So you're saying there's a chance...

I'm sitting in the Hyderabad Airport, reading yet another book on infertility. Sometimes I wonder why I even bother anymore. I've read so many books by so many different kinds of authors (doctors, patients, nutritionists, homeopathic experts, former infertiles, etc), that by this point, I feel like I've heard it all and there is nothing new for me to learn. Yet each new book does present information in a new way and every now and then I do get inspired by new ideas.

The book I'm reading now on my iPad has a few words on varicoceles. As we know, B had varicocele repair surgery back in April. He had very large varicoceles on one side, and fairly large on the other. Dr. J had said that with most patients, a significant number see improvement in sperm counts and achieve pregnancy after 3 months post-surgery. Then another large percentage will see improvement and pregnancy success after 6 months. A few more after a year.

This book claims that men with large varicoceles may see improvement within 6-12 months after the repair.



This gives me some renewed hope because we are exactly at the 6 month mark as of RIGHT NOW!

I'd actually already given up faith in us seeing any improvement from the surgery, and just figured we were going to have to wait more than a year until we could afford IVF. But if the stats in this book are accurate, then we may now just be entering into our prime time for TTC!

Best part of all, after my ordeal two months ago, I was relieved to get my period on time (like clockwork) while I was here in India. It did last an extra day or two longer than normal, but that is common when traveling, especially with a nearly 12 hour time change, so I'm not worried about that at all. Anyway, my point is, I'll be in my fertile period next week and should ovulate once B joins me for our vacation in Northern India! Maybe the stars will finally align for us and we'll be able to make our own little Indian baby here together ;)

- Posted using BlogPress from my iPad

Varicocele Repair Surgery

• There are three methods in which varicoceles can be surgically treated: open surgery, laparoscopic surgery, and the third, which isn't even really surgical (it's performed by a radiologist), is percutaneous embolization.
  Open surgery. This treatment usually is done on an outpatient basis, using general anesthetic or local anesthetic. Commonly, the surgeon will approach the vein through the groin (transinguinal), but it's also possible to make an incision in your abdomen or below the 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.
• Laparoscopic surgery. The surgeon makes a small incision in the 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 the groin or neck through which instruments can be passed. Viewing 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 is done with local anesthesia on an outpatient basis. This procedure isn't as widely used as surgery.
• So what's best?
• According to Dr. J's article, "Do varicoceles really affect male fertility?" although most methods yield similar short-term results, open micro-surgery tends to have lower long-term complications, such as recurrences and hydroceles.  This is due to the ability to tie off all veins while sparing the arterial blood supply and lymphatic vessels.  
• Although laparoscopic varicocele ligation was once touted as a minimally invasive method of repair, several experts have demonstrated similar recovery rates with open micro-surgical methods along with equal efficacy, fewer complications, and the advantage of not having to enter the abdomen.
• The most common complications from any of these varicocelectomy procedures are hydrocele, varicocele recurrence, and testicular artery injury.  Use of the operating microscope allows for reliable identification of spermatic cord lymphatics, internal spermatic veins and venous collaterals, and the testicular artery or arteries, so that the incidence of these complications can be reduced significantly.  Thus, the microsurgical technique of "open micro-surgery" provides a safe and effective approach to varicocele repair that preserves testicular function, enhances semen quality, and improves partners' pregnacy rates.
• What to expect from Open Micro-Surgery 
  Most men prefer general anesthesia, though the procedure can be performed under local with intravenous sedation.  Time to recovery varies, but most men get back to work within 3-4 days and and resume full activity within 7-10 days.
• From mayoclinic.com:
• You may be able to return to normal, nonstrenous activities after two days. As long as you're not uncomfortable, you may return to more strenuous activity, such as exercising, after two weeks.
  
  Pain from this surgery generally is mild. Your doctor may prescribe pain medication for the first two days after surgery. After that, your doctor may advise you to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others) to relieve discomfort.
  
  Your doctor may advise you not to have sex for one to two weeks. You'll have to wait three or four months after surgery to get a semen analysis to determine whether the varicocele repair was successful in restoring your fertility.

• **Dr. J has recommended Open Micro-Surgery for B.**

What the heck are varicoceles?

A varicocele (VAR-ih-koe-seel) is a dilation of the veins that drain the testis, known as the pampiniform plexus. A varicocele is similar to a varicose vein that can occur in your leg.

As it turns out, varicoceles are present in approximately 15% of the general male population. They account for up to 40% of male factor infertility, yet nearly two-thirds of men with varicoceles are fertile... so could varicoceles be causing mine & B's infertility?

The answer I've been able to come with so far is "maybe."

Causes

Varicoceles are typically not noticed until after puberty because testicular blood flow remains low prior to that and so these veins do not become apparent until adolescence when blood flow increases.  However many are not detected until a man is evaluated for fertility problems later in life. 

It's not certain what causes varicoceles, but many experts believe a varicocele forms when the valves inside the veins in the spermatic cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). 

Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles. 

Our doctor, Dr. Jay Sandlow (I like to refer to him as "Dr. J"), published an article called, "Do varicoceles really affect male fertility?" in Sexuality, Reproduction & Menopause, arguing that it is not the valve that is the issue, so much as the anatomy of the entire drainage system that plays a major role in the the development of varicoceles.

"Because the left side drains into a system with higher resistance (the renal vein), small venules may persist or open during embryogenesis." - Jay Sandlow

Don't ask me what that means... after looking up definitions for venules and embryogenesis, I think it means the way a man's anatomy is formed while still a fetus determines whether he'll have varicoceles, though they aren't detected until after puberty when things really start flowing down there.  Maybe I should ask Dr. J if I understand that correctly though :)

How can they affect fertility?

In cases of where men who have varicoceles happen to be experiencing infertility, varicoceles are thought to cause spermatogenic defects by raising the intratesticular temperature in both the affected and the adjacent testes. However, not all varicoceles affect sperm production, which explains why not all men with varicoceles (in fact, most of them), are fertile.

Diagnosis


When varicoceles are suspected of causing infertility, abnormalities in all of the seminal parameters are usually present.  However, they can also cause isolated defects in sperm count, motility, morphology, or function.  Therefore, according to the article written by Dr. J mentioned above, the results of semen analysis are not a good predictor of the presence or absence of varicoceles.  And so, they are typically diagnosed by physical examination.  Most experts agree that the only varicoceles to worry about are the ones that can be detected by physical examination, though ultrasound can be used to identify them as well.


In our case...


B's were visible right away upon physical examination, and he has them on both sides.  We discovered this back in April 2011, but because the results of his seminal parameters testing were all coming back within the range of normal fairly consistently, Dr. J instructed us to first continue trying naturally for 4-6 months, with timed intercourse (only every other day during the fertile period of my cycle).  


That brought us to September, when we did our first IUI, which failed.  That's also when we learned how low B's "good sperm" counts were post-washing.  It was at that time that Dr. J recommended doing one more IUI, and if the numbers came back that low again post-wash, then he would recommend varicocele repair surgery as our next course of action.


We attempted an IUI earlier this month (February 2012) and his count came back lower than last time, so in effort to save money, we didn't even go through with it.  I was on clomid that cycle for the IUI, so there could have been a chance of increased fertility for us naturally... but I got my period Wednesday night so [sigh] that's disappointing.


So we scheduled the surgery for early April.  I'll post more soon about what that entails and what the success rates are.

Surgery Scheduled

B's varicocele surgery has been scheduled for April 5th.  He'll need 5 days after the surgery to recover so we won't be going home for Easter this year.  This was the best time for us to schedule the surgery though because he only will have 3 days of sick time built up by then and his work gives him Good Friday off.  So between the weekend, the holiday, and his sick time, he'll have just enough time off.


I still plan to post more about what varicocele's are, how they can effect infertility, and what the surgery is all about soon.  In the meantime, we are just mentally preparing for this big next step.