Oligozoospermia is a lack of sperm when a man ejaculates, causing problems with fertility. A normal sperm count is considered 15 million or above sperm cells per millilitre of semen. Anything under that count is considered low and deemed as oligozoospermia. Depending on how mild or severe it is the numbers in a sperm analysis test will reflect that.

Azoospermia is when no sperm found in the ejaculate at all. It is quite common, occurring in around 10% of men with fertility problems and 1% of men overall. There are two ways that it can happen.

It can be caused by two things; an obstruction that is stopping the sperm from entering the ejaculate (obstructive) or because there is a problem with sperm production and productivity (non-obstructive).

The exact cause of this condition is not exactly known. It is thought that there are linked to genetic conditions such as Klinefelter’s syndrome, medical treatment such as chemotherapy or radiotherapy for cancer, drug abuse or varicocele. When appropriate, genetic tests may be undertaken by doing a blood test or Karyotype which checks for major chromosome abnormalities that could explain any related genetic issues to male infertility. Chana can help support any couple/male going through any genetic related disorders that have an impact on fertility.

Diagnosis: Patients will see their GP and are offered an initial assessment, including a semen analysis. If the result of the first semen analysis is abnormal, a repeat confirmatory test will be offered in an accredited laboratory in primary care or at a hospital with a minimum of a 12-week interval.

If azoospermia or severe oligozoospermia has been detected the repeat test will be undertaken as soon as possible. Once results have proven diagnosis of azoospermia a multi-disciplinary team (MDT) will take on the couple's case together to find the right treatment for them.

Patients prior to surgery or chemotherapy that would result in infertility, and who cannot produce sufficient sperm for storage (in number or quality of sperm, as determined by an embryologist) would be offered surgical sperm retrieval and follow the obstructive azoospermia treatment pathway.

Treatment Methods: Surgical sperm retrieval is the retrieval of sperm for fertilisation from the epididymis or testicles to assist conception for couples where the male partner suffers from azoospermia.

The retrieved sperm is used immediately for fertilisation or stored for future fertility treatment. This enables men to father their own genetic offspring through intra-cytoplasmic sperm injection (ICSI) fertility treatment. The alternative would be to use donor sperm.

Surgical sperm retrieval includes the following techniques:

Percutaneous epididymal sperm aspiration (PESA): the collection of sperm through a fine needle inserted directly from the epididymis, where sperm is stored, after it is formed in the testes.

Microsurgical epididymal sperm aspiration (MESA): the collection of sperm with an operating microscope directly from an epididymal tubule.

Testicular sperm aspiration (TESA): the collection of sperm by placing a needle attached to a syringe through the skin of the scrotum and sucking out the fluid and small quantities of tissue from inside the testicle. It is also described as testicular fine needle aspiration (TEFNA).

Testicular sperm extraction (TESE): the collection of sperm from a biopsy or several biopsies from the testicular tissue after making an incision in the scrotal skin and usually used for non-obstructive azoospermia.

Microdissection TESE (mTESE): A similar technique to TESE but an operating microscope is used to identify the best tissue within the testicle which has the highest probability of containing mature sperm. This aims to cause less damage to the structure inside the testicle and reduce the volume of tissue removed, and to therefore have fewer aftereffects such as blood supply problems. It also appears to increase the number of successful sperm retrievals.

Tests for:

Obstructive azoospermia-PESA MESA, TESA, TESE or mTESE.

Non-obstructive azoospermia- TESA, TESE or mTESE.

References: https://www.england.nhs.uk/wp-content/uploads/2018/07/Surgical-sperm-retrieval-for-male-infertility.pdf

www.jonathanramsay.co.uk

What is sperm DNA damage?

It takes around two months for mature sperm to be made and how the genetic material, DNA, is packaged in the sperm is complex. It has been suggested that during sperm cell maturation the DNA is susceptible to factors which may cause the DNA strands to break or fragment, furthermore that this may cause failed IVF cycles or miscarriage.

Several different tests might be used by your clinic to assess the level of DNA damage in your sperm. There is some evidence for a relationship between sperm DNA damage and the outcome of fertility treatment. However, the evidence is conflicting and depends on the type of test used by the clinic. The results of a sperm DNA damage test are unlikely to impact on the management of your treatment.

Is this test safe?

Sperm DNA damage testing is a non-invasive procedure performed on a semen sample, usually before treatment as an additional diagnostic test. This test does not carry any additional known risks for the person undergoing fertility treatment or any child born because of fertility treatment.

Reference- https://www.hfea.gov.uk/treatments/treatment-add-ons/sperm-dna-damage/

Using donated sperm is a major decision and you should take your time to think about whether it’s right for you. You may want to discuss your feelings with friends, family or a professional counsellor before going ahead. A clinic is likely to recommend donor conception if:

• You’re not producing sperm of your own

• Your own sperm is unlikely to result in a pregnancy

• You have a high risk of passing on an inherited disease

Do you need to pay for a donor?

In the UK, it’s illegal to pay a donor anything other than expenses. This means that most donors donate for altruistic reasons rather than financial gain.

The expenses limit is £35 for sperm donors. Normally the donor’s expenses should be covered in your overall treatment cost but double check with your clinic.

Are there any risks from using donated sperm, eggs or embryos?

If you use a donor through a licensed UK fertility clinic there are very few risks. Your donor’s family history will be checked to make sure they don’t have any serious genetic diseases that could be passed onto any children you conceive.

They’ll also be checked for infections including HIV, hepatitis, syphilis and gonorrhoea.

Expanded carrier screening (ECS) or testing involves identifying simultaneously the presence or the absence of many gene variants which might be associated with different conditions of varying severity and predictability. The HFEA does not require UK fertility clinics to carry out ECS and gamete donors are not required to have had this screening. You should discuss any questions that you may have about ECS with your fertility clinic.

How can I find a donor?

The safest option is to find a donor from your clinic. This ensures the donor will be given health checks and supported through the process with information and counselling, minimising the chance of something going wrong further down the line.

Some clinics have a list of sperm, egg or embryo donors that you can choose from. Waiting lists can be long however, particularly if you’re after something specific – choose a clinic to view current donor waiting times.

It’s possible for UK clinics to import sperm, eggs or embryos from abroad. However there are strict conditions that need to be met. You’ll need to find a licenced UK clinic who offers import/export services.

Does the donor have any rights to children conceived from their donation?

If you’re having treatment at a licensed fertility clinic in the UK, your donor will have no legal rights or responsibilities to any children born with their sperm, eggs or embryos. This means:

They will have no legal obligation to any children conceived from their donation.

They won’t be named on the birth certificate.

They won’t have any rights over how the child will be brought up.

They won’t be required to support the child financially.

If you don’t have treatment with a licensed clinic the situation is more complicated. There’s a risk that your donor will be considered a parent by law – with all the rights and responsibilities that brings. Talk to a solicitor to find out more about how this applies to you.

What can I find out about a potential donor?

If you use a donor through your fertility clinic you’ll be able to find out:

• A physical description (height, weight, eye and hair colour)

• The year and country of birth

• Their ethnicity

• Whether they had any children at the time of donation, how many and their gender

• Their marital status

• Their medical history

• A personal description and goodwill message to any potential children (if they chose to write one at the time of their donation).

You can choose to use a donor who you do not know by going to a fertility clinic. You will not know the identity of the donor, but you will be able to access anonymous information about them (such as height and eye colour) from your clinic.

Your child will be able to access anonymous information about their donor when they’re 16 years old and they will be able to find out their identity when they're 18 years old.

Going overseas

Some people choose to travel abroad for donor treatment. This may be because the cost of treatment is lower or that there is a greater availability of donors.

If you are going overseas for treatment because you have heard that waiting lists are long in the UK, you may want to check with a different clinic. Although some clinics report having long waiting lists, some may have shorter waiting times.

If you plan to go abroad for treatment, it is important to remember that different safety and legal rules may apply. Before going ahead with treatment abroad, you should carry out thorough research on:

1- Standards and safety issues abroad

2- Legal issues surrounding donors and parental responsibility

3- The process involved in recruiting and screening donors

4- Whether there are any limits on the number of families that can be created per donor

5- What information you can access about the donor and what information the child will be able to access. As a result, children born from donor treatment abroad may not be able to access information about their donor.

It is important to remember that if you go to a UK-licensed fertility clinic, the donor has no legal responsibility, or rights, towards the child. This is not necessarily the case when treatment takes place in other countries.

It is important to be aware that many fertility-related interventions such as gamete donation involve complex Halachic questions, which are often specific to a couple’s unique circumstances and therefore require individual Rabbinic guidance. Chana is here to assist you in either consulting with the Rabbi of your choice, or in consulting with our Rabbinic Panel on your behalf if you would prefer.

Reference- https://www.hfea.gov.uk/treatments/explore-all-treatments/using-donated-eggs-sperm-or-embryos-in-treatment/

Erectile dysfunction (impotence) is very common, particularly in men over 40 but can also happen in men below this age as well. Erectile dysfunction means that a man is either:

• Unable to get an erection, or;

• Unable to keep an erection for long enough to have intercourse.

• Sometimes, you might also have a low sexual drive.

It is usually nothing to worry about, and will go away on its own, but you should see a GP if it keeps happening.

For more information, causes and treatments see https://www.nhs.uk/conditions/erection-problems-erectile-dysfunction/

Asthenzoospermia- A condition characterized by reduced sperm motility

Azoospermia- A lack of measurable sperm in the male’s semen

Azoospermia factor (AZF)- One of several proteins or their genes, which are coded from the AZF region on the human male Y chromosome. Deletions in this region are associated with inability to produce sperm

CAVD (Congenital Absence of the Vas Deferen)- A condition in which the vasa deferential reproductive organs fail to form properly prior to birth. It may either be unilateral (CUAVD) or bilateral (CBAVD)

Chromosome- An organized package of DNA found in the nucleus of the cell. Different organisms have different numbers of chromosomes. Humans have 23 pairs of chromosomes--22 pairs of numbered chromosomes, called autosomes, and one pair of sex chromosomes, X and Y

Cryptorchidism- A condition in which one or both of the testes fail to descend from the abdomen into the scrotum.

CFTR gene- A gene that provides instructions for making a protein called the cystic fibrosis transmembrane conductance regulator. This protein functions as a channel across the membrane of cells that produce mucus, sweat, saliva, tears, and digestive enzymes

Cystic fibrosis (CF)- A genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections

Embolization- A procedure that uses particles, such as tiny gelatine sponges or beads, to block a blood vessel. Embolization may be used to stop bleeding or to block the flow of blood to a tumour or abnormal area of it

Epididymis- A long, coiled tube that stores sperm and transports it from the testes. It appears as a curved structure on the posterior (back) margin of each testis.

FSH (Follicle-Stimulating Hormone)- a hormone secreted by the anterior pituitary gland which promotes the formation of ova or sperm

Haematocele- A swelling caused by blood collecting in a body cavity

Haematoma- A solid swelling of clotted blood within the tissues

Hypergonadotropic hypogonadism- A disorder of abnormal function of gonads with decreased testosterone in males and oestradiol in females, which results in delayed sexual development

ICSI (Intracytoplasmic Sperm Injection)- A specialised form of In Vitro Fertilisation (IVF) that is used primarily for the treatment of severe cases of male-factor infertility. ICSI involves the injection of a single sperm directly into a mature egg.

IVF (Invitro fertilisation)- One of several techniques available to help people with fertility problems have a baby. During IVF, an egg is removed from the woman's ovaries and fertilised with sperm in a laboratory. The fertilised egg, called an embryo, is then returned to the woman's womb to grow and develop.

Klinefelter syndrome- A genetic condition that results when a boy is born with an extra copy of the X chromosome. It only affects males, and it often isn't diagnosed until adulthood.

LH (Luteinizing hormone)- A hormone secreted by the anterior pituitary gland that stimulates ovulation in females and the synthesis of androgen in males

Microscopic ligation- Surgical procedure performed under general anaesthetic in which the affected veins are dissected

Microsurgical epididymal sperm aspiration (MESA)- The collection of sperm with an operating microscope directly from an epididymal tubule.  

Mosaic Klinefelter syndrome- Results from a random event in cell division early in foetal development. As a result- there are two cell lines within the body. Individuals with mosaic Klinefelter may have less severe signs and symptoms

Non-obstructive azoospermia- The testicles are either producing no sperm or very low numbers of sperm and sperm is not present in the ejaculate. This could be due to a congenital problem or a previous disease or radiotherapy

Obstructive azoospermia- Sperm production is normal by the testes but are unable to be found in the ejaculated semen because of a blockage to the sperm transport tubules or absence of the vas.

Oligospermia- Semen with a low concentration of sperm

Percutaneous epididymal sperm aspiration (PESA)- The collection of sperm through a fine needle inserted directly from the epididymis, where sperm is stored, after it is formed in the testes

Retrograde ejaculation- When semen travels backwards into the bladder instead of through the urethra (the tube that urine passes through).  The main symptoms of retrograde ejaculation include producing no semen therefore inability to impregnate and producing cloudy urine 

Scrotum- A pouch of skin containing the testicles

Semen- Fluid that is emitted from the male reproductive tract and that contains sperm cells

Spermatogenesis- The production or development of mature spermatozoa

Spermogram- A semen analysis that evaluates certain characteristics of a male's semen and the sperm contained therein

Teratospermia- Abnormal sperm morphology (shape), caused by either defect in the head, midpiece and/or tail

Testicular fine-needle aspiration (TFNA)- A less invasive diagnostic tool in nonobstructive azoospermia (NOA) with a rapid recovery compared with conventional surgical testicular biopsy

Testicular sperm extraction (TESE)- The collection of sperm from a biopsy or several biopsies from the testicular tissue after making an incision in the scrotal skin and usually used for non-obstructive azoospermia.  

TRUS (trans-rectal ultrasound scan)- A procedure in which a probe that sends out high-energy sound waves is inserted into the rectum and forms a sonogram picture of the body tissue

Varicocele- An enlargement of the veins within the loose bag of skin that holds your testicles

Vas deferens- The duct which conveys sperm from the testicle to the urethra.

Male fertility problems can have a variety of causes. The most common cause is that the man’s semen has too few normal sperm to fertilise an egg. The first step in identifying the male factor fertility problem is a semen analysis.

A semen analysis should be carried out for any couple seeking treatment for fertility problems regardless of whether there is an identified female problem or a suspected male factor problem. It is a simple procedure which may reveal important information. Even if the male partner has previously fathered children, a semen analysis is necessary since problems may have developed in the intervening time.

A semen analysis includes the following tests:

• Semen volume and appearance

• Sperm concentration

• Number of sperm that are swimming (Motility and progression)

• Number of sperm that are normally shaped (Morphology)

  Sperm concentration is usually considered to be the most critical factor and is expressed in terms of the number of million sperm per milliliter of semen. Sperm motility, or the number of sperm that are active, is usually expressed as a percentage of the total number of sperm.

  Progressive motility is a more accurate value as it measures the percentage of sperm moving in one direction only (instead of round in circles) as these are the most likely sperm to fertilise the egg. Progressive motility is the most useful test from a semen analysis to predict fertility treatment success.

  The number of sperm that are normally shaped, i.e., with normal morphology, is expressed as a percentage of the total number of sperm in the ejaculate.

The following terms have been developed to describe conditions in which one or more of these factors are abnormal:

Aspermia – The patient produces no semen

Azoospermia – The patient produces semen containing no sperm

Oligozoospermia or oligospermia – sperm concentration is low, less than 16 million per ml

Asthenozoospermia or asthenospermia – less than 42% of the sperm are moving, and less than 30% are swimming progressively

Teratozoospermia – less than 4% of the sperm are normally shaped

Oligoasthenoteratozoospermia (sometimes referred to as OATS) – less than 16 million sperm per ml with less than 42% being motile and less than 4% are normally shaped

Necrospermia – all sperm are dead

Poor viability – less than 54% are alive

Pyospermia or leucospermia – presence of large number of white blood cells (more than one million/mL) in the semen, often associated with an infection

If semen analysis has identified an abnormality, a further semen analysis will be necessary 3 months later to check the result.

Causes of male fertility problems

The causes of male fertility problems may be genetic or physical.

Genetic causes

The most common genetic abnormality leading to infertility in the male is Klinefelter Syndrome where the man has an extra X chromosome. Usually, a female has two X chromosomes (XX) and a male has one X and one Y (XY). Men who have Klinefelter Syndrome are born with an extra copy of the X chromosome (XXY). Most men with Klinefelter Syndrome produce no sperm at all. It is untreatable and generally patients can only be offered donor sperm.

Some cases of oligozoospermia may be associated with genetic abnormalities as may some cases of azoospermia. If sperm are present, such cases can be treated using in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). However, it is important to take into account the possibility that these genetic defects may be passed on, and any male children may also have fertility problems.

In some men, sperm fail to be ejaculated because of obstruction in a tube called the vas deferens which carries the sperm from the testis to the ejaculate. This tube may be obstructed on one side or on both sides. In the majority of these cases this condition is the result of genetic mutation including Cystic Fibrosis. These men may have sperm retrieved surgically and may achieve pregnancies using ICSI. However, it is very important that these couples receive genetic counselling and genetic screening as their offspring may be at risk of Cystic Fibrosis or other genetic conditions.

Physical causes

Apart from congenital obstructions of the reproductive tract, obstructions may also result from infection or from surgery or injury. If a man apparently has no sperm in his semen, it is important to establish whether this is the result of an obstruction or whether his testes are not making sperm. A simple hormone test will usually give this information. If the obstruction occurs on one side only, then the sperm concentration may be reduced. If the obstruction is on both sides resulting in azoospermia, sperm can be retrieved surgically directly from the testis, in a tiny biopsy. This is performed as an out-patient procedure under local anaesthetic. However, because the numbers of sperm retrieved are usually low and these sperm may be immature, successful treatment is only likely with ICSI.

Other causes

There are other sperm problems that cannot be identified by semen analysis. This means that a normal semen analysis does not guarantee fertility.

Sperm DNA damage

Some clinics now offer sperm DNA tests in addition to the traditional semen analysis. These tests are usually provided at dedicated labs, outside the fertility clinic. If the sperm DNA damage is high, the clinic will consider this information along with that of test results from the woman. It may be decided ICSI is a better choice than IVF as ICSI may give the egg a better chance of repairing sperm DNA damage.

Sperm DNA tests are also useful for couples with unexplained infertility as these tests can often pick up anomalies. Testing sperm DNA may also be useful after a failed cycle of IVF, recurrent miscarriages, if the man has previously been ill, on medication or has changed his lifestyle for the better. This test might also include assessment of oxidative stress and the presence of free radicals. A sperm DNA test can guide the clinic and couple as to whether IVF or ICSI would be better for their next cycle of treatment.

Treatment

There are very few cases of male infertility or sub fertility that can actually be cured. Generally, when we refer to treatment, we mean techniques that enable us to circumvent the problem.

Assisted conception treatment such as IVF may enable a man to achieve a pregnancy with his own sperm, however he will still be infertile and will need assistance if he wishes to have more children.

IVF is successful with low numbers of normal motile sperm because the sperm and egg are placed together in a petri dish in the lab. This makes it must easier for the sperm to fertilise the egg. Success rates with IVF vary with the severity of the sperm problems.

If the sperm are of low quality, an advance form of IVF called intracytoplasmic sperm injection (ICSI) can be used instead. This is a process whereby a single sperm is injected directly into the egg and can be carried out even when there are very few sperm present in the semen. ICSI can be used very successfully with sperm that have been surgically retrieved from the testis or from the epididymis. This technique has superseded all other micromanipulation techniques and has become the treatment of choice where fertilisation fails with conventional IVF. Since this technique has allowed men to father children who previously would have been unable to do so, concerns have been raised about the inheritance of male infertility, as well as the possibility of other genetic defects. To date, research suggests that there is a slightly raised incidence of sex chromosome abnormalities in children born as a result of ICSI. This is not a result of the technique, but rather a result of the presence of genetic defects in the fathers. However, the incidence is still very low, at around 3%. Couples who need treatment by ICSI should make sure they understand the genetic implications by asking their fertility doctor all the questions they have.

Many patients ask whether there is anything they can do to improve their sperm. The answer is generally nothing other than to live a normal healthy lifestyle.

General tips might include:

Stop smoking (if you are a smoker)

Maintain a healthy BMI- (Body Mass index)

Reduce alcohol consumption

Wear loose underwear

Eat healthily (five portions of fruit and vegetables per day)

Future research is directed at improving results with the existing treatments, and also to find ways to improve fertility so that such invasive techniques such as ICSI or even IVF are not necessary.

Reference- https://fertilitynetworkuk.org/fertility-faqs/male-fertility/male-fertility-problems/

Sperm freezing is the most effective method of preserving a man’s fertility.

You may want to consider sperm freezing if:

• You have a condition, or are facing medical treatment for a condition that might affect your fertility

• You have a low sperm count or the quality of your sperm is deteriorating

• You have difficulty producing a sperm sample on the day of fertility treatment/you may not be around at the time of treatment e.g. if you work away a lot

• You are at risk of injury or death

IVF using frozen sperm is just as successful as IVF using fresh sperm and there are no known risks from using frozen sperm in treatment. Not all sperm survive the freezing and thawing process though. Before sperm is stored, it is usually divided between a number of ‘straws’, which means that not all sperm needs to be thawed at once and it can be used in multiple treatments. From 1 July 2022, all patients can store their eggs, sperm and embryos for their own treatment for up to 55 years, providing they reconsent every 10 years.

When you want to use your sperm, you and your partner will need to have fertility treatment which may involve either insemination, IVF or intracytoplasmic sperm injection (ICSI). Your doctor will discuss this with you when the time comes.

Using donated sperm is a major decision and you should take your time to think about whether it’s right for you. Your chosen clinic should offer implications counselling and you may want to discuss your feelings with a proffesional counsellor at Chana before going ahead. A clinic is likely to recommend donor conception if:

• you’re not producing sperm of your own

• your own sperm is unlikely to result in a pregnancy

• you have a high risk of passing on an inherited disease

*It is important to be aware that many fertility-related interventions such as gamete donation involve complex Halachic questions, which are often specific to a couple’s unique circumstances and therefore require individual Rabbinic guidance. Chana is here to assist you in either consulting with the Rabbi of your choice, or in consulting with our Rabbinic Panel on your behalf if you would prefer.

Reference: https://www.hfea.gov.uk/treatments/fertility-preservation/sperm-freezing/

Retrograde ejaculation happens when semen travels backwards into the bladder instead of through the urethra (the tube that urine passes through).

The main symptoms of retrograde ejaculation include:

• Producing no semen, or only a small amount, during ejaculation (called a dry orgasm)

• Producing cloudy urine (because of the semen in it) when you first go to the toilet after having ontercourse

• Inability to get a woman pregnant (male infertility)

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can cause male infertility. Treatment for retrograde ejaculation is generally only needed to restore fertility.

When to see a doctor:

If you have dry orgasms, see your doctor to be sure your condition isn't caused by an underlying problem that needs attention.

If you and your female partner have had regular, unprotected intercourse for a year or longer and have been unable to conceive, see your doctor. Retrograde ejaculation might be the cause of your problem if you ejaculate very little or no semen.

A dry orgasm is the primary sign of retrograde ejaculation. But dry orgasm — the ejaculation of little or no semen — can also be caused by other conditions, including:

Surgical removal of the prostate (prostatectomy)

Surgical removal of the bladder (cystectomy)

Radiation therapy to treat cancer in the pelvic area

Diagnosis

Your doctor will:

Ask questions about your symptoms and how long you've had them. Your doctor might also ask about any health problems, surgeries or cancers you've had and what medications you take.

Do a physical exam, which will likely include an exam of your penis, testicles and rectum.

Examine your urine for the presence of semen after you have an orgasm. This procedure is usually done at the doctor's office. Your doctor will ask you to empty your bladder, masturbate to climax and then provide a urine sample for laboratory analysis. If a high volume of sperm is found in your urine, you have retrograde ejaculation.

If you have dry orgasms, but your doctor doesn't find semen in your bladder, you might have a problem with semen production.

If your doctor suspects your dry orgasm is something other than retrograde ejaculation, you might need further tests or a referral to a specialist to find the cause.

Causes of retrograde ejaculation

Retrograde ejaculation is caused by damage to the nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder).

Usually when you ejaculate, semen is pushed out of your urethra. It is prevented from entering your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.

However, damage to the surrounding muscles or nerves can stop the bladder neck closing, causing the semen to move into the bladder rather than up through the urethra.

Other causes are diabetes, multiple sclerosis, and a class of medicines known as alpha blockers, which are often used to treat high blood pressure (hypertension).

Treating retrograde ejaculation

Retrograde ejaculation typically doesn't require treatment unless it interferes with fertility. In such cases, treatment depends on the underlying cause.

Medications might work for retrograde ejaculation caused by nerve damage. This type of damage can be caused by diabetes, multiple sclerosis, certain surgeries, and other conditions and treatments. Drugs generally won't help if retrograde ejaculation is due to surgery that causes permanent physical changes of your anatomy. Examples include bladder neck surgery and transurethral resection of the prostate.

If your doctor thinks drugs you are taking might be affecting your ability to ejaculate normally, he or she might have you stop taking them for a period of time. Drugs that can cause retrograde ejaculation include certain medications for depression and alpha blockers — drugs used to treat high blood pressure and some prostate conditions.

Drugs to treat retrograde ejaculation are drugs primarily used to treat other conditions, including:

Imipramine (Tofranil) , Midodrine, Chlorpheniramine (Chlor-Trimeton, others) and brompheniramine (Veltane, others), Ephedrine (Akovaz, others), pseudoephedrine (Sudafed, others) and phenylephrine (Vazculep, others)

These medications help keep the bladder neck muscle closed during ejaculation. While they're often an effective treatment for retrograde ejaculation, medications can cause side effects or adverse reactions with other medications. Certain medications used to treat retrograde ejaculation can increase your blood pressure and heart rate, which can be dangerous if you have high blood pressure or heart disease.

Infertility treatment

If you have retrograde ejaculation, you'll likely need treatment to get your female partner pregnant. In order to achieve a pregnancy, you need to ejaculate enough semen to carry your sperm into your partner's vagina and into her uterus.

If medication doesn't allow you to ejaculate semen, you will likely need infertility procedures known as assisted reproductive technology to get your partner pregnant. In some cases, sperm can be recovered from the bladder, processed in the laboratory and used to inseminate your partner (Intrauterine insemination-IUI).

Sometimes, more-advanced assisted reproductive techniques are needed (In-vitro fertilisation IVF).

Reference: https://www.nhs.uk/conditions/ejaculation-problems/

Diagnosis

When you see a doctor because you're having trouble getting your partner pregnant, he or she will try to determine the underlying cause. Even if your doctor thinks low sperm count is the problem, it is recommended that your partner be evaluated to rule out potential contributing factors and determine if assisted reproductive techniques may be required.

Testing and diagnosis may involve the following:

General physical examination and medical history

This includes examination of your genitals and asking questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility. Your doctor might also ask about your sexual habits and your sexual development.

Semen analysis

A low sperm count is diagnosed as part of a semen analysis test. Sperm count is generally determined by examining semen under a microscope to see how many sperm appear within squares on a grid pattern. In some cases, a computer might be used to measure sperm count.

Semen samples can be obtained in a couple of different ways. You can provide a sample by masturbating and ejaculating into a special container at the doctor's office. Because of religious or cultural beliefs, some men prefer an alternative method of semen collection. In such cases, semen can be collected by using a special condom during intercourse.

New sperm are produced continually in the testicles and take about 42 to 76 days to mature. So, a current semen analysis reflects your environment over the past three months. Any positive changes you've made won't show up for several months.

One of the most common causes of low sperm count is incomplete or improper collection of a sperm sample. Sperm counts also often fluctuate. Because of these factors, most doctors will check two or more semen samples over time to ensure consistency between samples.

To ensure accuracy in a collection, your doctor will:

• Ask you to make sure all of your semen makes it into the collection cup or collection condom when you ejaculate

• Have you abstain from ejaculating for at least two but no longer than 11 days before collecting a sample

• Collect a second sample at least two weeks after the first

• Have you avoid the use of lubricants because these products can affect sperm motility

Semen analysis results

Normal sperm densities range from 15 million to greater than 200 million sperm per milliliter of semen. You are considered to have a low sperm count if you have fewer than 15 million sperm per milliliter or less than 39 million sperm total per ejaculate.

Your chance of getting your partner pregnant decreases with decreasing sperm counts. Some men have no sperm in their semen at all. This is known as azoospermia.

There are many factors involved in reproduction, and the number of sperm in your semen is only one. Some men with low sperm counts successfully father children. Likewise, some men with normal sperm counts are unable to father children. Even if you have enough sperm, other factors are important to achieve a pregnancy, including normal sperm movement (motility).

Other tests

Depending on initial findings, your doctor might recommend additional tests to look for the cause of your low sperm count and other possible causes of male infertility. These can include:

Scrotal ultrasound. This test uses high-frequency sound waves to look at the testicles and supporting structures.

Hormone testing. Your doctor might recommend a blood test to determine the level of hormones produced by the pituitary gland and testicles, which play a key role in sexual development and sperm production.

Post-ejaculation urinalysis. Sperm in your urine can indicate your sperm are traveling backward into the bladder instead of out your penis during ejaculation (retrograde ejaculation).

Genetic tests. When sperm concentration is extremely low, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome — signs of a genetic abnormality. Genetic testing might also be ordered to diagnose various congenital or inherited syndromes.

Testicular biopsy. This test involves removing samples from the testicle with a needle. The results of the testicular biopsy can tell if sperm production is normal. If it is, your problem is likely caused by a blockage or another problem with sperm transport. However, this test is typically only used in certain situations and is not commonly used to diagnose the cause of infertility.

Anti-sperm antibody tests. These tests, which are used to check for immune cells (antibodies) that attack sperm and affect their ability to function, are not common.

Specialized sperm function tests. A number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg and whether there's any problem attaching to the egg. These tests are rarely performed and often do not significantly change treatment recommendations.

Transrectal ultrasound. A small lubricated wand is inserted into your rectum to check your prostate and check for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles).

Treatments for low sperm count include:

• Surgery. For example, a varicocele can often be surgically corrected or an obstructed vas deferens can be repaired. Prior vasectomies can be reversed. In cases where no sperm are present in the ejaculate, sperm can often be retrieved directly from the testicles or epididymis using sperm retrieval techniques.

• Treating infections. Antibiotics can cure an infection of the reproductive tract, but this doesn't always restore fertility.

• Treatments for sexual intercourse problems. Medication or counseling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation. Chana has therapists trained in this specialty.

• Hormone treatments and medications. Your doctor might recommend hormone replacement or medications in cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.

• Assisted reproductive technology (ART). ART treatments involve obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, depending on your specific situation and wishes. The sperm are then inserted into the female genital tract, or used for IVF or intracytoplasmic sperm injection.

When treatment doesn't work

In rare cases, male fertility problems can't be treated, and it's impossible for a man to father a child. If this is the case, you and your partner can consider either using sperm from a donor or adopting a child.

Preparing for your appointment-

You should start with your family doctor or a different provider. However, he or she might refer you to an infertility specialist. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as refraining from ejaculating for a certain period of time or stopping certain medications.

Write down any symptoms you're experiencing, including any that might seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Find out whether you have a family history of fertility problems. Having a male blood relative, such as your brother or father, with fertility problems or other reproductive issues might give clues to the cause of low sperm count.

Find out from your parents if you had undescended testes or other issues at birth or in early childhood.

Make a list of all medications, vitamins and supplements that you're taking.

Take your partner along. Even if you have a low sperm count, your partner also might need tests to see whether she has any problems that could be preventing pregnancy. It's also good to have your partner along to help keep track of any instructions your doctor gives you or to ask questions you may not think of.

Write down questions to ask your doctor.

Some basic questions to ask your doctor include:

What do you suspect might be causing my low sperm count?

Other than the most likely cause, what are other possible reasons my partner and I haven't been able to conceive a child?

What kinds of tests do I need?

Will my partner also need tests?

What treatments are available to increase my sperm count? Which do you recommend?

Are there any restrictions that I need to follow?

At what point should we consider other alternatives, such as a sperm donor or adoption?

Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

What to expect from your doctor

Some questions your doctor may ask you include:

At what age did you start puberty?

Have you had a vasectomy or a vasectomy reversal?

Do you use illicit drugs, such as marijuana, cocaine or anabolic steroids?

Have you been exposed to toxins such as chemicals, pesticides, radiation or lead, especially on a regular basis?

Are you currently taking any medications, including dietary supplements?

Do you have a history of undescended testicles?

Reference- https://www.mayoclinic.org/diseases-conditions/male-infertility/diagnosis-treatment/drc-20374780

The testicles are the 2 oval-shaped male sex organs that sit inside the scrotum on either side of the penis.

The testicles are an important part of the male reproductive system because they produce sperm and the hormone testosterone, which plays a major role in male sexual development.

Types of testicular cancer

The different types of testicular cancer are classified by the type of cells the cancer begins in.

The most common type of testicular cancer is germ cell testicular cancer, which accounts for around 95% of all cases. Germ cells are a type of cell that the body uses to create sperm.

There are 2 main subtypes of germ cell testicular cancer. They are:

• Seminomas – which have become more common in the past 20 years and now account for 40 to 45% of testicular cancers

• Non-seminomas – which account for most of the rest and include teratomas, embryonal carcinomas, choriocarcinomas and yolk sac tumours

Both types tend to respond well to chemotherapy.

Less common types of testicular cancer include:

• Leydig cell tumours – which account for around 1 to 3% of cases

• Sertoli cell tumours – which account for less than 1% of cases

How common is testicular cancer?

Testicular cancer is a relatively rare type of cancer, accounting for just 1% of all cancers that occur in men.

Testicular cancer is unusual compared with other cancers because it tends to affect younger men. Although it's relatively uncommon overall, testicular cancer is the most common type of cancer to affect men between the ages of 15 and 49.

For reasons that are unclear, white men have a higher risk of developing testicular cancer than men from other ethnic groups.

Causes of testicular cancer

The exact cause or causes of testicular cancer are unknown, but a number of factors have been identified that increase a man's risk of developing it.

Undescended testicles (cryptorchidism) is the most significant risk factor for testicular cancer. Around 3 to 5% of boys are born with their testicles inside their abdomen. They usually descend into the scrotum during the first year of life, but in some boys the testicles do not descend. In most cases, testicles that do not descend by the time a boy is a year old descend at a later stage. If the testicles do not descend naturally, an operation known as an orchidopexy can be carried out to move the testicles into the correct position inside the scrotum. It's important that undescended testicles move down into the scrotum during early childhood because boys with undescended testicles have a higher risk of developing testicular cancer than boys whose testicles descend normally. It's also much easier to observe the testicles when they're in the scrotum.

Family history- Having a close relative with a history of testicular cancer or an undescended testicle increases your risk of also developing it.

Previous testicular cancer -Men who have previously been diagnosed with testicular cancer are between 12 and 18 times more likely to develop it in the other testicle.

For this reason, if you have been diagnosed with testicular cancer, it's very important that you keep a close eye on the other testicle.

If you have been diagnosed with testicular cancer, you also need to be observed for signs of recurrence for between 5 and 10 years, so it's very important that you attend your follow-up appointments.

Outcome

Almost all men who are treated for testicular germ cell tumours are cured, and it's rare for the condition to return more than 5 years later.

Treatment almost always includes the surgical removal of the affected testicle (orchidectomy or orchiectomy), which does not usually affect fertility or the ability to have intercourse.

In some cases, chemotherapy or, less commonly, radiotherapy may be used for seminomas (but not non-seminomas).

Typical symptoms

Painless swelling or lump in 1 of the testicles, or any change in shape or texture of the testicles. The swelling or lump can be about the size of a pea, but may be larger. Most lumps or swellings in the scrotum are not in the testicle and are not a sign of cancer, but they should never be ignored.

Other symptoms

• An increase in the firmness of a testicle

• A difference in appearance between 1 testicle and the other

• Dull ache or sharp pain in your testicles or scrotum, which may come and go

• Feeling of heaviness in your scrotum

When to see a GP

See a GP if you notice a swelling, lump or any other change in 1 of your testicles. Lumps within the scrotum can have many different causes, and testicular cancer is rare.

Your GP will examine you and if they think the lump is in your testicle, they may consider cancer as a possible cause.

Only a very small minority of scrotal lumps or swellings are cancerous. If you do have testicular cancer, the sooner treatment begins, the greater the likelihood that you'll be completely cured.

As well as asking you about your symptoms and looking at your medical history, a GP will usually need to examine your testicles.

They may hold a small light or torch against your scrotum to see whether light passes through it.

Testicular lumps tend to be solid, which means light is unable to pass through them.

A collection of fluid in the scrotum will allow light to pass through it.

Tests for testicular cancer

If you have a non-painful swelling or lump, or a change in the shape or texture of 1 of your testicles, and a GP thinks it may be cancerous, you'll be referred for further testing within 2 weeks.

Some of the tests you may have are described below.

• Scrotal ultrasound

A scrotal ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your testicle.

• Blood tests

To help confirm a diagnosis, you may need a series of blood tests to detect certain hormones in your blood, known as markers.

Testicular cancer often produces these markers, so it may indicate you have the condition if they're in your blood. Markers in your blood that'll be tested for include:

• Alpha feto-protein (AFP)

• Human chorionic gonadotrophin (HCG)

• A third blood test is also often carried out as it may indicate how active a cancer is. It's called lactate dehydrogenase (LDH), but it's not a specific marker for testicular cancer.

Not all people with testicular cancer produce markers. There may still be a chance you have testicular cancer even if your blood test results come back normal.

• Histology - The only way to definitively confirm testicular cancer is to examine part of the lump under a microscope. These tests and reports are called histology.

Unlike many cancers where a small piece of the cancer can be removed (a biopsy), in most cases the only way to examine a testicular lump is by removing the affected testicle completely. Also, a biopsy may injure the testicle and spread cancer into the scrotum, which is not usually affected.

Your specialist will only recommend removing your testicle if they're relatively certain the lump is cancerous.

Losing a testicle will not affect your intimate life or the ability to have children.

The removal of a testicle is called an orchidectomy. It's the main type of treatment for testicular cancer, so if you have testicular cancer, it's likely you'll need to have an orchidectomy.

In almost all cases, you'll need further tests to check whether testicular cancer has spread.

When cancer of the testicle spreads, it most commonly affects the lymph nodes in the back of the abdomen or the lungs.

• You may need to have a chest X-ray to check for signs of a tumour. You'll also need a scan of your entire body. This is usually a CT scan to check for signs of the cancer spreading.

• In some cases, a different type of scan known as an MRI scan may be used.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before discussing your treatment options with your specialist, you may find it useful to write a list of questions to ask them. For example, you may want to find out the advantages and disadvantages of particular treatments.

Orchidectomy - An orchidectomy is a surgical procedure to remove a testicle.

If you have testicular cancer, the whole of the affected testicle will need to be removed because only removing the tumour may lead to the cancer spreading. The operation is carried out under general anaesthetic. By removing the entire testicle, your chances of making a full recovery are greatly improved. Your intimate life and ability to father children will not be affected.

In such circumstances, it's sometimes possible to only remove the part of the testicle containing the tumour. You should ask your surgeon about this if you're in this position.

If testicular cancer is detected in its very early stages, an orchidectomy may be the only treatment you require. You can have an artificial (prosthetic) testicle inserted into your scrotum so the appearance of your testicles is not greatly affected. The artificial testicle is usually made of silicone, a soft type of plastic. It probably will not be exactly like your old testicle or the one you still have. It may be slightly different in size or texture.

If only 1 testicle is removed, there should not be any lasting side effects.

If both testicles are removed (a bi-lateral orchidectomy), you'll be infertile and need to look into alternative options such as donor sperm when considering future parenthood. You may be able to bank your sperm before having a bilateral orchidectomy to allow you to father children if you decide to.

Sperm banking and fertility

Most people are still fertile after having 1 testicle removed. But some treatments for testicular cancer can cause infertility.

Some people with testicular cancer may have low sperm counts because of changes that occur in the testicles before the cancer develops.

For some treatments, such as chemotherapy, infertility may occur, but standard chemotherapies have a less than 50% chance of causing infertility if the remaining testicle is normal. In people who need to have post-chemotherapy removal of lumps at the back of the abdomen, known as retroperitoneal lymph node dissection (RPLND), the ability to ejaculate may be affected, even though the remaining testicle can still produce sperm.

Before your treatment begins, you may want to consider sperm banking. This is where a sample of your sperm is frozen so it can be used at a later date to impregnate your partner during artificial insemination.

Before sperm banking, you may be asked to have tests for HIV, hepatitis B and hepatitis C.

If you're having complex chemotherapy for stage 2 and 3 testicular cancer, you should always be offered sperm banking. Ask if you're concerned about your fertility.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonably high quality.

There may also be situations where it's considered too dangerous to delay treatment for sperm banking to take place.

Most NHS cancer treatment centres offer a free sperm banking service. But it's up to each area of the country to decide whether they store sperm for free or whether you have to pay.

Cancer Research UK has more information about sperm banking, including the cost of sperm storage. https://www.cancerresearchuk.org/about-cancer/coping/physically/sex/men/sperm-banking

Testosterone replacement therapy

If you still have a remaining healthy testicle, it should make enough testosterone so you will not notice any difference.

If there are any problems with your remaining testicle, you may experience symptoms caused by a lack of testosterone.

These symptoms can be caused for other reasons, but can include:

-Tiredness

-Weight gain

-Loss of libido (sex drive)

-Reduced beard growth

-Reduced ability to achieve or maintain an erection (erectile dysfunction)

Testosterone replacement therapy is where you're given testosterone in the form of an injection, skin patch or gel to rub into your skin. If you have injections, you'll usually need to have them every 2 to 3 months. After having testosterone replacement therapy, you'll be able to maintain an erection and your sex drive will improve.

Side effects associated with this type of treatment are uncommon, and any side effects that you do experience will usually be mild.

Lymph node and lung surgery

More advanced cases of testicular cancer may spread to your lymph nodes. Lymph nodes are part of your body's immune system, which helps protect against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your tummy are the nodes most likely to need removing.

In some cases, the nerves near the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation.

If you have retrograde ejaculation, you'll still experience the sensation of having an orgasm during ejaculation, but you will not be able to father a child.

There are a number of ways of treating retrograde ejaculation, including the use of medicines that strengthen the muscles around the neck of the bladder to prevent the flow of semen into the bladder.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or IVF.

Some people with testicular cancer have deposits of cancer in their lungs, and these may also need to be removed after chemotherapy if they have not disappeared or reduced sufficiently in size.

This type of surgery is also carried out under general anaesthetic and does not usually significantly affect breathing in the long-term.

Radiotherapy

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells.

Sometimes seminomas may require radiotherapy after surgery to help prevent the cancer returning. It may also be needed in advanced cases where someone is unable to tolerate the complex chemotherapies usually used to treat stage 2 and 3 testicular cancer. If testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.

Chemotherapy

Chemotherapy uses powerful medicines to kill the malignant (cancerous) cells in your body or stop them multiplying. You may require chemotherapy if you have advanced testicular cancer or it's spread within your body. It's also used to help prevent the cancer returning. Chemotherapy is commonly used to treat seminomas and non-seminoma tumours.

Chemotherapy medicines for testicular cancer are usually injected into a vein. In some cases, a special tube called a central line is used, which stays in a vein throughout your treatment so you do not have to keep having blood tests or needles placed in a new vein.

Sometimes chemotherapy medicines can attack your body's normal, healthy cells. This is why it can have many different side effects.

These side effects are usually only temporary and should improve after you have completed your treatment.

Having children

You should not father children while having chemotherapy and for a year after your treatment has finished. This is because chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects.

You'll need to use a reliable method of contraception . This is to protect your partner from any potentially harmful effects of the chemotherapy medication in your sperm.

Chana is able to help you look at the options and liase with our Rabbinical Panel to advice you in the best way.

Follow-up and testing is usually recommended depending on the extent of the cancer and the treatment offered.

This is usually more frequent in the first year or 2, but follow-up appointments may last for up to 5 years. In certain cases, it may be necessary to continue follow-up appointments for 10 years or longer.

Reference: https://www.nhs.uk/conditions/testicular-cancer/

A varicocele (VAR-ih-koe-seel) is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum). A varicocele is similar to a varicose vein you might see in your leg.

Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to fail to develop normally or shrink.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and many don't need treatment. If a varicocele causes symptoms, it often can be repaired surgically.

Symptoms

A varicocele often produces no signs or symptoms. Rarely, it might cause pain. The pain may:

• Vary from sharp to dull discomfort

• Increase with standing or physical exertion, especially over long periods

• Worsen over the course of a day

• Be relieved when you lie on your back

• Impaired fertility

• With time, varicoceles might enlarge and become more noticeable. A varicocele has been described as looking like a "bag of worms." The condition might cause a swollen testicle, almost always on the left side.

When to see a doctor

Because a varicocele usually causes no symptoms, it often requires no treatment. Varicoceles might be discovered during a fertility evaluation or a routine physical exam.

However, if you experience pain or swelling in your scrotum, discover a mass on your scrotum, notice that your testicles are different sizes, or develop a varicocele in your youth, or you're having problems with fertility, contact your doctor. Several conditions can cause a scrotal mass or testicular pain, some of which require immediate treatment.

Causes

-Male reproductive system . Your spermatic cord carries blood to and from your testicles. It's not certain what causes varicoceles. However, many experts believe a varicocele forms when the valves inside the veins in the cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). This might cause damage to the testicle and result in worsened fertility.

-Varicoceles often form during puberty. Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein.

Risk factors

There don't appear to be any significant risk factors for developing a varicocele.

Complications

• Shrinkage of the affected testicle (atrophy). The bulk of the testicle comprises sperm-producing tubules. When damaged, as from varicocele, the testicle shrinks and softens. It's not clear what causes the testicle to shrink, but the malfunctioning valves allow blood to pool in the veins, which can result in increased pressure in the veins and exposure to toxins in the blood that may cause testicular damage.

• Infertility. Varicoceles might keep the local temperature in or around the testicle too high, affecting sperm formation, movement (motility) and function.

Diagnosis

Your doctor will conduct a physical exam, which might reveal a nontender mass above your testicle that feels like a bag of worms. If it's large enough, your doctor will be able to feel it.

If you have a smaller varicocele, your doctor might ask you to stand, take a deep breath and hold it while you bear down (Valsalva maneuver). This helps your doctor detect abnormal enlargement of the veins.

If the physical exam is inconclusive, your doctor might order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside your body, might be used to ensure there isn't another reason for your symptoms. In certain cases, further imaging might be recommended to rule out other causes for the varicocele, such as a tumor compressing the spermatic vein.

Treatment

Varicocele treatment might not be necessary. Many men with varicoceles can father a child without any treatment. However, if your varicocele causes pain, testicular atrophy or infertility or if you are considering assisted reproductive techniques, you might want to undergo varicocele repair.

The purpose of surgery is to seal off the affected vein to redirect the blood flow into normal veins. In cases of male infertility, treatment of a varicocele might improve or cure the infertility or improve the quality of sperm if techniques such as in vitro fertilization (IVF) are to be used.

Clear indications to repair a varicocele in adolescence include progressive testicular atrophy, pain or abnormal semen analysis results. Although treatment of a varicocele generally improves sperm characteristics, it's not clear if an untreated varicocele leads to progressive worsening of sperm quality over time.

Varicocele repair presents relatively few risks, which might include:

Buildup of fluid around the testicles (hydrocele)

Recurrence of varicoceles

Infection

Damage to an artery

Repair methods include:

Open surgery. This treatment usually is done on an outpatient basis, during general or local anesthetic. Commonly, your surgeon will approach the vein through your groin (inguinal or subinguinal), but it's also possible to make an incision in your abdomen or below your groin.

Advances in varicocele repair have led to a reduction of post-surgical complications. One advance is the use of the surgical microscope, which enables the surgeon to see the treatment area better during surgery. Another is the use of Doppler ultrasound, which helps guide the procedure.

You might be able to return to normal, nonstrenuous activities after two days. As long as you're not uncomfortable, you might return to more strenuous activity, such as exercising, after two weeks.

Pain from this surgery generally is mild but might continue for several days or weeks. Your doctor might prescribe pain medication for a limited period after surgery. After that, your doctor might advise you to take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) to relieve discomfort.

Your doctor might advise you not to have intercourse for a period of time. Most often, it will take several months after surgery before improvements in sperm quality can be seen with a semen analysis. This is because it takes approximately three months for new sperm to develop.

Open surgery using a microscope and subinguinal approach (microsurgical subinguinal varicocelectomy) has the highest success rates when compared with other surgical methods.

Laparoscopic surgery. Your surgeon makes a small incision in your abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. This procedure requires general anesthesia.

Percutaneous embolization. A radiologist inserts a tube into a vein in your groin or neck through which instruments can be passed. Viewing your enlarged veins on a monitor, the doctor releases coils or a solution that causes scarring to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure isn't as widely used as surgery.

After embolization, you can often return to work after two days, and begin exercising after seven to 10 days.

Lifestyle and home remedies

If you have a varicocele that causes you minor discomfort, but doesn't affect your fertility, you might try the following for pain relief:

Take over-the-counter painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).

Wear an athletic supporter to relieve pressure.

Preparing for your appointment

You're likely to start by seeing your primary care doctor. However, in some cases when you call to set up an appointment, you might be referred immediately to a urologist.

Here's some information to help you get ready for your appointment, and know what to expect from your doctor.

Write down any symptoms you're experiencing, including any that might seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins and supplements that you're taking.

Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Preparing a list of questions will help you make the most of your time with your doctor. List your questions from most important to least important. For varicocele, some questions to ask include:

What's the most likely cause of my symptoms?

What kinds of tests do I need?

Is my condition likely temporary or more permanent?

Will this condition affect my fertility?

What treatments are available? Which do you recommend?

I have these other health conditions. How can I best manage these conditions together?

Are there any restrictions on sexual activity that I need to follow?

Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions you've prepared, don't hesitate to ask questions that arise during your appointment.

What to expect from your doctor

Your doctor is likely to ask you several questions, including:

When did you begin experiencing symptoms?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

Does anything appear to make your symptoms worse?

What you can do in the meantime

Take an over-the-counter pain reliever and wear an athletic supporter to relieve pressure

Reference: https://www.mayoclinic.org/diseases-conditions/varicocele/diagnosis-treatment/drc-20378772