Varicocele Subfertility and Venous Pressure in the Left Internal Spermatic Vein

Vo\. 29, No.3, March 1978 PrinlRd in U.s.A.

FERTILITY AND STERILITY Copyright

©

1978 The American Fertility Society

VARICOCELE SUBFERTILITY AND VENOUS PRESSURE IN THE LEFT INTERNAL SPERMATIC VEIN

JOEL SAYFAN, M.D,* YEHUDA G, ADAM, M,D,

Department of Surgery "A," Asaf Harofe Hospital, Tel Aviv University Medical School, Zerifin, Israel

Although it is well known that varicocele is one of the most common causes of male infertility, there is no consensus concerning the pathophysiology of the testicular suppression in these cases.1 One of the earliest and still-accepted theories is that increased mechanical pressure in the dilated pampiniform plexus causes the testicular dysfunction. 2 The validity of this hypothesis was studied and is described in the following

TABLE 1. Internal Spermatic Venous Pressures in the Three Groups in Supine and Erect Positions Venous pressure Group B

Group A

Group C

em H 2 0

Supine Maximum Minimum Erect Maximum Minimum

30 6

18 8

17 10

34 15

27 15

24 19

report. A, 10.2 cm H 20; group B, 10.0 em H 20; group C, MATERIALS AND METHODS

Three groups of young adults were studied: (1) group A, 20 subfertile men with varicocele; (2) group B, 5 men with varicocele and normal fertility; and (3) group C, 5 men with left inguinal hernia, without varicocele, and with normal fertility. In each patient the internal spermatic venous pressure was determined by direct cannulation during surgery. Two pressure values were obtained in each case: in the supine position and in a 45° anti-Trendelenburg position simulating erect posture. RESULTS

The maximal and minimal values of the pressure determinations are shown in Table 1. There were no significant differences in the average pressures in the three groups in either position, as is shown in Table 2. The values of the "pressure differential" (extraction of the average "erect" pressure from the average "supine" pressure) were as follows: group

9.2 em H 2 0. The "pressure indices," obtained by dividing the average "erect" pressure by the average "supine" pressure, in each group were as follows: group A, 1.81; group B, 1.85; group C, 1.83. (The "index" eliminates variations which might be due to technical or environmental factors.) DISCUSSION

The lack of a significant difference in the "pressure differentials" and the nearly identical values of the "pressure indices" in the various groups point toward the fact that the venous pressure surrounding the left testis is practically stable in both fertile and subfertile men, with or without varicocele. It can be concluded that the distended scrotal pampiniform plexus, pathognomonic of the TABLE 2. Comparison of Average Pressures in the Three Groups in Supine and Erect Positions Venous pressure Group

Supine

A B C

15.27 12.20 12.60

Erect em H 2 0

Received May 4, 1977; revised October 20, 1977; accepted October 20, 1977. *Reprint requests: Joel Sayfan, M.D., Department of Surgery "A," Asaf Harofe Hospital, Zerifin, Israel.

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COMMUNICATIONS-IN-BRIEF

disease,3 serves as a "defense" mechanism to preserve a stable pressure environment around the testis despite the increased venous blood volume due to spermatic reflux. The theory that increased venous pressure is the etiology of subfertility in the patient with varicocele does not seem to be valid.

REFERENCES 1. Dubin L, Amelar RD: Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 22:469, 1971 2. Brown JS, Dubin L, Hotchkiss RS: Varicocele as related to fertility. Fertil Steril 18:46, 1967 3. Dubin L, Amelar RD: Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 21:606, 1970