الفهرس 
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Abstract
Male factor infertility accounts for 30-50% of infertility cases. Many sub-fertile couples have suboptimal semen quality ,either because of low sperm count,poorly motile sperm or sperm with abnormal size and shape.in more than 50%of male infertility cases , the aetiology remains unkown and the infertility is classified as idiopathic.
A varicocele is the most common cause of male infertility and it is a surgically correctable or at least improvable form of infertility. It is consist of elongated, dilated and tortuous spermatic veins within the pampiniform plexus.
The incidence of varicocele in general population is about 15%, while in infertile men the incidence between 19 and 41%. In men with secondary infertility, the incidence is as high as 70-80%. The left side is affected in 95% of cases.The etiology of varicocele is probably multifactorial. Several factors are considered as possible causes for development of varicocele and its predominance on the left side:
1. Longer left internal spermatic veins.
2. The proximal nutcracker effect with compression of the left renal vein between the aorta and superior mesenteric artery.
3. Incompetent valves
4. Left adrenal venous flow into the LRV opposite the confluence of the left spermatic vein.
5. The distal nutcracker with compression the left common iliac vein by the left common iliac artery.
The pathophysiology of varicocele infertility has not been delineated but there are many theories that may explain the pathophysiological changes that can occur with varicocele which include:
. Increase testicular temperature.
. Nuclear DNA damage and high oxidative stress.
. Endocrine abnormalities.
. Elevated nitric oxide.
. Testicular atrophy.
. Leydig cell dysfunction.
. Altered blood flow.
. Formation of antispermatozoal antibodies.
Varicocele is diagnosed by the following: clinically the patient is complaining of either pain or fertility problems or discrepancy of the testicular size, varicocele is diagnosed mainly by physical examination where the palpable varicocele has been described as feeling like a bag of warms at the scrotal neck. Varicocele grades are defined as follow:
. Grade I; palpable only with valsalva.
. Grade II: palpable without Valsalva.
. Grade III: visible.
The following investigation done to diagnose varicocele and its effect on the fertility: Radiological as scrotal ultrasonography( Doppler, high resolution ultrasound, color coded duplex), venography and semen
analysis.
The main goal of treatment of varicocele is preservation of fertility this is done by different surgical methods of treatment of varicocele either by open surgical approaches which include scrotal approach, retroperitoneal or high ligation approach, inguinal approach and laparoscopic approach.
This study included 51 patients with subfertility, 27 of them with clinical left sided and bilateral varicocele presenting with either primary infertility. And follow-up postoperatively by semen analysis and scrotal duplex for detection of pregnancy rate . Six cases of 22 patients ,their female partner developed pregnancy during their follow up .
Conclusion:
.Varicocelectomy is recommended for all patient with primary infertility with any semen abnormality as there is significant improvement occur in all semen parameters after varicoceletomy.
. Laparoscopic varicocelectomy has many advantages as, decrease operative time, postoperative hospital stay, decrease pain, early return to work and better outcome due to good visualization of lymphatic , vessels. In addition to detect intrabdominal pathologydecrease incidence of hydrocele formation.
. inguinal varicocelectomy has advantage decrease incidence of recurrence of varicocele and higher spontaneous pregnancy rates.