It was Dr. Yigal Gat’s expertise in hydraulics and fluid mechanics (he has a master’s degree in engineering at the Technion in Haifa) that enabled him years later – as a physician – to understand the main cause of male infertility.
No – it’s not impotence! It is varicocele, an abnormality of the spermatic veins. There is a breakdown of the one-way valves inside these blood vessels, which – 45 centimeters long on the left side and 40 cm on the right – are not symmetrical.
Sperm flow through the vas deferens, which connects the epididymis to the prostate gland. The vas deferens is in the scrotum and is part of a larger tissue bundle called the spermatic cord, which contains the vas deferens, blood vessels, nerves and lymphatic channels. The pampiniform plexus is composed of the spermatic veins of the spermatic cord, which drains blood from the testes, epididymis and vas deferens and eventually become the spermatic veins that drain into the kidneys.
Nearly half of all fertility problems are “blamed” on the male, and more than 80 percent of those are due to varicocele. Male animals that walk on all fours don’t suffer from this condition. But men, including adolescents, walking erect can develop hydrostatic pressure in the spermatic vein, weakening the valves and causing hypoxia, a reduction of oxygen in the testes.
“THERE IS no active pump to drain the venous blood upward against gravity,” says Gat. “It’s done by a complex physical process relying on the one-way valves along the drainage system, and with the help of randomized pressures stemming from the natural movements of the body operating on the elastic walls of the veins. They open and close 100,000 times a day and can wear out.
“With too little oxygen, sperm production declines, and the quality of the sperm that are produced is harmed. The lack of oxygen can create abnormal sperm forms, especially an oval-shaped head rather than the usual arrow-shape that makes it possible for a sperm to penetrate the ‘shell’ of an ovum.
“With too little oxygen, the DNA may be damaged, and because the sperm are not fully developed, they cannot impregnate.”
(Gat, who comes from a Mea Shearim family, notes that the Talmud describes a fertile man as being like an arrow.)
Varicocele usually causes no symptoms, so a man is unaware of it unless he and his partner are trying to conceive. An obvious varicocele is often described as feeling like a bag of worms in a physical examination, but many are not obvious.
If men spent all their time hanging by the legs they wouldn’t suffer from varicocele, jokes Gat, who is director of the male fertility department at Bnei Brak’s Ma’ayanei Hayeshua Hospital and on leave from the Rabin Medical Center in Petah Tikva. Gat was the one who discovered and proved by fluid mechanical analysis over a decade ago that hypoxia as a result of varicocele is a physical and measurable factor responsible for male infertility. And, with US-born X-ray and invasive radiology expert Dr. Menachem Goren, he developed a minimally invasive technique that they claim cures 85% of varicocele patients, replacing the need for abdominal surgery.
“Now I am an expert in the hydraulics of the male pelvis,” says Gat with a smile. “I am a pelvic plumber,” Goren adds, “but the pipes are more complicated than metal ones, because they are elastic and dynamic.”
Researchers have found that waste products of the adrenal glands and kidneys flow back into the testicular tissue when the one-way valves fail to function properly. But varicocele is reversible: When oxygen-rich blood gets through to the testes, they can begin producing healthy sperm again, Gat and Goren said. “The sperm-producing tissue in the testes does not disappear, because when men sleep in a horizontal position, enough oxygen gets through to keep them alive.”
Gat, who studied medicine at the Technion and Tel Aviv University, was a gynecology intern and specialized in male fertility. Later he was an intern at the University Hospital at Ghent (Belgium) with renowned Prof. Frank Comhaire, a developer of male infertility treatments. Goren, who studied medicine at Temple University in Philadelphia, has years of experience in treatments based on catheterization. They met at the Rabin Medical Center’s Beilinson Campus, and when they decided to work in partnership, Goren went to the University of Ghent to study the non-surgical treatment of varicocele via interventional radiology. Their collaboration resulted in the development of the Gat-Goren Method of treating varicocele, which they have performed on more than 300 patients so far.
VARICOCELE was first recognized as a problem in the 16th century by Ambro se Par, a surgeon who said this abnormality was the result of “melancholic blood.” In the late 19th century, a British surgeon named Barfield first proposed the relationship between infertility and varicocele. In the 1950s, after a man who didn’t produce any sperm underwent surgical repair of varicocele and suddenly became fertile, the idea of surgically correcting varicoceles with a high ligation of the left internal spermatic vein gained support among US surgeons.
Goren notes that many doctors were unaware of the complicated anatomy involved, as “you can’t see the vein in the abdomen via ultrasound, or in autopsies, since these networks deteriorate quickly after death.”
Varicocele has long been regarded by male fertility experts as a disease of the left spermatic vein, but with Gat’s understanding of hydraulics and years of research, he discovered that it’s also common on the right side.
“We concluded that the disease wasn’t fully diagnosed, and therefore was not treated properly.”
Gat also found that variocele causes the temperature in the testicles to rise from the reflux (backing up) of body-temperature blood instead of the cooler blood that normally exists in the testes because they are outside the pelvis. “Testicles hang outside the body because there is an enzyme for transcription of genetic material that won’t work if the environment is hotter than 33 C,” explains Gat. The four degrees’ difference between that and normal body temperature makes all the difference.
“In the conventional procedure, in which men undergo general anesthesia in an operating room, a urological surgeon performs a left high ligation and blockage of the central vein. It takes 20 minutes, but urologists didn’t do the right side, or weren’t aware of the whole network of bypasses in the system, so in a significant number of cases, it didn’t solve the problem,” Gat says.
But the Gat-Goren catheterization method locates and treats defective blood vessels on both sides and improves oxygen supply necessary for the production of sperm cells. It costs NIS 9,000, but is unfortunately not included in the basket of health services, although some private and public supplementary health policies cover some of the cost. Varicocele patients who do not undergo the Gat-Goren Method submit to less-expensive abdominal surgery but require significantly longer recovery times.
Many of the patients they receive in their Ramat Gan clinic are haredi men who “fight to have children, or more children. It is the most important thing in life for them,” says Gat. About 15% of his patients are Arabs.
During the past two years, Gat and several of his colleagues published seven articles in respected journals about the technique, including Fertility and Sterility,, the Journal of Urology and Human Reproduction. Gat recently received an honorary doctorate from the University of Ghent in recognition of his pathfinding work.
DR. URIEL LEVINGER, deputy director of the internal medicine B Department at the Rabin Medical Center, says: “The Gat-Goren Method is the best way to treat male infertility, offering a complete cure. It’s a genuine breakthrough. Every couple suffering from infertility should have the man checked as well. In light of my close acquaintance with the method and its successes, I suggest every man suffering from infertility get examined for consideration of treatment by the Gat-Goren Method.”
Dr. Zvi Zukerman, former head of the male fertility unit at Rabin, adds: “Dr. Gat and Dr. Goren developed a unique catheterization method that locates and treats defective blood vessels on both sides, and improves the oxygen supply necessary for the production of sperm cells. The results are impressive.”
DURING THE procedure, which is performed under local anesthesia, Goren inserts a catheter through a vein in the upper thigh. The catheter is used to inject a fluid that selectively closes off all the malfunctioning veins, thereby enabling the testicular tissues to recover and begin to produce normal sperm in normal amounts. It takes one to two hours (plus half an hour of rest before going home), and causes virtually no discomfort. Within 48 hours, the patient resumes his normal routine.
They claim that previously infertile men whom they treated – including some who were considered azoospermic (with no functioning sperm cells, or no sperm at all) – were able to father children. Improvement in sperm production, sperm shape and function, they say, is usually evident within six months, but may sometimes be discernible in only 80 days.
Gat and Goren are the only team in the world using their technique, which is still regarded with some suspicion by urological surgeons, although they are teaching the method in France and Belgium.
“During the past four years,” they continue, “we have handled dozens of cases in which azoospermic men suddenly began to produce sperm, and some couples achieved spontaneous conception (mainly those who had children already), while others succeeded in the first or second cycle of in-vitro fertilization treatments.”
Liron L., one of their patients, called the two doctors “my saviors, my angels. After four years of fertilization treatments, when we almost gave up on having children, I found out the problem was with me. We had already been discouraged from trying to have a baby. We visited a professor who said nothing more could be done, and a doctor who suggested invasive surgery. But I heard of the Goren-Gat Method and went to them, and a few months later my wife got pregnant.
“Two years later, I am the proud father of two.”
(Originally appeared in The Jerusalem Post)