Opinion: 'Varicocele: the silent male infertility battle' by Zadok Kwame Gyesi

An estimated 40 percent of men being investigated for infertility have varicocele. Varicoceles are common condition that affect male fertility— this infertility condition is related to decreased sperm production, quality and quantity due to increased temperature in the testes or the scrotum.

Zadok Kwame Gyesi explores this health condition, how it is affecting male fertility in Ghana, its treatment options and how people who are affected by this condition can seek medical help. The story also touches on the stigma and challenges childless couples face in Ghanaian societies.

For the purposes of confidentiality, I will use pseudo names to refer to the couples I interviewed for this article. Similarly, I will also use pseudo names for some institutions and individuals who provided me with some information but would not want their identities to be disclosed.

Joycy, not her real name, now 38, and her husband, Akwasi, also not his real name, now 40, have a lot of stories to share with couples who are struggling to have a child they can call their own. I’m talking about infertile couples. Their battle with infertility, stigma and pressure from friends and family, nearly sucked out all the joy and happiness in their marriage.

Joycy and Akwasi's wedding was the envy of many young and prospective couples at their local branch of their church. They married in 2009. It was one of the most talked-about weddings to be held at their church, at least, within the period they did their wedding. The attendance was huge, and everything, from decoration, singing, officiating, and reception, were also on point. Many leaders of their church—pastors, prophets and apostles, all attended the wedding, including the overall leader of their church. They call their leader, Chairman. Luckily for them, the Chairman, did not only attend the wedding, he was the one that joined the two couple together and blessed their marriage.

Having the honour of the overall leader and senior clergy men of this church, which is one of the most popular churches in Ghana, attending your wedding is a rare opportunity. Those who have such honours are usually the children of the pastors, apostles or prophets within the church, and in some cases, the affluent people who support the work of the Lord with their resources or expertise.

Fortunately for Joycy and Akwasi, their parents, all members of the church, happened to be influential in the church – they held positions and also supported the church with their resources. Because of this, many of the church’s leadership and all those who matter in the church, attended the wedding.

For Joycy, due to pressure and anxiety that usually come with weddings, she did not pay attention to the sermon that the leader of the church delivered on their ‘big day’. But she could remember portions of the prayer that their leader prayed for them after blessing the marriage—"May you be blessed with the fruit of the womb.”

Joycy said, she said a big amen to the man of God’s prayer, with a high hope that the prayer will be fulfilled in the shortest possible time in her life. But her expectations hit the rocks when days turned into months and months into years, and still, pregnancy did not come.

"I was so scared; I didn’t believe I was going to be part of people who will struggle to give birth,” she voiced out her ordeal.

For Joycy, the “May you be blessed with the fruit of the womb” prayer lingered all the time in her ears, saying “Anything about our wedding that I saw reminded me of the prayer.”

As normal practice in many Ghanaian churches, whenever the church holds any major programme such as prayer meetings, crusades or conventions, they usually holds an intersessional prayers for people who need God’s favour, and during times like this, couples struggling to have children, are normally called in front of the congregation to be prayed for. Joycy said they were prayed for all the time.

“Anytime my church held any programme, I felt so scared to attend because I knew they will call to pray for us; and whenever such thing happened and I got home, I sobbed,” she noted.

For her, anytime there was a child’s naming ceremony at her church, she felt the weight of her childlessness.

“When we come to church and people are dropping their children at the Sunday school, I felt so sorry for myself. I was crying within me all the time,” she disclosed.

As she continued to be “embarrassed with naming ceremonies” in the church, as she would put it, and many ‘insensitive comments’ people passed about her, she decided with her husband to leave their local assembly to another branch of the church. At least, they will be new there. But unfortunately for them, due to their parents’ influence in the church, when they got to the new church, they were highly introduced. For her, she felt relieved at the new branch since the people there didn’t know how long they had married.

“Six years without a child is no joke. I had so many things running through my mind,” Joycy recounted, adding “I visited many hospitals but I was not getting result.”

Breakthrough

Joycy said their breakthrough came five months after they joined their new church. According to her, the church held a health talk programme in which they invited many health experts, including fertility specialists. She said she attended the programme with her husband after the programme, she went to speak with the fertility specialists, who also happened to be a member of the church but in a different branch.

“The doctor asked me to call my husband too so that he can speak with us both, which I did. He spoke with us for about 10 minutes and asked that we see him for some tests at his workplace,” she recollected, adding “We went to see him as he requested and when he conducted the test, it came out that my husband had a condition called varicocele.”

Joycy, now a mother two, said they started having their babies when her husband was treated of her varicocele condition.

Varicocele

Varicocele is the enlargement or extension of the veins that surround the spermatic cords—the cords the testes hangs on. It is a medical disorder that results in infertility in men.

A study published by Kenneth Kee in December 12, 2016, titled: “Varicocele, (Scrotal Varicose Vein) A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions” estimates that varicocele occurs in about 15-20% of all males and in 40% of infertile males.

Health experts say that varicoceles differ in sizes and can be categorised into 3 groups, namely large, moderate and small.

According to some health journals, varicoceles generally form during puberty and are more commonly found on the left side of the scrotum. Although it can occur at both sides of the testes, its rarely happens due to the differences in the anatomy of the right and left sides of the scrotum.

Understanding varicoceles

A urologist and kidney transplant surgeon, Dr Isaac O. Asiedu of the Korle-Bu Teaching Hospital, explains why varicocele is linked to male infertility, its symptoms, correctional methods and what helps are available for those with the condition.

He said varicoceles are associated with male infertility because it is associated with the testes, which is the site for sperm production, adding that the enlarged veins around the testes cause infertility by raising the temperature in the scrotum and decreasing sperm production, quality and quantity.

He said although the condition is common, it is not commonly seen in boys who are yet to attain puberty, but the condition is present in about 15 per cent of the general population of men. He, however, pointed out that varicocele is seen in up to 40 per cent of men who are undergoing investigations or treatment for infertility.

Even though Dr Asiedu said varicoceles are not common in boys yet to attain puberty, he was quick to add that there have been sporadic occurrence of varicocele in younger boys.

On what causes varicocele, he said, there is no one exact cause of the condition and that there are several factors responsible for its cause.

“We don’t have an exact cause of varicocele but we have factors that predisposes to the development of varicocele,” he observed.

Dr Asiedu explained that varicoceles are much common in the left side of the scrotum than the right, saying “This is because the internal spermatic vein (the blood vessel that carries the blood from the testes back into circulation); on the left side of the testes, joins the left renal vein in a right angle, forming a ‘T’ junction.

He added that “and anytime there is a T-junction, there is hydrostatic pressure (hydrostatic pressure refers to the pressure that any fluid in a confined space exerts).”

The hydrostatic pressure, he said, pulls more blood into the left spermatic vein and then also into the left Pampiniform plexus (it is a network of many small veins found in the male spermatic cord; they also play a role in the temperature regulation of the testes) of veins within the scrotum.

“So the increase hydrostatic pressure on the left side of the scrotum can affect sperm production and quality,” he said.

Dr Asiedu noted that although one could have hydrostatic pressure also on the right side of the testes, but because the right side vein does not join the right renal vein and instead joins the inferior venacava (a large vein that carries blood to the heart from other areas of the body) at an acute angle, one would not have so much of hydrostatic pressure.

He further explained that defective valves in the veins of the spermatic cord could also cause varicocele. He said every vein has valves in it and that the valves make sure that there is only one directional flow of blood. But in the case of varicocele, he noted, the valves become defective such that they don’t work effectively as they are supposed to function, hence blood pulling back instead of going in one direction.

“When you have a lot of pressure with the blood pulling back, it distends the veins around the testes in the scrotum,” he explained.

Dr Asiedu added that the development of varicocele could also be a sign of a tumor growing in the abdomen, hence compressing the internal spermatic vein which brings pressure into the scrotum.

How does varicocele cause infertility?

He said the reason why the testes is located outside of the body or the abdomen was because of the production of sperm (spermatogenesis). He explained that the sperm is produced in a temperature slightly lower than the core body temperature; and so when blood pulls around the testes due to enlarged veins, it increases the temperature around the testes, hence reducing the sperm production and even the semen quality.

Dr Asiedu further explained that the increase hydrostatic pressure in the scrotum also compresses the arteries (the arteries are the ones that bring oxygenated blood) and once there is so much pressure in the vein, it also compresses the arteries bringing in the oxygenated blood into the testes.

He said when a tissue doesn’t receive enough oxygenated blood, it starts shrinking or dying and that can reduce the testicular volume, hence affecting sperm production and quality.

Symptoms

Dr Asiedu, who is a fertility specialist said varicoceles are usually asymptomatic, meaning, they may not show any sign or symptom at all. However, he added, “there are things you could see to suspect that you probably have the condition.”

He said men could examine their scrotum to see if one side is bulkier than the other, adding that if one side of the scrotum is bigger than the other, it could be a sign of varicocele. He, however, added that there are other reasons one could have scrotal swelling.

He explained that there are times that scrotal swelling is very severe and when one holds the scrotum, it feels like a bag of worms.

He said a pain in the groin area leading to the testes could also mean the presence of a varicocele; but said a pain in the scrotum is not equal to varicocele.

The definitive diagnosis is reached when your doctor examines your scrotum and also performs an ultrasound scan of the scrotum.

Correcting varicoceles

Touching on the treatment for varicocele, Dr Asiedu said, there are several ways varicoceles can be corrected. He, however noted, correction of varicocele is usually surgical.

“We can have open varicocelectomy – what it means is that we go in into the groin, identify the vein that has been enlarged and then we blocked them,” he explained.

He added that surgeons can also block all the enlarged veins; such that there will be no pulling of blood into them to cause hydrostatic pressure that could increase the scrotal temperature.

Explaining further on correctional methods, Dr Asiedu said, it can be corrected using technology—saying “so we have interventional radiologists where they just puncture a little hole in the thigh and then thread an electric coil into the blood vessel that are enlarged and then blocked them.”

He noted that varicoceles can also be corrected laparoscopically, where cameras and the surgical instruments are introduced through pinholes in the abdomen to look for the distended vessels in the abdomen for them to be blocked.

The good news, Dr Asiedu said, is that all the treatment options for varicoceles are available in Ghana.

Infertility

Infertility though a problem that affect both males and females, it has become a common thing to always blame women for it. It is not surprising that many authors have written books to help address this issue, affecting many people around the world, particularly in Sub-Saharan Africa.

Books such as “The Joys of Motherhood” by Buchi Emecheta; “The Sex Lives of African Girls” by Taiye Selasi and “Anowa” by Ama Atta Aidoo all sought to address the menace of infertility and its associated stigma. This is because in Sub-Saharan Africa, marriage, must at all cost, result in a childbirth. But must couples be stigmatised for their inability to give birth? The answer obviously is no. We can change the narrative on infertility stigmatisation with our collective actions. Women are more than mothers and men are more than fathers.