Loss of fertility in men with varicocele**Presented in part at the 45th Annual Meeting of The American Fertility Society, San Francisco, California, November 13 to 16, 1989

Clinical presentations and semen characteristics of men attending the secondary referral infertility clinic at Mumbai, India

Background:

Limited information is available on the aetiology and semen profiles of male infertility in Indian population.

Aim:

The aim of this study is to study the clinical and semen characteristics of men attending the infertility clinic and also to understand the impact of World Health Organization (WHO) 2010 reference values on the diagnosis of male infertility.

Setting and Design:

A retrospective study evaluating the medical case records (January 2005 to December 2015, [n = 1906]) of men attending infertility clinic in Mumbai, India.

Materials and Methods:

The aetiology was classified based on the andrology evaluation and other investigations. Semen profiles were compared during the years 2005–2010 and 2011–2015 using WHO 1999 and WHO 2010 criteria, respectively.

Statistical Analysis:

The Chi-square and Mann–Whitney U tests were performed using Open Source Epidemiological software and Social science calculators.

Results:

The aetiology of male infertility was determined in 62% of the men; while the cause remained undetermined in 38%. Varicocele (25%), urogenital infections (10%), sexual dysfunctions (8%) and vas aplasia (8%) were identified as major aetiologies in our cohort. Men with sexual dysfunctions and vas aplasia were significantly higher during the years 2011–2015 as compared to 2005–2010. Men having normozoospermia (10%) and azoospermia (3%) were increased, whereas those having oligoasthenozoospermia (17%) were reduced in 2011–2015 as compared to 2005–2010. According to WHO 1999 criteria , 12-15% of men showed abnormal semen profiles. The semen parameters of these men became normal on using WHO 2010 reference values.

Conclusions:

Varicocele is the most common aetiology in infertile men. Idiopathic infertility was seen in a higher proportion among the infertile men.

Platelet indices and varicocele: A systematic review and meta-analysis

The updated systematic review and meta-analysis was conducted to assess the platelet indices between patients with varicocele and healthy subject. The main purpose of our study was to explore the relationship between platelet and the pathogenesis of varicocele. Databases including Cochrane Library, PubMed, and MEDLINE were retrieved to identify studies. Two independent investigators extracted the related information of the included original passages. In order to estimate the difference of varicocele patients and healthy subjects, we applied the standardised mean difference (SMD) and the corresponding 95% confidence intervals (95% CIs). 1,156 patients and 797 healthy subjects of nine studies met the pre-set inclusion criteria. The estimated SMD in MPV between varicocele patients and healthy subjects was 0.61 (95% CI: 0.29-0.93, p < 0.001). The estimated SMD in MPV between preoperative varicocele patients and post-operative varicocele patients was 0.22 (95% CI: 0.03-0.41, p = 0.02). The estimated SMD in PLT between varicocele patients and healthy subjects was -0.19 (95% CI: -0.28, -0.08, p = 0.001). The available data suggest that a higher MPV level in varicocele patients, and the varicocele operation can normalise the preoperatively elevated mean platelet volume levels. Further researches are needed to investigate the potential role of platelet with varicocele.

Sperm biology and male reproductive health

Sperm are unique cells, produced through the complex and precisely orchestrated process of spermatogenesis, in which there are a number of checkpoints in place to guarantee delivery of a high-quality and high-fidelity DNA product. On the other hand, reproductive pressure in males means that to produce more is, in very general terms, to perform better. Balancing quantity and quality in sperm production is thus a delicate process, subject to specific cellular and molecular control mechanisms, and sensitive to environmental conditions, that can impact fertility and offspring health. This Collection is focused on these aspects of sperm biology, as well as their impact on reproductive performance and male infertility.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

Association between genetic polymorphism of XRCC6 T-991C and risk of varicocele

Background

The DNA non-homologous end-joining repair gene XRCC6 (Ku70) plays an essential role in the DNA double-strand break (DSB) repairs. Defects in the DSB repair pathway results in genomic instability. Varicocele is characterized by high pressure and stasis in the veins of the testis. There is little knowledge about the molecular mechanisms underlying varicocele. One of the reasons for increased spermatozoa DNA damage is high concentrations of reactive oxygen species (ROS), which leads to DNA-DSBs. We assumed that a promoter T-991C (rs5751129) polymorphism in the XRCC6 gene was associated with susceptibility to varicocele in infertile men. Therefore, 63 infertile varicocele men and 150 healthy controls were recruited in our study. The healthy controls had no history of varicocele, and they were matched with patients by age.

Results

Our results showed that infertile varicocele patients and control groups had significant differences in the distribution of their genotypic and allelic frequency (p = 0.00) in the XRCC6 promoter T-991C polymorphism. Men who carried CC genotype had a 5.22-fold increased odds ratio of developing infertile varicocele compared to those who carried the wild-type TT genotype (95% CI 2.31–11.81, P < 0.001).

Conclusions

Our results suggested that the CC genotype and the C allele in the promoter region of XRCC6 gene might play an important role in developing infertility in the varicocele men. Further research is needed to provide the effect of this polymorphism.

Role of microsurgical varicocelectomy in the management of non-obstructive azoospermia with varicocele: our tertiary care centre experience

Background

Varicocele is an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. Varicocele is associated with progressive testicular damage and infertility. Azoospermia is associated with a varicocele in approximately 4–14% cases. For men with azoospermia or severe oligoasthenospermia, varicocele repair may result in modest improvement in semen quality which may have a significant advantage on couple’s fertility options. The aim of the study was to evaluate the role of microsurgical varicocelectomy in the men of non-obstructive azoospermia (NOA) with clinical varicocele.

Methods

This was a retrospective study conducted between August 2012 and January 2017, a backward review of 104 patients with the diagnosis of infertility and NOA with palpable varicocele that underwent microsurgical varicocelectomy at our institution was performed. In addition, microdissection testicular sperm extraction (MDTESE) results of these post-varicoceletomy patients were compared with the patients of NOA without varicocele.

Results

A total of 104 patients underwent varicocelectomy; out of these, 19 patients (18.26%) had sperm on sperm analysis post-operatively. Two of them had spontaneous pregnancy (10.5%), and 3 had children by intracytoplasmic sperm injection (15.78%). Out of the 85 patients who had MDTESE, 29 patients (34.11%) had sperms in their testis. The fertilization rate was 89.65%. Sperm retrieval rate (SRR) in NOA men with varicocele was 34.11% which was higher from those who had NOA without varicocele (24.03%). Live birth rate was 31.03% in NOA men who had varicocelectomy which was more in comparison to NOA men without varicocele (24%).

Conclusions

In NOA men with varicocele microsurgical varicocelectomy may have favourable effects which results in recovery of motile sperms in the post-operative ejaculate and also on spontaneous or assisted pregnancies, but it appears that this effect was more remarkable on MDTESE results when following successful intracytoplasmic sperm injection. Importantly, Sperm retrieval rate, pregnancy rate and subsequent live birth rate were higher in these patients in comparison to patients affected by NOA alone. In patients with NOA and coexisting varicocele, varicocelectomy can be considered to be essential to the overall reproductive outcome in these patients.

Robotic Surgery for Male Infertility

The robotic platform offers theoretical and practical advantages to microsurgical male infertility surgery. These include reduction or elimination of tremor, 3-dimensional visualization, and decreased need for skilled surgical assistance. This article reviews the application of robotic surgery to each of the 4 primary male infertility procedures: vasectomy reversal, varicocelectomy, testicular sperm extraction, and spermatic cord denervation. Historical perspective is presented alongside the available outcomes data, which are limited in most cases. Before the robotic approach can be widely adopted, further clinical trials are needed to compare outcomes and costs with those of other validated surgical techniques.

Determination of the time for improvement in semen parameters after varicocelectomy

This retrospective study aimed to determine the time for improvement in semen parameters after varicocelectomy. A total of 175 patients over 18 years of age, who underwent microscopic inguinal varicocelectomy in a tertiary centre between 2005 and 2016 and had post-operative follow-up data of at least 12 months, were included in the study. Serial semen analyses in the pre-operative period and at the post-operative third, sixth, ninth and 12th months were retrospectively documented. With respect to their pre-operative total motile sperm counts, the patients were classified into three subgroups as <5 million, 5-9 million and >9 million. In the overall cohort and the group with a total motile sperm count of >9 million, the semen parameters continued to improve up to the post-operative 12th month. No further significant improvement was observed after the post-operative third and sixth months for the patients with pre-operative total motile sperm counts of <5 million and 5-9 million respectively. For the candidates of varicocelectomy, the decision of treatment strategies, such as assisted reproductive technologies and waiting for spontaneous pregnancy can be based on the prediction of the time for improvement in semen parameters.

Effects of Primary Varicocele and Related Surgery in Male Infertility: A Meta-Analysis

Purpose: To investigate the effect of primary varicocele and related surgery in male infertility through meta-analysis.

Methods: A systematic search of the literature was conducted using the Medline, Embase, Cochrane, and CNKI databases. The search was up to September 2019. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Data were analyzed using RevMan 5.2. A random-effects model was used to calculate the overall combined risk estimates.

Results: After screening 687 articles, 4 randomized controlled trials with 349 patients were included. One hundred seventy two patients were addressed in embolization/ligation, with 177 patient's observation treatment. The number of spontaneous pregnancies in the two groups was 41 and 40, respectively. There was no significant difference in pregnancy rate between the operation group and the control group. RR = 1.05 [0.72, 1.54].

Conclusion: There is not enough evidence to explain the surgical treatment of varicocele can improve the natural fertility of the infertile couples, and there is still a need for most of prospective randomized controlled trials to verify the efficacy of varicocele surgery for treating of male infertility. We do not deny the importance of this operation, we just want to call on everyone to strictly grasp the indications of the operation, avoid ineffective medical expenses, and avoid unnecessary pain to patients.

Varicocele in paediatric age: Is the scientific community on the correct pathway?

Varicocele is the primary cause of male infertility and the interests of research about varicocele have changed in the last years. The aim of the study was to analyse how topics of interests about varicocele have changed in the last two decades. Literature about paediatric varicocele between 2000 and 2018 was reviewed, and the subjects of the articles were analysed, selecting the main and secondary topics of each article. A study of their prevalence over the years was performed. In the research, 625 articles were found but only 169 provided data in the paediatric age. The total percentage of exclusively paediatric works was 27.04%, being above average in Europe, North and South America. The main subject both for Europe and North America was surgical technique, while for Asia it was videolaparoscopy. The main issue in South America was fertility; Africa and Oceania do not have enough publications to make statistics. Paediatric articles account for less than one-third of overall articles. The first interest of research is surgical technique. In Europe, the topics seem to exclude fertility potential.

Efficacy of varicocelectomy in primary infertile patients with isolated teratozoospermia. A retrospective analysis

The present study assessed the results of varicocelectomy in patients with isolated teratozoospermia. Sixty-two infertile men with isolated teratozoospermia were evaluated retrospectively. There were significant improvements between preoperative and postoperative mean percentages of spermatozoa with normal morphology (1.15 ± 1.1% versus 2.3 ± 1.8%, p < .001) and spermatozoa with head abnormalities (92.9 ± 4.5% versus 88.6 ± 7.4%, p < .001). Nineteen (31%) patients had children through natural conception, 4 (6%) patients had children with assisted reproductive techniques and 39 (63%) patients had got no children within a mean follow-up period of 31.3 months. In patients who had children with natural conception, significant improvements were detected in postoperative mean percentages of spermatozoa with normal morphology (p < .001), head abnormalities (p < .001), neck/midpiece abnormalities (p = .003) and tail abnormalities (p = .007). When semen parameters of men who had children via natural conception was compared with the men with no children, we found that the percentage of spermatozoa with normal morphology was significantly higher (p = .008) and percentage of spermaztozoa with head anomalies was significantly lower (p = .019) in men who had children via natural conception. We believe that varicocelectomy is a beneficial surgical method for the treatment of isolated teratozoospermia and better postoperative rates of spermatozoa having normal morphology and head abnormalities are related with natural conception.

Recent advances in clinical diagnosis and treatment of male factor infertility

Infertility is a significant global health issue affecting around 8-12% of couples worldwide with male factor infertility accounting for a substantial proportion of these cases. Despite significant advances within the past few decades, an etiology for male factor infertility cannot be identified in up to 80% of patients and thus, this continues to be an area of active study. This review aims to provide an update on recent advances in the field of male infertility including semen analysis and at-home semen testing, genetics, DNA fragmentation, surgical approaches, and the rise of telemedicine in the era of COVID19.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.

1H NMR-based metabonomics for infertility diagnosis in men with varicocele

PURPOSE

"Omics" techniques have been used to understand and to identify biomarkers of male infertility. We report on the first metabonomics models created to diagnose varicocele and infertility among men with varicocele.

METHODS

We recruited 35 infertile men with varicocele (VI group), 21 fertile men with varicocele (VF group) and 24 fertile men without varicocele (C group). All men underwent standard semen analysis, scrotal duplex ultrasonography, and sexual hormone level measurement. Hydrogen-1 nuclear magnetic resonance (1H NMR) spectra of seminal plasma were used to create metabonomics models to discriminate between men with and without varicocele, and between fertile and infertile men with varicocele.

RESULTS

Using the statistical formalisms partial least square discriminants analysis and genetic algorithm-based linear discriminant analysis (GA-LDA), we created two models that discriminated the three groups from each other with accuracy of 92.17%. We also created metabonomics models using orthogonal partial least square discriminants analysis and GA-LDA that discriminated VF group from VI group, with an accuracy of 94.64% and 100% respectively. We identified 19 metabolites that were important in group segregation: caprate, 2-hydroxy-3-methylvalerate, leucine, valine, 3-hydroxybutyrate, lactate, alanine, 4-aminobutyrate, isoleucine, citrate, methanol, glucose, glycosides, glycerol-3-phosphocoline, n-acetyltyrosine, glutamine, tyrosine, arginine, and uridine.

CONCLUSIONS

1HNMR-based metabonomics of seminal plasma can be used to create metabonomics models to discriminate between men with varicocele from those without varicocele, and between fertile men with varicocele from those infertile with varicocele. Furthermore, the most important metabolites for group segregation are involved in the oxidative stress caused by varicocele.

A review of varicocele treatment and fertility outcomes

Varicoceles are reported to be present in a significant proportion of men presenting with subfertility and are more common amongst this group than in the general population. Opinion still remains divided amongst clinicians managing male factor infertility as to whether varicoceles alter the probability of spontaneous conception and/or pregnancy and live birth rates after fertility treatment. The debate as to whether varicoceles should be treated or not has intensified in recent years. This is due to the concerns regarding the impact of varicoceles on not only conventional semen parameters, but also the potential effects that they may have at the cellular level (an increase in circulating reactive oxygen species (ROS) resulting in sperm DNA fragmentation, even when conventional semen parameters are within the normal reference ranges). It has been suggested that treating the varicocele may result in improvements in the semen parameters, the fertilization and pregnancy rates for both spontaneous pregnancy as well as following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. ICSI can still be used for Assisted Reproduction Treatment (ART) in the presence of suboptimal semen parameters. However, it is an invasive and expensive technique with potential adverse effects on the offspring. As far as we are aware, there are no randomized controlled trials comparing the clinical/cost effectiveness of varicocele treatment versus the immediate use of ICSI on pregnancy rates. Previous modelling exercises are old and do not take into consideration current practices and trends such as rising female age and time to pregnancy. The conflicting advice that patients sometimes receive, challenges our commitment to evidence-based practice. The only way to resolve the controversy is to undertake an appropriately powered randomized trial, assessing clinical- and cost-effectiveness and the time to pregnancy following varicocele treatment and comparing this to a no treatment group.

Seminal plasma protein networks and enriched functions in varicocele: Effect of smoking

To verify a possible synergistic effect of smoking and varicocele on the seminal plasma proteome and biological functions, a cross-sectional study was performed in 25 smokers and 24 nonsmokers. Samples were used for conventional semen analysis, functional analysis (DNA fragmentation, acrosome integrity and mitochondrial activity) and proteomics by a shotgun approach. Functional enrichment of biological pathways was performed in differentially expressed proteins. Smokers presented lower ejaculate volume (p = .027), percentage of progressively motile spermatozoa (p = .002), total sperm count (p = .039), morphology (p = .001) and higher percentage of immotile spermatozoa (p = .03), round cell (p = .045) and neutrophil count (p = .009). Smokers also presented lower mitochondrial activity and acrosome integrity and higher DNA fragmentation. We identified and quantified 421 proteins in seminal plasma, of which one was exclusive, 21 were overexpressed and 70 were underexpressed in the seminal plasma of smokers. The proteins neprilysin, beta-defensin 106A and histone H4A were capable of predicting the smoker group. Enriched functions were related to immune function and sperm machinery in testis/epididymis. Based on our findings, we can conclude that cigarette smoking leads to the establishment of inflammatory protein pathways in the testis/epididymis in the presence of varicocele that seems to act in synergy with the toxic components of the cigarette.

Effect of varicocelectomy on fertility. Indications, techniques and results

We define varicocele as the dilation of the veins that make up the pampiniform plexus, which is made up of three branches, the internal spermatic, deferential and external spermatic. The World Health Organization (WHO) has determined that varicocele is an important cause of male infertility. This has been acknowledged by several studies that have shown this cause-effect relationship. Varicocele does not always generate infertility. In fact, many patients with varicocele are fertile, decreasing their percentage in the progression of the pathology and the association with other factors such as tobacco, marijuana or endocrine disorders (diabetes or hypothyroidism). Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO). SURGICAL THERAPEUTICS: Surgery is indicated in cases of grade 3 varicocele (when seen through the scrotal skin and palpable as a 'bag of worms' without Valsalva maneuver), cases of atrophy or growth arrest with volume differences of more than 2cm³ between testes, when accompanied by pain and alterations in the spermiogram in young patients. CONCLUSION: The presence of varicocele determines the performance of varicocelectomy, with the inguinal approach in its three branches being the approach of preference. The laparoscopic approach will be used in specific cases.

Decisional Conflict and Knowledge Among Patients With Varicocele Seeking Treatment for Infertility

OBJECTIVE

To study disease-specific knowledge and decisional quality in men with varicocele being counseled for infertility.

MATERIALS AND METHODS

An instrument designed to measure decisional quality by evaluating disease-specific knowledge, decisional conflict, and the impression that shared decision-making was administered to 92 men identified to have a varicocele seeking their initial infertility consultation. Mean scores on disease-specific knowledge questionnaire, prevalence of decisional conflict, and impact of consultation on preferred infertility treatment were analyzed.

RESULTS

Fifty-five percent of patients were found to have decisional conflict. Compared to those with decisional conflict, men without decisional conflict scored higher on the infertility knowledge assessment (63% vs 53% correct) and were more likely to feel that they discussed treatment options with their physician in detail (98% vs 82%) (all P <0.01). Prior to consultation, 28% of all patients preferred assisted reproductive technologies and 2% preferred varicocelectomy as the primary treatment for infertility. Following consultation, 12% and 17% preferred assisted reproductive technologies and varicocelectomy, respectively. The increase in preference for varicocelectomy was greater in men without decisional conflict (5%-31%) than those with conflict (0%-8%) (P = 0.03).

CONCLUSION

Infertile men with varicocele have limited knowledge of their disease and high rates of decisional conflict. Before consultation, men with varicoceles showed preference for assisted reproductive technology over varicocele surgery; this trend reversed after consultation. Men with decisional conflict were less likely to prefer varicocelectomy, even after consultation.

Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele

Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.

[Initial experience in microsurgical treatment of varicocele: Comparative analysis with conventional macrosurgical varicocelectomy]

INTRODUCTION

Varicocele is the most common cause of male infertility and the standard treatment is varicocelectomy. Having recently started performing microsurgical varicocelectomy (MV) in our centre, the objective of this study is to determine the differences in clinical outcomes and laboratory findings between MV and the conventional varicocelectomy (CV).

MATERIAL AND METHODS

This is a comparative study between MV and CV in our centre between 01/2013 and 12/2016. We included patients with clinical varicocele and altered seminal parameters. We analyzed the following variables: age, laterality, grade of varicocele, testicular volume, surgical technique used, seminogram parameters prior to and after surgery and recurrence.

RESULTS

Between 01/2013 and 12/2016 46 varicocelectomies were performed in our centre, excluding from the study 12 patients due to lack of follow-up. Of the remaining 34, 19 (55.9%) underwent CV and 15 (44.1%) MV. There were no significant differences between the baseline characteristics of both groups. The preoperative sperm count was 30.1±35.6 10⁶/mL for MV vs. 25.6±19.9 10⁶/mL for CV (P=.64) and progressive sperm motility (a+b) was 17.7±13.6% vs. 16.5±10.1% respectively (P=.77). Postoperative sperm count was 29.16±33 10⁶/mL for MV vs. 45.6±55.5 10⁶/mL for CV (P=.32) and progressive motility (a+b) was 26.4±20.1% vs. 27.7±20.4% respectively (P=.85). We observed a tendency towards recurrence in the CV group (26.3%, vs. 6.7% for MV), although not statistically significant (P=.15).

CONCLUSIONS

Despite the learning curve with MV, we obtained improvements in seminal analysis similar to those with CV. Even though not statistically significant, there was a tendency to less recurrence in the MV group, consistent with what is already described in medical literature.

The change in Thiol-Disulphide Homeostasis levels as an oxidative stress marker after varicocelectomy: Is there a relationship with sperm parameters?

One of the most important causes of varicocele-related infertility is oxidative stress (OS). One of the markers considered as an indicator of OS is thiol-disulphide homeostasis (TDH). Based on the hypothesis that OS should decrease after varicocelectomy in the light of this information, in our current study, we investigated the relationship between TDH levels and sperm parameters. The data of 56 infertile varicocele men were prospectively analysed. The post-operative total and native thiol levels were significantly higher than those pre-operative total and native thiol levels (477.7 & 436.7 nmol/L, 417.6 & 372.1 nmol/L). Positive correlation was found between total thiol change and change in semen volume (ρ: .277, p: .039), ratio of spermatozoa with normal morphology (ρ: .342, p: .01), progressive (ρ: .334, p: .012) and nonprogressive motility (ρ: .385, p: .003). Positive correlation was also found between native thiol change and semen volume (ρ: .349, p: .008), ratio of spermatozoa with normal morphology (ρ: .362, p: .006), progressive (ρ: .297, p: .026) and nonprogressive motility (ρ: .368, p: .005). Change in the level of TDH was found as positively correlated with progressive and nonprogressive motility change. According to these results, OS decreases with varicocelectomy in infertile patients and TDH can be used as a useful method for measuring OS.

Does varicocelectomy improve semen in men with azoospermia and clinically palpable varicocele?

The effectiveness of varicocelectomy in nonobstructive azoospermia is controversial. The current study assessed the efficacy of microsurgical subinguinal varicocelectomy in nonobstructive azoospermic men with palpable varicocele and to evaluate predictive parameters of outcome. We reviewed the records of 723 patients who had microsurgical varicocelectomy and diagnostic testicular biopsy between 2012 and 2016 at a tertiary medical centre. Data pertaining to the physical, laboratory (semen analysis and hormonal profile) and histopathology features were examined, exploring the predictors of improvement in semen analysis post-varicocelectomy. In total, 42 patients with mean age 35.71 ± 6.35 years were included. After a mean varicocelectomy follow-up of 6.7 months, motile spermatozoa in the ejaculate could be observed in 11 patients (26.2). Out of all the factors examined, only testicular histopathology significantly predicted post-varicocelectomy outcome, where 8/11 patients exhibited hypospermatogenesis, and 3/11 Sertoli cell-only regained spermatozoa in semen. Microsurgical varicocelectomy in nonobstructive azoospermic men with clinically palpable varicocele can result in sperm appearance in the ejaculate with the highest success expected in hypospermatogenesis.

Left spermatic vein reflux after varicocele repair predicts pregnancies and live births in subfertile couples

PURPOSE

Varicocele repair (VR) is proposed to improve fertility in subfertile couples with a poor semen quality. We explored whether the disappearance of a left continuous spermatic venous reflux (SVR) at scrotal colour-Doppler ultrasound (CDUS), an objective evidence for a VR, is predictive for improved fertility outcome in subfertile couples.

METHODS

VR was performed by left internal spermatic vein sclero-embolisation in 88 males seeking a consultation for subfertility. Semen analysis and scrotal CDUS were evaluated before and 6 months after VR. Serum levels of FSH and total testosterone (TT) were obtained at baseline. Telephone interview was used to obtain information about fertility outcome. Significant predictors of pregnancy and live births, selected by univariate analyses, were included into multiple logistic regression models to assess independent associations.

RESULTS

At the adjusted model, independent significant predictors of pregnancy after VR were a disappeared SVR at CDUS (OR = 5.5, 97.5% CI 2.01-15.4; p = 0.0009) and an improved sperm total motile count (TMC) (OR = 5.5, 97.5% CI 1.4-27.9; p = 0.02). Even live births were independently associated with both disappeared left SVR at CDUS (OR = 4.3, 97.5% CI = 1.6-11.8; p = 0.003) and improved TMC after VR (OR = 4.8, 97.5% CI 1.3-24.2; p = 0.02).

CONCLUSION

The still controversial effect of varicocele repair on fertility in subfertile couples may reside on the undefined objective methods to document a successful VR and its effect on couple fertility. The disappearance of a continuous left SVR at CDUS after VR was the objective best predictor for subsequent improved fertility in subfertile couples.

Extended indications for varicocelectomy

The relationship between varicoceles and subfertility is well-established, but recent evidence suggests that varicoceles may cause global testicular dysfunction. This has led to exploration into expanding the indications for varicocelectomy. This review examines the literature regarding varix ligation as a treatment for non-obstructive azoospermia, elevated DNA fragmentation, and hypogonadism.

Lower body mass index and higher height are correlated with increased varicocele risk

To evaluate the anthropometric indexes in subjects with varicocele compared to controls and the incidence of varicocele in different body mass index (BMI) groups for the purpose of exploring the association between varicocele and anthropometric indexes. A comprehensive literature search was conducted by using PubMed, MEDLINE, EMBASE databases and Cochrane Library up to February 2019. A systematic review and meta-analysis was conducted by STATA, and Newcastle-Ottawa Scale was utilised for assessing risk of bias. Ultimately, 13 articles containing seven case-control studies and six cross-sectional studies with 1,385,630 subjects were involved in our study. Pooled results demonstrated that varicocele patients had a lower BMI (WMD = -0.77, 95% CI = -1.03 to -0.51) and a higher height than nonvaricocele participants, especially in grade 3 varicocele patients. Subgroup analyses showed that normal BMI individuals had a higher risk of varicocele than obese or overweight individuals and a lower risk than underweight individuals. In conclusion, this study indicates that varicocele patients have a lower BMI and a higher height than nonvaricocele participants. Moreover, men with excess bodyweight have a lower incidence of varicocele compared to normal weight or underweight people. That is to say, high BMI and adiposity protect against varicocele and high BMI is associated with a decreased risk of varicocele.

Efficacy of antioxidant therapy on sperm quality measurements after varicocelectomy: A systematic review and meta-analysis

Antioxidants were proved to be efficient to improve the quality of spermatozoa after varicocelectomy. We carried out a systematic review and performed a meta-analysis to evaluate the efficacy of antioxidant therapy in sperm parameters' quality after varicocelectomy during 3 or 6 months' treatment cycle. During research, randomised controlled trials were searched by MEDLINE, EMBASE and the Cochrane Controlled Trials Register, and necessary parameters were compared between two groups after varicocelectomy. Finally, six studies including 576 patients were included in our meta-analysis. As for sperm parameters, significant improvements of sperm concentration (p < .0001), sperm motility (p = .03), progressive sperm motility (p < .00001) and sperm morphology (p < .00001) were existed in antioxidant group 3 months after varicocelectomy. With regard to the 6 months' outcomes, sperm parameters were improved as well except sperm motility (p = .72) and progressive sperm motility (p = .57). Referring to pregnancy rate, no significant difference was existed between two groups (p = .36), and the FSH level of antioxidant group was lower than placebo group 3 or 6 months after varicocelectomy (3 months, p = .02; 6 months, p = .03). In conclusion, compared with the placebo, the antioxidant therapy after varicocelectomy can improve the quality of sperm parameters and construct a favourable living condition for spermatozoa by reducing FSH level.

Sperm and Seminal Plasma Proteomics: Molecular Changes Associated with Varicocele-Mediated Male Infertility

Male infertility is a rising problem and the etiology at the molecular level is unclear. Use of omics has provided an insight into the underlying cellular changes in the spermatozoa of infertile men. Proteomics is one the promising omics techniques for biomarker screening that can provide complete information on molecular processes associated with male infertility. Varicocele is a pressing issue in the field of male infertility and the search for an appropriate diagnostic and therapeutic biomarker is still ongoing. In this review, we discuss the reports on proteomic profiles of sperm and seminal plasma in male infertility and provide an in-depth insight into varicocele studies associated with male infertility.

Microsurgical varicocele ligation: surgical methodology and associated outcomes

The impact of clinical varicoceles on semen parameters and male infertility has long been established. In the era of assisted reproduction, clinical discussion has questioned the role of varicocelectomy, offering the potential to bypass, rather than treat, varicocele-associated male infertility. However, current literature supports improved semen parameters and reproductive outcomes following repair. This article presents the stepwise operative approaches to microsurgical varicocelectomy and discusses the recent publications on outcomes.

Comparison between microsurgical varicocelectomy with and without testicular delivery for treatment of varicocele: A systematic review and meta-analysis

The present study was conducted to assess the semen parameters, complications and clinical effect of microsurgical varicocelectomy with testicular delivery (TD) for treatment of varicocele. Relevant studies were collected and reviewed systemically from PubMed, Medline, Embase, Web of Science, China National Knowledge Infrastructure databases and the Cochrane Library and a meta-analysis was performed. Relative ratio (RR), standardised mean difference (SMD) and their 95% confidence intervals (CIs) were adopted to estimate the outcome measures. Eight articles and a total of 1,139 subjects including 487 patients with TD in microsurgical varicocelectomy and 652 patients without TD were enrolled in this meta-analysis. The pooled RR indicated that microsurgical varicocelectomy with TD increased the incidence of orchiepididymitis (RR = 4.36, 95% CI = 1.12-16.99, p = 0.034) and scrotal oedema (RR = 4.25, 95% CI = 2.40-7.54, p = 0.000) than microsurgical varicocelectomy without TD postoperatively. In conclusion, compared to microsurgical varicocelectomy without TD, TD to further ligate the gubernacular veins in microsurgical varicocelectomy results in a higher incidence of orchiepididymitis and scrotal oedema and take longer operation time. However, TD may not have any beneficial influences on semen parameters, serum testosterone, varicocele occurrence, wound infection and natural conception.

Comparison of the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain

We investigated the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain. We retrospectively reviewed the records of patients who underwent varicocelectomy. The age, body mass index, grade, laterality of varicocele, testicular volume difference, time to hospital visit, serum testosterone level and semen parameters were evaluated. A total of 954 patients were included. The painful group had lower mean age, lower BMI, higher grade of varicocele, smaller testicular volume difference and shorter time to hospital visit than the painless group. In addition, the median serum total testosterone level and total sperm count, concentration and motility were higher in the painful group than in the painless group. In multivariate analysis, there were significant differences between the two groups in age, grade of varicocele, testis volume difference, time to hospital visit, total sperm count and concentration. Patients with painful varicocele visited hospital earlier because of the pain and tended to start treatment sooner. They were also younger, had smaller testis atrophy and had higher sperm concentration, even though they had a higher grade of varicocele than patients without pain. Although scrotal pain in varicocele patients is difficult to treat, it leads to early diagnosis and treatment.

Comparison of main molecular markers involved in autophagy and apoptosis pathways between spermatozoa of infertile men with varicocele and fertile individuals

Abnormal dilatation and tortuosity of the pampiniform plexus within the spermatic cord are termed varicocele which leads to impaired spermatogenesis due to heat-related oxidative stress and cell death. Previously, it was shown that both apoptosis and autophagy pathways were activated by heat in germ cells of mouse in vivo and in vitro. But, status of these pathways is not clear in chronic state of heat stress such as varicocele. Therefore, we aimed to access sperm apoptotic markers (active caspases 3/7 and DNA fragmentation), and autophagic markers (Atg7 and LC3 proteins) as primary outcomes, and also sperm parameters and protamine deficiency as secondary outcomes between 23 infertile men with varicocele and 16 fertile individuals. Sperm parameters were assessed according to World Health Organization 2010 protocol. Apoptotic markers (active caspases 3/7 and DNA fragmentation), autophagic markers (Atg7 and LC3 proteins), and protamine deficiency were evaluated by flow cytometry, fluorescence microscope, and western blotting techniques. Mean of autophagy and apoptosis markers, and also protamine deficiency have significantly increased in infertile men with varicocele compared to fertile individuals, but autophagy and apoptosis markers did not significantly correlate with each other. In conclusion, it seems that both apoptosis and autophagy pathways are independently active in spermatozoa of infertile men with varicocele.

Clinical Consultation Guide on Imaging in Male Infertility and Sexual dysfunction

Imaging can benefit clinicians in evaluating men with infertility or sexual dysfunction by giving an overview of a patient's overall clinical condition before undertaking an invasive procedure. An understanding of the limitations and advantages of image modalities used in clinical practice will ensure that clinicians can optimize patient care with imaging when necessary. PATIENT SUMMARY: The objective of this article was to review the current literature on imaging modalities used for the diagnosis and management of male infertility and sexual dysfunction. An understanding of the advantages and limitations of these imaging modalities will ensure that clinicians can optimize patient care with imaging when necessary.

Best practice in the diagnosis and treatment of varicocele in children and adolescents

A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.

With a new clip technique surgically inducing varicocele in Sprague-Dawley rats

BACKGROUND

We introduced and recreated a more consistent and effective experimental varicocele rat model by a new clip technique.

METHODS

A total of 40 rats were numbered and randomly assigned to 5 groups of 8 each, including sham surgery (Group I), conventional (Group II) and clip groups with 0.7, 0.8, 0.9 mm gap widths, respectively (Group III, IV, V). All of the rats in each group were sacrificed at 8 weeks after initial surgery, and the rats forming out with less than 1 mm diameter of left spermatic vein or no presence of the pampiniform plexus dilation were excluded from the experimental groups. The left spermatic vein (LSV) diameter, testicular weight, left kidney weight to body weight coefficients, kidney and testicular histology were determined.

RESULTS

The baseline mean diameter of the LSV in Group I, II and III was 0.22 ± 0.02, 0.23 ± 0.02 and 0.22 ± 0.03 mm, respectively (P = 0.7504). At 8 weeks after initial surgery, varicocele was successfully created in 6/8 (75%), 7/8 (87.5%), 3/8 (37.5%), 3/8 (37.5%) in GroupII-V, no varicocele was observed in Group I. In Group I, II and III, no pathological changes were observed and the left kidney weight to body weight coefficients showed no significant differences. The diameter of LSV was remarkably increased both in Group II and III compared to Group I (1.72 ± 0.13, 1.57 ± 0.19 and 0.25 ± 0.02, respectively), and Group II and III had a smaller testicular weight than the rats in Group I (1.67 ± 0.05, 1.62 ± 0.06, and 1.92 ± 0.12, respectively).

CONCLUSIONS

With a new clip technique, surgically inducing varicocele rat model becomes convenient and safe. This appears to improve the effectiveness of the model and this innovation may allow us to further understand the pathophysiology of varicocele.

Relationship of Hormonal Parameters to Sperm Production in Patients with Varicocele

Idiopathic varicocele is a one of the all too often organic causes of male infertility and may can affect hormonal and spermatogenic function of the testis. We demonstrated relationships of hormonal parameters to sperm production on follicle-stimulating hormone (FSH), (LH) and testosterone blood concentrations to sperm production. The investigations involved a total of 329 patients with varicocele, at aged from 20 to 48 years, mean age 28.76 ± 0.66 years, divided into three groups: group I – patients with varicocele dextra; group II – patients with varicocele sinistra; and group III – patients with varicocele bilateralis. We established in our investigations that in 65.35% of cases the varicocele was attended coupled by with some disorders in the fertilizing ability, included including oligospermia Gr I-II (groups I and II) in 41.33% of cases, oligospermia (Gr.II-IIIgroups II and III) in 15.5% of cases and azoospermia in 8.52% of cases. In 56.83% of cases, the low sperm concentration was attended by decreasedcoupled with reduced sperm motility and velocity. Our data did not demonstrated a statistically significant increase in blood plasma T testosterone and we noted no significant correlation between the magnitude of the change in serum androgen and improvements in sperm concentration or total sperm motility per ejaculate in patients with varicocele. No significant correlations were noted in mean blood LH and FSH concentrations in patients with varicocele and in controls group.

The Role of Varicocele in Male Factor Subfertility

PURPOSE OF REVIEW

Varicocele may play a significant role in a subset of patients presenting with male factor infertility. Despite its relatively high prevalence amongst subfertile men, there has been controversy over the effectiveness of surgical treatments, patient selection, and when to administer treatment, particularly in the era of assisted reproductive technology.

RECENT FINDINGS

In line with earlier finding, recent evidence strongly suggests that varicocelectomy improves pregnancy rates and semen parameters. The currently available literature still does not clearly elucidate the answer to this question, due to flaws in retrospective study design. Patients undergoing subinguinal microsurgical varicocelectomy appear to have the highest pregnancy rates, and lowest complication rates, compared to other surgical approaches. Current research has given us a better understanding of the relationship between varicocele and infertility. Amongst men presenting with semen analysis abnormalities and varicoceles, including those patients presenting with non-obstructive azoospermia or couples with a significant male factor component failing previous attempts at in vitro fertilization, varicocelectomy may improve take home baby rates. More robust, prospective, controlled studies are needed to further clarify the population of subfertile men with varicocele most likely to benefit from varicocelectomy.

Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review

OBJECTIVE

The purpose of this study is to assess the current evidence regarding the safety and effectiveness of the various embolic materials used in varicoceles embolization.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for clinical studies that investigated the clinical outcomes of embolization treatment for the management of testicular varicoceles. Study methodological quality was analyzed.

RESULTS

23 retrospective and 7 prospective clinical studies were identified with a total of 3505 patients. Technical success rates appear to be above 90% for all embolic materials without any significant differences. In terms of recurrence rates, glue (N = 251) appeared to have the lowest and sclerosants alone (N = 728) the highest recurrence rates which were 4.2% (11-3.08%, SD: 5.9) and 11.03% (18.8-5.15%, SD: 6.06) within an average follow up (f/u) of 16.13 and 25.48 months respectively. Coils alone (N = 898) had an average recurrence rate of 9.1% (17.8-1.4%; SD: 5.79) and a mean f/u of 39.3 months. After an average of 12 months of f/u, the addition of sclerosants (N = 1628) as an adjunct to coils did not improve recurrence rates (8.44%, 16.5-5.1%; SD: 3.4). No differences were reported regarding the safety profile of the various embolic materials.

CONCLUSION

Despite the heterogeneity of the included studies, preliminary evidence supports the safe and effective use of the various embolic materials currently used for the management of varicoceles. At 1 year, glue appears to be the most effective in preventing recurrence with coils being the second most effective. The addition of sclerosants to the coil embolization did not appear to have an impact on recurrence rates. Further research is required to elucidate the cost-effectiveness of these approaches. Advances in knowledge: Varicocele embolization appears to be a safe and effective technique regardless of the embolic agent. Addition of a sclerosant agent to coil embolization does not appear to improve outcomes.

Varicocele management for infertility and pain: A systematic review

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Varicocelectomy with primary gubernaculum veins closure: A randomised clinical trial

To evaluate the effect of microsurgical inguinal varicocelectomy with testicular delivery on semen parameters. A total of 416 patients, diagnosed with grade III varicocele, were randomised into two groups. One group underwent microsurgical inguinal varicocelectomy without testicular delivery. For the other group, testicular delivery and ligation of gubernacular and all collateral veins were performed. A semen analysis was performed before and 6 months after the procedure. Mean age of the patients in the case and control groups was 27.3 ± 6.1 years and 25.9 ± 4.6 years respectively (p = .1). The total number of recurrence after 6 months in the conventional and testicular delivery groups was 13 (6.5%) and 3 (1.5%) (p < .05). No case of hydrocele formation was observed in any of the groups. All sperm parameters were improved 6 months after the surgery in both groups. But comparing the mean improved difference between the two groups revealed a significant difference in improvement in sperm motility for patients who had undergone varicocelectomy with testicular delivery (p = .05). Microsurgical inguinal varicocelectomy is a safe and efficient technique with a minimum chance of post-operative complications and recurrence and also may have role in improvement of sperm motility compared with conventional techniques.