Fertility: Varicocele surgery, infertility despite normal partners, and sexual activity during pregnancy

**80. Does varicocele require surgery?**

Varicocele is an abnormal dilation, elongation, and tortuosity of the pampiniform plexus within the spermatic cord. The incidence rate is approximately 20% in the general male population and about 40% in infertile men. It is more common in young adult men, and relatively rare in adolescents; the overall incidence rate of varicocele in adolescents aged 6–19 years is 10.76%.

Varicocele not only affects male fertility, depriving patients of the right to fatherhood, but also poses a threat to their reproductive health. Many men with varicocele frequently experience neurasthenia symptoms such as mood swings, poor mental state, insomnia, and fatigue. Over time, this can lead to decreased libido, painful intercourse, and erectile dysfunction.

For patients with more severe symptoms, high ligation of the internal spermatic vein can be performed, which involves ligating all branches of the internal spermatic vein at the internal inguinal ring. Missing any branches often leads to recurrence. After ligation of the internal spermatic vein, venous blood returning from the testis and epididymis can return to the inferior vena cava via the external spermatic vein, or return to the femoral vein via subcutaneous venous branches below the external inguinal ring. However, a scrotum crease should still be used before and after surgery to elevate the scrotum and increase the success rate of treatment.

81. Why do couples, both of whom are of normal reproductive health, struggle to conceive after several years?

The incidence of infertility is rising year by year, becoming one of the major problems in today's society. The causes of infertility are complex, and either the man or woman can be responsible. Therefore, both partners must undergo comprehensive examinations to identify the underlying problem.

Common causes in women:

(1) Uterine factors: About 75% of patients with endometriosis have a history of infertility. This is because it can cause retroverted uterine adhesions, poor mobility, and fallopian tube adhesions, leading to decreased peristalsis. Ectopic endometrium can act as an autoantigen, causing hyperimmunity in women, such as the production of anti-endometrial antibodies. Ectopic endometrium can also produce more prostaglandins, which can lead to strong contractions of the uterine and fallopian tube muscles, interfering with the movement of sperm and eggs and the implantation of fertilized eggs, thus causing infertility.

(2) Fallopian tube factors: Excessively long or narrow fallopian tubes, inflammation causing lumbar obstruction, hydrosalpinx, or adhesions can all hinder the transport of sperm, eggs, or fertilized eggs. Fallopian tube diseases account for up to 25% of female infertility, making them a significant cause of infertility. Inflammatory diseases include tuberculosis, endometriosis, trichomoniasis, gonorrhea, and other pathogenic infections. Blocked fallopian tubes can be reopened through laparoscopy, tubal flushing, and microsurgical reconstructive surgery. In vitro fertilization (IVF) (in-vitro fertilization and embryo transfer) can also help patients achieve pregnancy.

(3) Ovarian factors: Incomplete development of follicles in the ovary, inability to ovulate and form a corpus luteum, premature ovarian failure, polycystic ovary syndrome, ovarian tumors and other factors that affect follicle development or ovulation can all cause infertility.

Common causes in men:

(1) Sperm abnormalities mainly include azoospermia, oligospermia, asthenospermia, hematospermia, sperm malformation and necrospermia. Among them, oligospermia or asthenospermia, azoospermia, necrospermia and hematospermia are the main causes of infertility.

(2) Spermatogenesis disorders such as varicocele, congenital testicular hypoplasia, cryptorchidism, orchitis or testicular atrophy, endocrine diseases, etc. can all cause a decrease in sperm count, reduced motility, or sperm malformation, leading to infertility.

(3) Obstruction of sperm transport, such as lesions of the epididymis, vas deferens, ejaculatory duct and urethra, can cause obstruction of sperm transport. Clinically, it usually manifests as obstructive azoospermia, which directly affects male fertility.

**82. Is it okay to have sex with your wife while she's pregnant?**

Sexual activity during pregnancy does not need to be completely prohibited. Healthy and moderate sexual activity is not only permissible, but can also greatly enhance the intimacy between couples.

So, when should sexual intercourse be avoided? During pregnancy, couples should be cautious and moderate in their sexual activity, adhering to the following principle: sexual intercourse should be stopped during the first three months of pregnancy and the last three months, while intercourse can be appropriately restricted during the middle trimester. Additionally, intercourse is not advisable for those experiencing abdominal pain or vaginal bleeding, or those with a history of miscarriage, recurrent miscarriage, or premature birth, to reduce the possibility of further miscarriage or premature birth. Intercourse is also not recommended for those with placenta previa or serious complications, as it could harm the offspring.

What precautions should be taken regarding sexual activity during pregnancy? Firstly, couples should avoid putting pressure on or bumping the abdomen during intercourse, and secondly, avoid direct or strong stimulation of the uterus. When the pregnant woman's uterus has not yet significantly enlarged, the missionary position (man on top, woman on bottom) can still be used, but avoid putting pressure on the pregnant woman's abdomen, and the man's penis should not be inserted too deeply. As the belly grows larger, avoid putting pressure on it; the front-side position, side-lying position, or front-sitting position can be used, and the movements should not be too vigorous. In the later stages of pregnancy, the rear-entry position can also be used. If the pregnant woman does not wish to have intercourse, it should never be forced. Both partners must be understanding and considerate of each other, and work together to navigate this special period of life.