.

“Double-sided varicocele? I have read that it only happens on the left side…And only occurs on the right as a result of a tumour!”
Conversation with a patient, who is also a medical student, Moscow

Varicocele on the left... or double-sided?

Վարիկոցելեն լինում է ոչ միայն ձախակողմյան
Thinking that scrotum vein enlargement only happens on the left side is a misconception!

Recently I was present at medical school examination. An all ‘A’s student, future urologist, was answering the exam questions...
— Varicocele is the enlargement of spermatic cord veins, and occurs on the left side in 95% of all cases.
— And what if it occurs on the left and on the right?
— Then we need to look for a kidney or other pelvic organ tumour...
— Well, let’s say there is no tumour, what then?
— Then…Then you are splitting hairs. Varicocele very rarely occurs on the right side. In spite of the student being wrong I gave him an A. He was really trying, it is not his fault that most textbooks in this country postulate left-sided varicocele and do not describe double-sided varicocele at all. The price of such ignorance is often a wrong diagnosis.

There are some western scientists’ articles where it is clearly demonstrated that in fact, in most cases the enlargement of testicular veins it is a double-sided pathology. Therefore the treatment should apply to both sides which will ensure a better result.
The reason for “overlooking” the double-sided varicocele is in the deeply rooted belief in the prevalence of vein enlargement only on the left. Meanwhile this belief is fundamentally wrong, which has been demonstrated in the array of studies using a coloured Doppler ultrasound probe. Unfortunately when the old urology textbooks were written this technology simply did not exist.

What tests and investigations are necessary for a patient with suspected varicocele?

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When investigating a patient with infertility and suspected scrotum varicose veins I carry out an ultrasound scan and coloured Doppler probe of the scrotum on both sides with the patient standing and lying down. Before this I ask the patient to remain standing for a short period of time, and if it is cold outside, to get warm. 
Why do I do this? Because often the filling of the testicular veins only happens when standing up. And cold temperatures can cause blood vessels to constrict which will lead to the lessening of their diameter and I will simply not see the enlarged veins.  
Therefore, if based on the ultrasound scan and a Doppler probe test you have been given the diagnosis on “left-sided varicocele” please think if you have been asked to stand for a short period before the test was carried out. Were both sides of the scrotum checked? Were you cold during, immediately before or after the investigation? Were you examined first in the standing position and then lying down? 
If your answer to at least one of these questions is “no” then there is a possibility of a wrong diagnosis and one should pay close attention to where and how these diagnostics tests are carried out...

“Yes I understand that I have varicocele. But I do not understand what I can do to with it. I apply honey with nuts on my scrotum every day but it does not help!”
Conversation with a patient

How to treat varicocele?

The essence of this condition is the enlargement of the veins of the testicle and reverse flow of warm and poisoned blood to the testicle. The problems that result from this vein enlargement are male infertility, scrotum pain and sometimes prostatitis. Which naturally raises the question about what exactly do I mean talking about varicocele “treatment” and how exactly I am going to do it? 

Varicocele treatment is not limited or entirely defined by surgical removal of varicocele but also aims to cure the patient’s infertility get rid of the pain and prostatitis, in other words it solves the problems caused by the “worms in the scrotum”.

“Doctor, is it at all possible to avoid the operation? It’s a little strange…maybe we could try some stimulation first, or some pills instead of cutting it straight away?”
From a conversation with a patient.

Varicocele surgery

Without surgical intervention the sperm will continue to develop in a poisoned environment therefore any type of stimulation be it with Speman, Spermactine, hormonal medication etc. will simply lead to a greater number of defective sperm with low motility and unable to fertilise an egg.  Is Varicocele treatment at all possible without surgery? Unfortunately all therapeutic, medicinal and traditional home remedies are ineffective at best and in the worst case scenario they waste time and lower the chances for restoring testicular function. 

“IVF/ICSI — is not a panacea. As with any treatment method it has its indications and contraindications”
From a conversation with a fertility specialist.

Would it not be easier to go straight to IVF/ICSI?

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Unfortunately not. Several western studies have shown that in the presence of scrotal veins enlargement the chances for conception to occur and pregnancy continuing with IVF treatment are considerably lower than after the operation. Besides, surgical intervention spikes the chances of the pregnancy occurring naturally. According to some German studies the most effective surgical procedure is the Marmar method operation. In the year following surgery the chance of pregnancy is raised by 52% which after 12 to 18 months rises to 65-7-%.
 

“Five year nightmare is finally over. Thank you Oganes for this precious gift, our baby girl”
Patient feedback

Marmar method surgery is the gold standard in Varicocele treatment

Marmar method surgical intervention
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When suggesting surgical intervention to my patients I tell them about the advantages and disadvantages of all possible methods of treatment. The Marmar microsurgical procedure for treatment of Varicocele is considered to be the best surgical option. Neither the very popular in the past Ivanissevich procedure nor modern laparoscopic surgery or hardening of testicular veins offer the same advantages and effectiveness. 

Marmar operation: What you need to know
Venous outflow after Marmar method surgical intervention.
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Based on years of comparative studies European and American Urology Associations recommend the Marmar method as the gold standard for varicocele treatment. Every patient that I suggest this operation to asks the same question: Why this particular method? Why not laparoscopic surgery? Why not the standard Ivanissevich operation? Why not the testicular vein embolization or microsurgical inosculation? 

Result

First and possibly most important is that Marmar operation leads to great improvement in sperm quality and to pregnancy occurring naturally. This is not just in my experience but also the data from European and American Urology Association. It has been shown that even in really difficult cases of male infertility operated patients have a much higher change of conception.   

Relapses

What is special about the Marmar  method is the use of a very powerful surgical microscope which allows  treatment of the smallest veins. This is why after this particular surgical procedure Varicocele relapse occurrence is no greater than 0,5-1,0%, while laparoscopic surgery results in relapses in 5–10%, and Ivanissevich method up to 40%.

Complications

During most types of surgery testicular artery is damaged in 10 to 40% of cases, which can lead to dramatic fall of nutrients getting to the testicle. In our case we use a surgical microscope, which allows us to save the testicular artery. Applying the European gold standard while preparing the patient for surgery lowers the chances of complications to zero.

Hydrocele

This is a standard complication (up to 30%) of almost all types of surgical procedures. The occurrence of Hydrocele warrants a repeat operation. Microsurgical treatment of Varicocele is an exception. Sevenfold magnification of the operation area allows us to avoid tying of the lymphatic vessels thus avoiding the risk of hydrocele. 

Inflammation and pain

Due to minimal incision (no more than 1,5 cm) pain after microsurgery is practically absent. The patient is discharged the following day. At the same time the Ivanissevich method is characterised by a large incision and up to one week of pain symptoms. Laparoscopy treatment involves entering the abdominal cavity and risk of organ damage.

Radiation

It is known that x-rays damage the testicles, which can lead to an incurable condition of radiation infertility. This is the only reason why I do not recommend embolization or hardening of the testicular vein as the operation is carried out under x-ray and often with high radiation exposure for the patient.

Our Advantages

Professional approach: up to date diagnostic methods of male infertility causes.

Our Team: Specialised science based clinical andrology team.

Board of doctors specializing in infertility: Urologist/andrologist, thyroid specialist, reproductive health gynaecologist.

Our equipment:  Karl Storz surgical microscope and KLS Martin microsurgery kits.

Comfort: no queueing or waiting for a consultation and premium inpatient facility.

Safety: Use of methods recommended by professional associations such as EAU and AAU.

Result: Elimination of testicular varicose veins and its complications.

We are also GCP certified, which confirms we provide the highest standards of diagnosis and treatment.

Certificates

Участник мастер-класса по андрохирургии

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Our guarantees

- We guarantee your safety by using modern and highest quality anaesthesia manufactured in Austria or France. 
-We DO NOT USE low quality equivalents of any drug which significantly lowers the risk of any complications.
-Use of Karl Storz microsurgery microscope guarantees the integrity of the testicular artery for all my patients. 
- Andrology surgical work placements in Austria and Italy together with over 500 Marmar operations ensure absence of complications.   
- We DO NOT REFER our patients to unknown clinics for follow up and further treatment and provide outpatient follow up as well as inpatient treatment. 
 
 

Every patient is provided with a discharge summary with detailed recommendations and an official sick leave certificate.
Information for foreign patients:

If you require treatment for Varicocele in Moscow please contact us. We will arrange admission to hospital on the day of your arrival and carry out all necessary investigations and tests and carry out the Marmar surgery on the following day.  You will be able to return home the day following the operation. 

Your city - Ashburn. Learn how we can organize your visit to Moscow for treatment.
Reviews
Vitaliy D.

Reviews form Prodoctorov.ru website
I underwent a double-sided Varicocele operation in January 2016. Really pleased with the result. Would recommend Dr Dilanyan as a highly professional doctor in his field of expertise. It was also very easy to arrange coming to Moscow for the operation. Hospital stay was 1 day. The rooms were clean and well equipped. The medical staff were polite and well-disposed.

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Sergey D.

Review from Prodoctorov.ru website

My long-distance acquaintance with Dr. Dilanyan started long before I became his patient. I used to read his Live Journal stories with great interest and always admired his talent for writing. Then I found out that the author of these amazing stories is also a great doctor. In every man’s life there comes a point when your body starts to malfunction. I was no exception. At the first sign of discomfort I decided to see a urologist and had no doubt regarding which one I needed to see. I got hold of his email address and wrote to him describing my situation. I was pleasantly surprised by his warm and welcoming attitude. All the necessary tests and investigations were done very quickly. As a result I was given the diagnosis of double-sided varicocele and the decision was made to operate. Dr. Oganes has performed an intricate operation to eliminate my condition. After spending 2 days in a clean and cosy hospital I was discharged. I never even thought about my condition again. I recommended Dr. Dilanyan to many of my friends some of whom had more serious problems and all of them thanked me for this recommendation. Dr. Oganes is a true professional, an amazing doctor and a great person. He is one of the few doctors that inspire trust and make you feel calm. I could not recommend him enough! 

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Ivan T.

Review from Prodoctorov.ru website
I would like to thank Dr. Oganes and his team for performing such intricate work during my surgery on double-sided varicocele. I suffered with chronic prostatitis for 2 years and no one could diagnose me correctly. I came across a web article “ varicocele as a cause for chronic prostatitis” by accident and realised there was a connection despite many urologists being of the opinion that there is no connection between varicocele and prostatitis. I took a very long time choosing the right doctor. And chose Dr. Dilanyan due to his most modern approach to surgery (Marmar Operation) and minimally invasive procedure. It helped and I am now extremely happy! A big thank you to you and your team!

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Artyom R.

Review from Prodoctorov.ru website

I contacted Dr.Oganes a few years ago with a rather unpleasant male problem. I cannot remember the exact name of it but my wife was seriously doubting her choice of life partner when it came to night time activities. Unlike other doctors, Oganes made the correct diagnosis and solved my problem very promptly although hearing him say “We will operate” after examining me frightened me a little initially. Now I am happy to watch my daughter grow and realise that had it not been for Dr Oganes things might not have had such a happy ending. In addition I would like to say that Dr. Oganes also helped my father, a man that has great mistrust in medicine, to combat his kidney stones and became the only doctor that my father trusts.  

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Olga K.

Review from Prodoctorov.ru website
My family has known Dr. Dilanyan for 6 years. I say “family” because I am able to use this term only thanks to him. He was recommended to me by another great doctor, a gynaecologist, E. Govorkova. I had very high white blood cell count in the urine, which almost permanently remained at 17000 mark and sometimes more. I had cystitis which did not only start from intercourse with my husband once in the blue moon but no longer went away at all, and got worse following intercourse. I was 33, it was 2010. My attempts to get pregnant were unsuccessful and gynaecologists could not help me due to my urine test results and constant inflammation. I saw 3 urologists, who looked at me with a dull expression, sighed and wrote “other chronic cystitis” in my notes and prescribed “Phytolysin”, herbs and antibiotics never even offering a follow up consultation while they sat in their huge leather chairs behind the oak desks with palm trees in the office and little fountains in the waiting rooms. Not a single one of them examined me even once. My gynaecologist advised me to see Dr. Dilanyan and I am grateful to her ever since. I rang him. His consultations took place very far away in the middle of nowhere in an old aviation hospital in Sokolniki where he occupied an old and simple consultation room. He examined me, performed an ultrasound scan and explained in great detail what was wrong with me. He sent me for a CT scan to a specific specialist and explained what I needed to do. As a result all the tests were done very quickly and with no hassle and another potential serious problem was quickly ruled out. Diagnosis was made of advanced gaping urethra. The solution was surgery with urethral transposition. While I was getting ready for my surgery my husband continued to be investigated for fertility issues by urologists and andrologists. Semen analysis, ultrasounds and other tests. His semen analysis results were not great and every subsequent one was worse than the one before. Ultrasound did not show anything. I mentioned this to Dr. Dilanyan during one of my consultations. He asked my husband, who was waiting for me outside to come in and see him. 10 minutes later I hear him exclaim “bingo” and varicocele diagnosis was made. My husband had his surgery before me.  My husband is 31. Intricate Marmar operation was performed under spinal anaesthetic. After the operation I immediately received a phone call to inform me the operation went well. He stayed in hospital for 1 night in a clean room with very friendly medical staff. Recovery took 1.5 days. He was fully recovered after about 6 months. Sperm quality gradually improved over this period of time and was back to normal after 6 months. My operation for urethral transposition was also performed under spinal anaesthetic and I spent 1 day in hospital. The staff were very attentive and the food was very good too. The operation was not the easiest as my case was quite complicated as they come.  I recovered very well with no post-operative pain.  Mucous membranes recovery went well under doctor’s control and he also kept in touch with my gynaecologist and gastroenterologist as I have an ulcer. I was fully recovered 7 months later. I have not had a single relapse and my sex life is great. And I had a baby at last. I still call Dr. Oganes with any questions I have. I will never use any other urologist. Over the past 6 years I recommended this great doctor to my friends several times. They are all very grateful for the chance to know this doctor.  Thank you Dr. Oganes for our family! You are a very skilful and attentive professional. Precise work, quick diagnosis and no unnecessary tests. Dr. Oganes does not make his patients run around and deals with a lot of things over the phone. He is very polite. He explains everything in simple terms. He is a very attentive doctor and never abandons his patients after the surgery has been done. He always rings to check up on them.

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