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The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study. J Pediatr Urol 2017; 13:77.e1-77.e5. [PMID: 27815047 PMCID: PMC5453725 DOI: 10.1016/j.jpurol.2016.09.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/21/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Adolescent males with varicoceles present a dilemma for surveillance and treatment. Testicular volumetrics have not been shown to predict SA outcomes. Serial SAs are thus recommended in asymptomatic adolescent males with varicoceles and normal testicular development, but the natural history of semen parameters is unknown. OBJECTIVE To explore the natural history of semen parameters in adolescent boys with a left varicocele under active surveillance. STUDY DESIGN Adolescents with an asymptomatic unilateral left varicocele, Tanner V development, normal testicular volumes, and an initial SA were retrospectively reviewed in a single-institution prospectively followed cohort. Total motile count (TMC) was calculated. A cutoff of TMC Z 20 million was used to dichotomize SA results into "normal" or "poor." Those with poor SA were offered repeat SA. Cumulative probabilities of normal TMC over successive rounds of SA were calculated. Bivariate models were used to explore associations of a second consecutive poor TMC with age and varicocele grade. RESULTS A total of 216 patients provided an initial SA between 1992 and 2015. We excluded 17 for a history of cryptorchidism or incomplete SA data for a final cohort of 199 patients with median follow-up of 3.3 years (interquartile range 1.5-5.6 years). The mean age at initial SA was 17.9 years (range 14.8-21.8 years). One hundred and nine out of 199 had an initial normal TMC. Of the 90 out of 199 with an initially poor TMC, 51 had repeat SA and 24 of the 51 patients improved to normal TMC. Of the 27 patients with two consecutive poor TMCs, 15 had a third SA and five out of 15 improved to normal TMC. Thus, cumulatively, 55%, 67%, and 69% of all patients had a normal TMC after an initial, second, and third SA, respectively. However, fewer patients in each round of SA normalized their TMC (Figure). Neither age nor varicocele grade was associated with a second consecutive poor TMC. DISCUSSION Two-thirds of Tanner V boys with an uncorrected varicocele and normal testicular volumes achieve a normal TMC regardless of varicocele grade or age. Despite Tanner V development, 47% with an initial "poor" SA will improve to normal status without surgery. However, a small subgroup of patients will have persistently poor TMC and thus should be targeted in future research for timely intervention. CONCLUSION Semen parameters improve over time. SA should be followed and repeated at least once in symptomatic Tanner V boys with varicoceles.
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Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry? J Pediatr Urol 2017; 13:76.e1-76.e5. [PMID: 27818033 PMCID: PMC5329071 DOI: 10.1016/j.jpurol.2016.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/16/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The main indications for adolescent varicocelectomy are testicular hypotrophy or pain. However, we have previously shown that both serial total testicular volume and volume differential are weakly associated with semen quality. The ultimate patient goal is paternity, but semen analysis is critical to appropriate management of varicocele. We hypothesize that varicocelectomy improves total motile count (TMC) among patients who only have abnormal semen analysis (SA) parameters, but not among those with potential hormonal dysfunction such as Klinefelter syndrome or cryptorchidism. METHODS We retrospectively reviewed our registry of adolescent males followed with a clinical left varicocele. For this study, subjects without sustained testicular asymmetry, who were Tanner V, and gave at least one preoperative SA were included. Subjects were excluded if they had embolization for their varicocele or no postoperative SA. Primary outcome was change in TMC before and after surgery, compared using the Wilcoxon signed rank test after stratifying by surgical indication. Secondary outcomes included rates of improved TMC and normalized TMC (>20 million) after surgery, compared across covariates using the Fisher exact test. RESULTS Seventeen patients met the eligibility criteria, 11 of whom underwent repair for only abnormal preoperative TMC. Overall, median age (interquartile range [IQR]) at first preoperative SA was 17.6 (15.9-17.9) years. The median preoperative TMC across all SA was 2.8 (0.7-7.4) million. The median age at surgery was 18.2 (16.8-18.9) years. Postoperatively, the median TMC across all SA increased to 18.2 (3.6-18.2) million (Wilcoxon signed rank test, p < 0.01; see Figure). The improvement in TMC occurred primarily in the group who only had abnormal preoperative TMC (82% improved, 55% normalized); lack of improvement was seen in patients who had a history of Klinefelter or orchiopexy for cryptorchidism. CONCLUSIONS Adolescent varicocele patients should undergo SA after development of Tanner V. Varicocelectomy has a high success rate for improving TMC in adolescent or young adult males who only have abnormal TMC and no history of cryptorchidism.
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Pathak P, Chandrashekar A, Hakky TS, Pastuszak AW. Varicocele management in the era of in vitro fertilization/intracytoplasmic sperm injection. Asian J Androl 2017; 18:343-8. [PMID: 27030086 PMCID: PMC4854076 DOI: 10.4103/1008-682x.178482] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Varicocele is the most common surgically treatable cause of male infertility, and often results in alterations in semen parameters, sperm DNA damage, and changes to the seminal milieu. Varicocele repair can result in improvement in these parameters in the majority of men with clinical varicocele; data supporting repair in men with subclinical varicocele are less definitive. In couples seeking fertility using assisted reproductive technologies (ARTs), varicocele repair may offer improvement in semen parameters and sperm health that can increase the likelihood of successful fertilization using techniques such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), or may decrease the level of ART needed to achieve successful pregnancy. Male infertility is an indicator of general male health, and evaluation of the infertile male with an eye toward future health can facilitate optimal screening and treatment of these men. Furthermore, varicocele may represent a progressive lesion, offering an argument for its repair, although this is currently unclear.
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Affiliation(s)
| | | | | | - Alexander W Pastuszak
- Scott Department of Urology, Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Wu K, Yan G, Yin W, Chen X, Wang G, Cheng Y. A Novel Approach of Microscopic Subinguinal Varicocelectomy With a "Pulling" Strategy. Urology 2016; 104:97-101. [PMID: 28042049 DOI: 10.1016/j.urology.2016.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/13/2016] [Accepted: 12/20/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of a novel approach of microscopic subinguinal varicocelectomy with a "pulling" strategy. MATERIALS AND METHODS Fifty-two male patients with varicocele were enrolled in this study. Twenty-six patients underwent conventional microscopic subinguinal varicocelectomy, whereas the remaining 26 patients accepted our novel approach of treatment. In this method, with a subinguinal incision, we dissociated the spermatic cord from the external ring. And thus we pulled the spermatic cord down and away from the external ring and exposed the spermatic cord that initially was proximal to the external ring in the surgical field. The remainder of the procedure was similar to that of the conventional method. Follow-up was made at 1 and 3 months. Postoperative complications were recorded and sperm parameters were evaluated by semen analysis. RESULTS Fewer vein branches were ligated in the novel method group compared with the conventional method group (6.9 ± 2.1 vs 9.8 ± 2.2, P < .001; t = -5.316). There was no significant difference in the number of testicular arteries or lymphatic ducts between the 2 groups. The mean microsurgical operative time in the novel method group was significantly shorter than that in the conventional method group (34.7 ± 6.5 minutes vs 45.7 ± 8.8 minutes, P < .001; t = -5.621). The incidence of postoperative complications was similar for the 2 groups. There was no significant difference regarding semen quality improvement between the 2 groups. CONCLUSION This study demonstrates that our novel approach of microscopic subinguinal varicocelectomy with a "pulling" strategy significantly reduces the number of internal veins to ligate and shortens operating time, with no increase in complications. It is a safe and effective method of varicocele treatment.
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Affiliation(s)
- Kerong Wu
- Department of Urology, Zhejiang University Ningbo Hospital, Ningbo First Hospital, Ningbo, Zhejiang, China; Department of Urology, First Affiliated Hospital, Soochow University, Suzhou, Jiangsu, China
| | - Guang Yan
- Soochow University, Suzhou, Jiangsu, China
| | - Weiqi Yin
- Department of Urology, Zhejiang University Ningbo Hospital, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Xueqin Chen
- Department of Reproductive Medicine, Zhejiang University Ningbo Hospital, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Guoyao Wang
- Department of Urology, Zhejiang University Ningbo Hospital, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Yue Cheng
- Department of Urology, Zhejiang University Ningbo Hospital, Ningbo First Hospital, Ningbo, Zhejiang, China.
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105
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[Comparison of subinguinal microsurgical varicocelectomy vs percutaneous embolization in infertile men]. Prog Urol 2016; 26:1178-1184. [PMID: 27825582 DOI: 10.1016/j.purol.2016.09.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Subinguinal microscopic ligation is the current standard of treatment of varicocele, and percutaneous embolization is a new alternative. We aimed to compare these procedures for reproductive and functional aspects. MATERIAL A consecutive series of 76 patients with clinical varicocele, alteration of semen parameters and infertility, undergoing either procedure (microsurgery in 49 cases and embolization in 27 cases) was prospectively analyzed preoperatively and postoperatively (at 1, 3, 6, 9 and 12 months). Outcome measures were: semen parameters, pregnancies, pain, side effects, recovery time and overall satisfaction. Subsequently, all patients were contacted by telephone in January 2015 (with a median delay of 4 years after the procedure) in order to determine reproductive events. RESULTS Preoperatively, both groups were identical for clinical and biological items. We observed an improvement of sperm concentration at 3, 6, 9 and 12 months (P<0.001, <0.001, 0.012, 0.018, respectively) and sperm motility at 6 months (P=0.002). The sperm concentration was higher at 6 months in PE group (P=0.043). With a median follow-up of 4 years after the procedure, 27 pregnancies occurred (spontaneous pregnancy rate of 32%). There was no difference between procedures on the sperm quality, pregnancy rate and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (P=0.002) and less postoperative pain (P=0.007). CONCLUSION Both procedures give equivalent results regarding sperm quality, pregnancy rate and satisfaction even though recovery seems faster and postoperative pain seems lower after percutaneous embolization. LEVEL OF EVIDENCE 4.
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Abstract
Varicocele is present in approximately 15% of men, and, although it is the most commonly diagnosed cause of male infertility, nearly two-thirds of men with varicoceles remain fertile. It was decided to make use of the current evidence obtained from the previous meta-analyses between 2004 and 2015 as well as available articles covering this field, preferably randomized controlled articles dealing with the topic of semen analysis before and after repair. Two important meta-analyses were discussed as well as other articles dealing with the topic of semen analysis before and after varicocelectomy. The evidence suggests that all semen parameters improve after varicocele repair. Based on the available evidence, it is clear that there is a benefit in treating men with a palpable varicocele. One can expect that all semen parameters will improve within 3 months after repair.
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Affiliation(s)
- Thinus Kruger
- Aevitas Clinic, Pinelands and Reproductive Biology Unit, Stellenbosch University/Tygerberg Hospital, South Africa
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107
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Chiles KA, Schlegel PN. Cost-effectiveness of varicocele surgery in the era of assisted reproductive technology. Asian J Androl 2016; 18:259-61. [PMID: 26732113 PMCID: PMC4770496 DOI: 10.4103/1008-682x.172644] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The advent of innovative techniques for addressing infertility has made for exciting times in the arena of andrology. The success of microTESE for retrieving sperm has enabled azoospermic men to have the opportunity to father biological children when it was previously impossible. The ability to offer a variety of assisted reproductive techniques that includes intracytoplasmic sperm injection has opened the door for couples with male factor infertility who were otherwise untreatable. With the multitude of options available to infertile couples, however, comes an unsurprising degree of controversy regarding what treatments should be offered and when. Complicating the picture is the question of if and when varicocele repair should be undertaken, and the financial implications of the treatment decisions that are made. The infertile couple with varicocele warrants careful consideration. The overall efficacy of varicocele repair as well as cost-effectiveness of repair compared to immediate microTESE in azoospermic men and assisted reproductive technology in men with suboptimal semen parameters will be reviewed.
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Affiliation(s)
| | - Peter N Schlegel
- Department of Urology, Weill Cornell Medical College, New York, USA
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108
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Tiseo BC, Esteves SC, Cocuzza MS. Summary evidence on the effects of varicocele treatment to improve natural fertility in subfertile men. Asian J Androl 2016; 18:239-45. [PMID: 26806080 PMCID: PMC4770493 DOI: 10.4103/1008-682x.172639] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.
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Affiliation(s)
| | | | - Marcello S Cocuzza
- Department of Urology, University of Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 7 andar - Sala 710F, Sao Paulo, 05403-000, Brazil
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Crestani A, Giannarini G, Calandriello M, Rossanese M, Mancini M, Novara G, Ficarra V. Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique, complications, and results. Asian J Androl 2016; 18:292-5. [PMID: 26763550 PMCID: PMC4770501 DOI: 10.4103/1008-682x.171658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 106 to 21 × 106 ml−1 (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.
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Affiliation(s)
| | | | | | | | | | | | - Vincenzo Ficarra
- Academic Medical Centre Hospital Santa Maria della Misericordia; Department of Experimental and Clinic Medical Sciences, Urology Unit, University of Udine, Udine, Italy
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110
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Shridharani A, Owen RC, Elkelany OO, Kim ED. The significance of clinical practice guidelines on adult varicocele detection and management. Asian J Androl 2016; 18:269-75. [PMID: 26806081 PMCID: PMC4770498 DOI: 10.4103/1008-682x.172641] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Varicoceles are the most common correctable etiology of male factor infertility. However, the detection and management of varicoceles have not been standardized. This has led to decades of debate regarding the effect of varicocele on male infertility and subsequently whether repair leads to an improved fertility status. The current body of evidence investigating the role of varicocele and varicocelectomy is weak and conflicting. The stance taken by the AUA and ASRM suggests that there is insufficient outcomes data to support evidenced-based guidelines, citing evidence used to provide current recommendations are generally of a low quality level. On the other hand, the EAU Guidelines give a level 1a of evidence for management of varicoceles that are clinically palpable, associated with subnormal semen analyses and having otherwise unexplained fertility. Besides aiding with clinical varicocele detection and management, clinical practice opinion statements and guidelines aim to direct and strengthen the infrastructure of future studies. We review the current status of opinion statements and guidelines in varicocele and management detection with focus on their application in practice.
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Affiliation(s)
- Anand Shridharani
- Department of Urology, University of Tennessee College of Medicine, Chattanooga, TN 37403, USA
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111
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Shen JKC, Huang GO, Ko EYK. Controversies in varicocele repair--much ado about nothing? Asian J Androl 2016; 18:317-8. [PMID: 26732102 PMCID: PMC4770508 DOI: 10.4103/1008-682x.168789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | - Edmund Yuey Kun Ko
- Department of Urology, Loma Linda University School of Medicine, Loma Linda, California, USA
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112
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Li M, Wang Z, Li H. Laparoendoscopic single-site surgery varicocelectomy versus conventional laparoscopic varicocele ligation: A meta-analysis. J Int Med Res 2016; 44:985-993. [PMID: 27688686 PMCID: PMC5536546 DOI: 10.1177/0300060516659824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective To perform a meta-analysis of data from available published studies comparing laparoendoscopic single-site surgery varicocelectomy (LESSV) with conventional transperitoneal laparoscopic varicocele ligation. Methods A comprehensive data search was performed in PubMed and Embase to identify randomized controlled trials and comparative studies that compared the two surgical approaches for the treatment of varicoceles. Results Six studies were included in the meta-analysis. LESSV required a significantly longer operative time than conventional laparoscopic varicocelectomy but was associated with significantly less postoperative pain at 6 h and 24 h, a shorter recovery time and greater patient satisfaction with the cosmetic outcome. There was no difference between the two surgical approaches in terms of postoperative semen quality or the incidence of complications. Conclusion These data suggest that LESSV offers a well tolerated and efficient alternative to conventional laparoscopic varicocelectomy, with less pain, a shorter recovery time and better cosmetic satisfaction. Further well-designed studies are required to confirm these findings and update the results of this meta-analysis.
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Affiliation(s)
- Mingchao Li
- 1 Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengyun Wang
- 2 Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Li
- 1 Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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113
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Wang J, Xia SJ, Liu ZH, Tao L, Ge JF, Xu CM, Qiu JX. Inguinal and subinguinal micro-varicocelectomy, the optimal surgical management of varicocele: a meta-analysis. Asian J Androl 2016; 17:74-80. [PMID: 25248652 PMCID: PMC4291882 DOI: 10.4103/1008-682x.136443] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Conventional meta-analyses have shown inconsistent results for the efficacy of various treatments of varicoceles. Therefore, we performed a multiple-treatment meta-analysis to assess the effectiveness and safety of 10 methods of varicocelectomy and embolization/sclerotherapy. We systematically reviewed 35 randomized controlled trials and observational studies, from 1966 to August 5, 2013, which compared any of the following treatments for varococeles: laparoscopic, retroperitoneal, open inguinal and subinguinal varicocelectomy, microsurgical subinguinal and inguinal varicocelectomy, percutaneous venous embolization, Tauber antegrade sclerotherapy, retrograde sclerotherapy and expectant therapy (no treatment). Inguinal and subinguinal microsurgery, open inguinal, laparoscopic varicocelectomy showed a significant advantage over expectant therapy in terms of pregnancy rates (odds ratio (OR): 3.48, 2.68, 2.92 and 2.90, respectively). Compared with retroperitoneal open surgery, inguinal microsurgery showed an improvement of sperm density (mean difference (MD): 10.60, 95% confidence interval (CI): 1.92–19.60) and sperm motility (MD: 9.09, 95% CI: 4.88–13.30). Subinguinal and inguinal microsurgery outperformed retroperitoneal open surgery in terms of recurrence (OR: 0.05, 0.06 respectively). Tauber antegrade sclerotherapy and subinguinal microsurgery were associated with the lowest risk of hydrocele formation. The odds of overall complication, compared with retroperitoneal open varicocelectomy, were lowest for inguinal microsurgery (OR = 0.07, 95% CI: 0.02–0.19), followed by subinguinal microsurgery (OR = 0.09, 95% CI: 0.02–0.19). Inguinal and subinguinal micro-varicocelectomy had the highest pregnancy rates, significant increases in sperm parameters, with low odds of complication. These results warrant additional properly conducted randomized controlled clinical studies with larger sample sizes.
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Affiliation(s)
| | | | | | | | | | | | - Jian-Xin Qiu
- Department of Urology, Shanghai First People's Hospital, Medical College of Shanghai Jiao Tong University, Shanghai, China
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114
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Kimura M, Nagao K, Tai T, Kobayashi H, Nakajima K. Age is a significant predictor of early and late improvement in semen parameters after microsurgical varicocele repair. Andrologia 2016; 49. [DOI: 10.1111/and.12620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- M. Kimura
- Department of Urology; Teikyo University; Itabashi Tokyo Japan
| | - K. Nagao
- Department of Urology; Toho University; Omori Tokyo Japan
| | - T. Tai
- Department of Urology; Toho University; Omori Tokyo Japan
| | - H. Kobayashi
- Department of Urology; Toho University; Omori Tokyo Japan
| | - K. Nakajima
- Department of Urology; Toho University; Omori Tokyo Japan
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Sofimajidpour H, Ghaderi E, Ganji O. Comparison of the Effects of Varicocelectomy and Oral L-carnitine on Sperm Parameters in Infertile Men with Varicocele. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH : JCDR 2016; 10:PC07-10. [PMID: 27190879 DOI: 10.7860/jcdr/2016/18464.7557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/29/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Varicocele is defined as dilated and twisted veins of the pampiniform plexus in the spermatic cord. It is the most common cause of male infertility. There are various medical and surgical procedures for the treatment of this disease. AIM This study was aimed to compare the effects of oral administration of L-Carnitine and varicocelectomy on spermogram parameters. MATERIALS AND METHODS This study was conducted as a double blind clinical trial without randomization. Inclusion criteria were, all married infertile men with varicocele. Patients chose their treatment personally and spermogram was carried out for all patients before and after the third and sixth months of treatment. Then, the sperm parameters of the two groups were compared using repeated measures ANOVA. RESULTS In our study, trend of sperm count in the surgery group changed from 22 to 28.61 million (vs 34.6 to 45.37 in L-Carnitine group), motility changed from 21.74 to 35.38 percent (vs 33.9 to 47.48 in L-Carnitine group), normal sperm morphology changed from 46.25 to 60 percent (vs 56.61 to 69.7 in L-Carnitine group) and volume of semen changed from 3.5 to 4.17 cc (vs 2.95 to 4.33 in L-Carnitine group). These values were not statistically different between the two groups. CONCLUSION Based on the results of this study, we can say that medicinal treatment by administration of oral L-Carnitine is as effective as varicocelectomy in improving semen parameters and can be used as an alternative to surgery for varicocele grade II.
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Affiliation(s)
- Heshmatollah Sofimajidpour
- Associate Professor, Department of Urology, Faculty of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
| | - Ebrahim Ghaderi
- Assistant Professor, Department of Epidemiology, Faculty of Medicine Kurdistan University of Medical Sciences , Sanandaj, Iran
| | - Omid Ganji
- General Physician, School of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
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116
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Abstract
Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.
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Affiliation(s)
- Alexander W Pastuszak
- Center for Reproductive Medicine; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Keene DJB, Fitzgerald CT, Cervellione RM. Sperm concentration and forward motility are not correlated with age in adolescents with an idiopathic varicocele and symmetrical testicular volumes. J Pediatr Surg 2016; 51:293-5. [PMID: 26811206 DOI: 10.1016/j.jpedsurg.2015.10.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 11/18/2022]
Abstract
AIM Idiopathic varicocele is a common condition that may impair fertility. Its treatment in children and adolescents is reserved for those patients who develop symptoms or testicular growth arrest. We evaluated the trends in sperm parameters among adolescent varicocele patients with symmetrical testicular volumes who have not undergone varicocelectomy. METHOD Data were prospectively collected from a single institution (2009 to 2014). Post-pubertal patients aged 12 to 17years produced semen samples by masturbation. Outcomes measured were semen volume, sperm concentration, and forward motility. Additional variables recorded included: a) testicular volume (ultrasound measurement), b) clinical varicocele grade, c) venous Doppler grading. Linear regression analysis was performed using Fisher's transformation. P<0.05 was considered significant, and data are presented as median (IQ range). RESULTS Forty-one patients with a median age of 15.4 (15.0-15.9) years each provided a sperm sample during the study period. Thirty-five had grade 3 (visible) varicocele, and 6 had grade 2 (palpable) varicocele. All patients had spontaneous venous reflux on Doppler ultrasound, and none had undergone varicocelectomy prior to producing the sperm sample. Table 1 summarizes the sperm parameters according to patient age. The overall median sperm concentration was 37 (16-64) millions/ml and was not correlated with age. The overall median forward motility was 55% (44-64) and was not correlated with age. Thirty-four patients had normal sperm parameters, which remained within the WHO range of normality. CONCLUSIONS Following the European Association of Urology guidelines does not cause progressive deterioration of sperm parameters between the age of 12 and 17years.
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Affiliation(s)
- David J B Keene
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Cheryl T Fitzgerald
- Department of Reproductive Medicine, St Mary's Hospital, Manchester, United Kingdom
| | - Raimondo M Cervellione
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Manchester, United Kingdom.
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Abdelaziz AS, Burham WA, Aboelsaad AY, Badran YA, Ahmed AFAM. Impact of extensive laparoscopic venous disconnection on the recurrence rate and sperm DNA quality in infertile varicocele patients. Urol Ann 2015; 7:482-7. [PMID: 26692670 PMCID: PMC4660701 DOI: 10.4103/0974-7796.157964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Although there are many literature examining the possible effects of varicocelectomy on classic semen parameters and recurrence rate, few published articles have examined the effect of conventional laparoscopic varicocelectomy on sperm DNA integrity. Objectives: The objective was to evaluate the effect of extensive laparoscopic venous disconnections on the recurrence rate and sperm DNA damage in varicocele patients. Methods: Totally, 54 patients with varicocele underwent extensive laparoscopic venous disconnections were assessed by clinical evaluation, duplex scan, semen analysis, and sperm DNA fragmentation assay before surgery and after 6 and 12 months following surgery. Results: No intra- or post-operative complications were observed and out of 54 patients preoperatively complained from varicocele 2 (3.7%) patients' have recurrence during the follow-up period for 12 months. Out of 54 patients complaining from male infertility, 14 patients success to get pregnancy after 6 months with pregnancy rates of 25.92% and 22 (40.74%) after 12 months, and 28 patients (51.85%) had a preoperative DNA fragmentation index (DFI) >30%, decreased following surgery below 30% in 19 (35.18%) patients after 6 months, and 11 (20.37%) after 12 months, and the percentage of sperm with DFI > 30% was significantly decreased after 6 and 12 months, respectively (38.4 ± 10.6 vs. 31.3 ± 12.4, [P < 0.001] at 6 months, and 22.9 ± 13.2, [P < 0.001] after 1-year). Other spermatic parameter was significantly improved. Conclusions: An extensive laparoscopic venous disconnection was significantly decreasing the recurrence rate, DFI and improving normal semen parameters and fertility.
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Affiliation(s)
- Alsayed Saad Abdelaziz
- Department of Urology, Al-Azhar University, Cairo, Egypt ; Department of Urology, Al-Rafie Hospital, Makkah, KSA
| | | | | | - Yaser Ali Badran
- Department of Urology, Al-Azhar University, Cairo, Egypt ; Department of Urology, Dr. Soliman Fakeeh Hospital, Jeddeh, KSA
| | - Abul-Fotouh Abdel-Maguid Ahmed
- Department of Urology, Al-Azhar University, Cairo, Egypt ; Department of Urology, Salman Bin Abdulaziz University, Alkharji, KSA
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Kupis Ł, Dobroński PA, Radziszewski P. Varicocele as a source of male infertility - current treatment techniques. Cent European J Urol 2015; 68:365-70. [PMID: 26568883 PMCID: PMC4643713 DOI: 10.5173/ceju.2015.642] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/04/2015] [Indexed: 11/22/2022] Open
Abstract
To establish the extent of varicocele as the cause of infertility in men and compare the various techniques of treatment. We searched PubMed and the Cochrane Library database using varicocele, male infertility, varicocelectomy as keywords. Varicocele seems to be a growing problem considered to be one of the most common causes of male infertility in recent times. Nevertheless, its role remains unclear. The best treatment option seems to be microscopic surgery - the most effective and linked to rare surgical complications. But the greatest clinical problem remains the selection of patients to treat - recently it is believed that varicocelectomy is a possibly advisable option in patients with clinical varicocele and seminal parameter impairment [1]. More high-quality, multicenter, long-term randomized controlled trials (RCT's) are required to verify the findings.
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Affiliation(s)
- Łukasz Kupis
- Warsaw Medical University, Department of Urology, Poland
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120
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Wang H, Wang X, Fu D, Zhu H, Lai MK. Does varicocele grade predict the postoperative changes of semen parameters following left inguinal micro-varicocelectomy? Asian J Urol 2015; 2:163-166. [PMID: 29264137 PMCID: PMC5730707 DOI: 10.1016/j.ajur.2015.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 04/29/2015] [Accepted: 07/06/2015] [Indexed: 11/02/2022] Open
Abstract
Objective To evaluate the relationship between preoperative grade and postoperative changes of semen parameters following left inguinal varicocelectomy. Methods This study included 44 patients undergoing left microsurgical inguinal varicocelectomy. Internal spermatic veins were classified as large (4 mm or more in diameter), medium (2-4 mm), or small (2 mm or less). Changes in sperm activity, morphology and count were estimated perioperatively. The introperative findings and semen parameters were compared between varicocele groups of grades 2 and 3. Results Both sperm motility and count improved significantly postoperatively (from (31.9 ± 16.3)% to (47.3 ± 15.5)%, from (28.1 ± 28.1) × 106/mL to (52.1 ± 74.2) × 106/mL). In varicoceles with grade 2 and 3, significant differences were found in the number of large veins (0.4 ± 0.6 vs. 1.2 ± 0.7, p < 0.001) and ultrasonographic maximum diameters of spermatic vein in supine and standing positions (2.3 ± 0.4 cm vs. 2.8 ± 0.6 cm, 3.1 ± 0.7 cm vs. 3.9 ± 0.7 cm, p = 0.001 and 0.001 respectively). However no difference of changes in sperm motility and count was detected ((16.3 ± 13.5)% vs. (14.4 ± 12.6)%, (30.5 ± 84.4) × 106/mL vs. (12.9 ± 20.6) × 106/mL respectively, p = 0.65 and 0.40 respectively). Conclusion Preoperative varicocele grade might not predict postoperative semen changes regardless of possible existence of anatomic and ultrasonographic associations.
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Affiliation(s)
- Hongzhen Wang
- Division of Urology, Department of Surgery, Chang Gung Hospital, Xiamen, Fujian, China
| | - Xueke Wang
- Division of Urology, Department of Surgery, Chang Gung Hospital, Xiamen, Fujian, China
| | - Dingjun Fu
- Division of Urology, Department of Surgery, Chang Gung Hospital, Xiamen, Fujian, China
| | - Hua Zhu
- Division of Urology, Department of Surgery, Chang Gung Hospital, Xiamen, Fujian, China
| | - Ming-Kuen Lai
- Division of Urology, Department of Surgery, Chang Gung Hospital, Xiamen, Fujian, China
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Assessment of Time-dependent Changes in Semen Parameters in Infertile Men After Microsurgical Varicocelectomy. Urology 2015; 86:48-51. [DOI: 10.1016/j.urology.2015.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 04/01/2015] [Accepted: 04/06/2015] [Indexed: 11/19/2022]
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122
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Lai YW, Hsueh TY, Hu HY, Chiu YC, Chen SSS, Chiu AW. Varicocele is associated with varicose veins: A population-based case-control study. Int J Urol 2015; 22:972-5. [DOI: 10.1111/iju.12843] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/24/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Yu-Wei Lai
- Division of Urology; Taipei City Hospital Renai Branch; Taipei Taiwan
- Department of Urology; National Yang-Ming University School of Medicine; Taipei Taiwan
| | - Thomas Y Hsueh
- Division of Urology; Taipei City Hospital Renai Branch; Taipei Taiwan
- Department of Urology; National Yang-Ming University School of Medicine; Taipei Taiwan
| | - Hsiao-Yun Hu
- Department of Education and Research; Taipei City Hospital; Taipei Taiwan
- Departmentof Public Health; Institute of Public Health; National Yang-Ming University; Taipei Taiwan
| | - Yi-Chun Chiu
- Division of Urology; Taipei City Hospital Renai Branch; Taipei Taiwan
- Department of Urology; National Yang-Ming University School of Medicine; Taipei Taiwan
| | - Saint Shiou-Sheng Chen
- Division of Urology; Taipei City Hospital Renai Branch; Taipei Taiwan
- Department of Urology; National Yang-Ming University School of Medicine; Taipei Taiwan
| | - Allen W Chiu
- Division of Urology; Taipei City Hospital Renai Branch; Taipei Taiwan
- Department of Urology; National Yang-Ming University School of Medicine; Taipei Taiwan
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123
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Lee YJ, Cho SY, Paick JS, Kim SW. Usefulness of 2010 world health organization reference values for determining indications for varicocelectomy. Urology 2015; 85:831-5. [PMID: 25817106 DOI: 10.1016/j.urology.2015.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/10/2014] [Accepted: 01/13/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the impact of 2010 World Health Organization (WHO) reference values in patients who underwent microsurgical varicocelectomy. METHODS This retrospective cohort study included 206 men who underwent microsurgical varicocelectomy for a clinical varicocele with at least 1 abnormal semen parameter according to the 1999 WHO criteria. The preoperative semen analysis findings were reclassified according to the 2010 WHO criteria, and an improved seminal result after varicocelectomy was defined as a ≥20% increase in sperm count or motility. RESULTS Semen results of 114 men (55.3%) were reclassified as being above the reference values according to the 2010 WHO criteria. Among those with below reference values, 79.3% and 34.8% showed improved sperm counts and motility, respectively. However, in patients whose semen results converted to normal, 47.4% and 20.2% showed improved sperm counts and motility, respectively. Among those whose semen results were normal on the 2010 criteria, 58.8% showed improved sperm count or motility after microsurgical varicocelectomy. CONCLUSION More than half of the patients whose semen results converted to normal on the 2010 WHO criteria showed improved seminal results after microsurgical varicocelectomy. It is necessary to reconsider the 2010 WHO criteria when determining the surgical indication for microsurgical varicocelectomy.
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Affiliation(s)
- Young Ju Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Sung Yong Cho
- Department of Urology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jae-Seung Paick
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Soo Woong Kim
- Department of Urology, Seoul National University Hospital, Seoul, Korea.
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Spontaneous pregnancy rates in Chinese men undergoing microsurgical subinguinal varicocelectomy and possible preoperative factors affecting the outcomes. Fertil Steril 2015; 103:635-9. [DOI: 10.1016/j.fertnstert.2014.12.091] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 01/01/2023]
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125
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Lv KL, Zhuang JT, Zhao L, Wan Z, Zhang YD, Gao Y, Sun XZ, Qiu SP, Deng CH, Tu XA. Varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men. Andrologia 2015; 47:1190-5. [PMID: 25643753 DOI: 10.1111/and.12402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2014] [Indexed: 11/29/2022] Open
Abstract
Knowledge of subinguinal microsurgical varicocelectomy is of fundamental importance to ensure that varicocele is resolved and testicular function is preserved. Our study aimed to describe the number of veins, arteries and lymphatics in the subinguinal spermatic cord and to clarify their differences between two sides, between patients with different complaints and between varicoceles with different clinical grades. A total of 102 consecutive patients underwent 162 primary subinguinal microsurgical varicocelectomies, during which the number of vessels with different diameters was recorded. A mean number of 12.9 internal spermatic veins, 0.9 external spermatic veins, 1.8 internal spermatic arteries and 2.9 lymphatics were identified per cord. 88.2% of the internal spermatic arteries were surrounded by a dense complex of adherent veins. The external spermatic vein or veins were found in 49.4% of the cases. The mean number of medium (1-3 mm in diameter) internal spermatic veins on the left was larger than that on the right (P < 0.001). The mean number of medium internal spermatic veins in grade III varicocele was larger than that in grade I or grade II (P < 0.015). There was no significant anatomical difference between the men presenting for infertility, chronic testicular pain and both the two complaints.
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Affiliation(s)
- K-L Lv
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - J-T Zhuang
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - L Zhao
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Z Wan
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Y-D Zhang
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Y Gao
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - X-Z Sun
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - S-P Qiu
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - C-H Deng
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - X-A Tu
- Department of Urology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Benazzouz MH, Essatara Y, El Sayegh H, Iken A, Benslimane L, Nouini Y. [Impact of varicocele on testicular volume and sperm parameters]. Pan Afr Med J 2014; 19:334. [PMID: 25918574 PMCID: PMC4405070 DOI: 10.11604/pamj.2014.19.334.4693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/23/2014] [Indexed: 11/11/2022] Open
Abstract
Introduction La varicocèle est une pathologie masculine fréquente dont l'incidence est encore plus importante dans dans la population des hommes infertiles. Si ses mécanismes sont à ce jour incomplètement expliqués il semble acquis que la varicocèle peut être associée a une dysfonction testiculaire avec diminution du volume testiculaire et de la concentration en spermatozoïde de l’éjaculat. Méthodes Dans un premier temps nous exposons les résultats d'une étude rétrospective sur 5 ans (de Mars 2009 à Mars 2014), réalisée au service d'urologie A de l'hôpital Ibn Sina de Rabat et ayant comme objectif d’évaluer l'impact de la varicocèle palpable sur le volume testiculaire et les paramètres spermatiques. Tous les patients inclus dans notre étude avaient une varicocèle palpable. Dans un deuxième temps, et à travers une revue de la littérature nous discutons l'impact du traitement de la varicocèle sur la fertilité. Résultats 39 patients ont été inclus dans notre étude. L’âge moyen était de 29,71 ans et la varicocèle siégeait dans 89,74% des cas du coté gauche. Une atrophie testiculaire homolatérale à la varicocèle était retrouvée dans 7% des cas alors que des anomalies du spermogramme se voyaient dans 69,23% des cas. Conclusion L'impact de la varicocèle sur l'altération des paramètres spermatiques a été clairement établi bien que sa physio pathogénie ne soit pas bien élucidée. Le traitement chirurgical de la varicocèle semble indiqué chez les hommes infertiles présentant une varicocèle clinique et une altération significative du sperme.
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Affiliation(s)
| | | | | | - Ali Iken
- Service d'Urologie A, Hopital Ibn Sina, CHU Rabat, Maroc
| | | | - Yassine Nouini
- Service d'Urologie A, Hopital Ibn Sina, CHU Rabat, Maroc
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Report on varicocele and infertility: a committee opinion. Fertil Steril 2014; 102:1556-60. [PMID: 25458620 DOI: 10.1016/j.fertnstert.2014.10.007] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/02/2014] [Indexed: 01/08/2023]
Abstract
This document discusses the evaluation and management of varicoceles in the male partners of infertile couples, and presents the controversies and recommendations regarding this condition. This document replaces the ASRM Practice Committee document titled "Report on Varicocele and Infertility," last published in 2008, and was developed in conjunction with the Society for Male Reproduction and Urology (Fertil Steril 2008;90:S247-9).
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128
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Cho KS, Seo JT. Effect of varicocelectomy on male infertility. Korean J Urol 2014; 55:703-9. [PMID: 25405011 PMCID: PMC4231146 DOI: 10.4111/kju.2014.55.11.703] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/18/2014] [Indexed: 11/25/2022] Open
Abstract
Varicocele is the most common cause of male infertility and is generally correctable or at least improvable by various surgical and radiologic techniques. Therefore, it seems simple and reasonable that varicocele should be treated in infertile men with varicocele. However, the role of varicocele repair for the treatment of subfertile men has been questioned during the past decades. Although varicocele repair can induce improvement of semen quality, the obvious benefit of spontaneous pregnancy has not been shown through several meta-analyses. Recently, a well-designed randomized clinical trial was introduced, and, subsequently, a novel meta-analysis was published. The results of these studies advocate that varicocele repair be regarded as a standard treatment modality in infertile men with clinical varicocele and abnormal semen parameters, which is also supported by current clinical guidelines. Microsurgical varicocelectomy has been regarded as the gold standard compared to other surgical techniques and radiological management in terms of the recurrence rate and the pregnancy rate. However, none of the methods has been proven through well-designed clinical trials to be superior to the others in the ability to improve fertility. Accordingly, high-quality data from well-designed studies are needed to resolve unanswered questions and update current knowledge. Upcoming trials should be designed to define the best technique and also to define how to select the best candidates who will benefit from varicocele repair.
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Affiliation(s)
- Kang Su Cho
- Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ju Tae Seo
- Department of Urology, Cheil General Hospital & Women's Healthcare Center, Catholic Kwandong University College of Medicine, Seoul, Korea
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Effects of Varicocele on Serum Testosterone and Changes of Testosterone After Varicocelectomy: A Prospective Controlled Study. Urology 2014; 84:1081-7. [DOI: 10.1016/j.urology.2014.05.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/01/2014] [Accepted: 05/27/2014] [Indexed: 11/18/2022]
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131
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Kovac JR, Fantus J, Lipshultz LI, Fischer MA, Klinghoffer Z. Cost-effectiveness analysis reveals microsurgical varicocele repair is superior to percutaneous embolization in the treatment of male infertility. Can Urol Assoc J 2014; 8:E619-25. [PMID: 25295133 DOI: 10.5489/cuaj.1873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Varicoceles are a common cause of male infertility; repair can be accomplished using either surgical or radiological means. We compare the cost-effectiveness of the gold standard, the microsurgical varicocele repair (MV), to the options of a nonmicrosurgical approach (NMV) and percutaneous embolization (PE) to manage varicocele-associated infertility. METHODS A Markov decision-analysis model was developed to estimate costs and pregnancy rates. Within the model, recurrences following MV and NMV were re-treated with PE and recurrences following PE were treated with repeat PE, MV or NMV. Pregnancy and recurrence rates were based on the literature, while costs were obtained from institutional and government supplied data. Univariate and probabilistic sensitivity-analyses were performed to determine the effects of the various parameters on model outcomes. RESULTS Primary treatment with MV was the most cost-effective strategy at $5402 CAD (Canadian)/pregnancy. Primary treatment with NMV was the least costly approach, but it also yielded the fewest pregnancies. Primary treatment with PE was the least cost-effective strategy costing about $7300 CAD/pregnancy. Probabilistic sensitivity analysis reinforced MV as the most cost-effective strategy at a willingness-to-pay threshold of >$4100 CAD/pregnancy. CONCLUSIONS MV yielded the most pregnancies at acceptable levels of incremental costs. As such, it is the preferred primary treatment strategy for varicocele-associated infertility. Treatment with PE was the least cost-effective approach and, as such, is best used only in cases of surgical failure.
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Bozhedomov VA, Lipatova NA, Alexeev RA, Alexandrova LM, Nikolaeva MA, Sukhikh GT. The role of the antisperm antibodies in male infertility assessment after microsurgical varicocelectomy. Andrology 2014; 2:847-55. [DOI: 10.1111/j.2047-2927.2014.00254.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 06/20/2014] [Accepted: 07/09/2014] [Indexed: 11/26/2022]
Affiliation(s)
- V. A. Bozhedomov
- Department of Obstetrics, Gynecology, Perinatology and Reproduction; I.M. Sechenov First Moscow State Medical University; Moscow Russia
- Department of Clinical Andrology; The Federal State Budget Institution Peoples’ Friendship University of Russia; Moscow Russia
| | - N. A. Lipatova
- Department of Clinical Andrology; The Federal State Budget Institution Peoples’ Friendship University of Russia; Moscow Russia
| | - R. A. Alexeev
- Department of Clinical Andrology; The Federal State Budget Institution Peoples’ Friendship University of Russia; Moscow Russia
| | - L. M. Alexandrova
- Department of Clinical Andrology; The Federal State Budget Institution Peoples’ Friendship University of Russia; Moscow Russia
| | - M. A. Nikolaeva
- The Federal State Budget Institution “Research Center for Obstetrics, Gynecology and Perinatology” of the Ministry of Healthcare of the Russian Federation; Moscow Russia
| | - G. T. Sukhikh
- Department of Obstetrics, Gynecology, Perinatology and Reproduction; I.M. Sechenov First Moscow State Medical University; Moscow Russia
- The Federal State Budget Institution “Research Center for Obstetrics, Gynecology and Perinatology” of the Ministry of Healthcare of the Russian Federation; Moscow Russia
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Abstract
Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.
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Kimura M, Nagao K. Role of varicocele repair for male infertility in the era of assisted reproductive technologies. Reprod Med Biol 2014; 13:185-192. [PMID: 29699160 DOI: 10.1007/s12522-014-0181-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/30/2014] [Indexed: 01/10/2023] Open
Abstract
Varicocele is an abnormal condition characterized by dilatation of the pampiniform plexus veins draining the testis and is present in 15 % of men. Varicoceles have an adverse effect on spermatogenesis and are the most common cause of male infertility. Approximately 35 % of infertile men and more than 70 % of men with secondary infertility were reported to have varicoceles. Although data on methods of varicocele repair are accumulating, there remains controversy regarding the indications and techniques for varicocele repair. In addition, the role of varicocele repair in this era of assisted reproductive technologies continues to be debated. In this study, we performed a comprehensive PubMed search in order to review the current status of varicocele repair for male infertility. We reviewed English-language studies published from 1992 through 2013. After reviewing the articles, we identified a recent meta-analysis of four randomized controlled trials, which found that varicocele repair for oligozoospermic men was associated with better pregnancy rates as compared with observation. Our review of prospective studies showed that all semen parameters, including sperm concentration, motility, and progressive motility, were significantly improved after varicocele repair. We also summarize the findings of recent studies reporting beneficial effects of varicocele repair, i.e., decreased oxidative stress and sperm DNA fragmentation after varicocele repair and superior cost effectiveness versus in vitro fertilization/intracytoplasmic sperm injection alone, which may be important in the era of assisted reproductive technologies. Varicocele repair is a widespread, well-established procedure that can improve semen parameters in men with infertility. The effect of such treatment on the pregnancy rate is unclear because evidence is limited due to difficulties in recruiting patients for studies. Among the repair techniques, microsurgical repair using a subinguinal approach is potentially the best practice, although this procedure requires training in microsurgery. All these topics require further research in studies with sufficient patient enrollment and follow-up.
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Affiliation(s)
- Masaki Kimura
- Department of Urology Teikyo University School of Medicine Tokyo Japan
| | - Koichi Nagao
- Department of Urology Toho University School of Medicine Tokyo Japan
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135
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Ollandini G, Trombetta C, Mazzon G, de Concilio B, Bucci S, Pavan N, Belgrano E, Liguori G. Should older patients be offered varicocoele correction to improve their fertility? Andrology 2014; 2:402-7. [PMID: 24634284 DOI: 10.1111/j.2047-2927.2014.00197.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 11/26/2022]
Abstract
We reviewed a large number of patients from 2000 to 2010 that underwent varicocoele correction using the retrograde sclerotization approach. Three hundred and seventy-six of them were included in the study, as they met the inclusion criteria. Mean age at the time of surgery was 32 years (SD: 6.5); 32% of them were 35 years and older. Patients were classified according to the clinical classification (GC) and Sarteschi's Doppler ultrasound classification (GS). The patients showed up at the clinic after an average time of 30 months of referred infertility related (SD: 28.54). Patients underwent pre-operative assessment with physical examination, sperm analysis and Doppler ultrasound, and again the same assessment at least 3 months after surgery. We evaluated the following parameters: sperm concentration (millions/mL, CONC), percentage motility (a+b, MOT) and the percentage of morphologically typical spermatozoa (MOR). Univariate and Multivariate analysis were performed. The research of Pearson's coefficients was performed to test the correlation between sperm parameters and age, SG, CG. Semen specimens were evaluated according to WHO 1999 criteria. Mean CONC varied from 34.5 to 47.0 millions/mL (+12.5; p < 0.001); MOT from 27.2 to 34.5% (+7.3%; p < 0.001); and MOR from 44.0 to 47.6% (+3.6%; p = 0.001). Univariable and multivariable analysis of variance related to age showed no significant difference of parameters improvement. Pearson's correlation coefficient for pre-operative and post-operative sperm MOT related to patients' age was respectively -0.11 (p < 0.001) and -0.18 (p = 0.04). No other significance was found. Usefulness of treating infertile patients affected by varicocoele is confirmed: varicocoele correction leads to significant sperm parameters improvement. There is no evidence of different improvement related to patients' age. The decline in sperm motility related to age of the patients seems to be only age-dependent: the usefulness of treating patients affected by varicocoele is not influenced by their age: treatment should also be offered to older patients.
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Affiliation(s)
- G Ollandini
- Department of Urology, University of Trieste, Trieste, Italy
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136
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Influence of preoperative pain duration on microsurgical varicocelectomy outcomes. Adv Urol 2014; 2013:370969. [PMID: 24454350 PMCID: PMC3888677 DOI: 10.1155/2013/370969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/31/2013] [Accepted: 10/08/2013] [Indexed: 11/21/2022] Open
Abstract
Objective. To investigate the question of whether duration of pain before surgery ultimately affects sperm parameters after varicocelectomy. Methods. Fifty patients with painful grade-3 varicocele were investigated prospectively. The patients were divided into two groups according to their symptom period. The patients having had grade-3 varicocele for less than 1 year were included in Group-1 (Ge, n = 25). Twenty-five patients who had painful grade-3 varicocele for more than 1 year (Gs, n = 25) were classified in Group-2. Semen analysis was performed after 3 days of sexual abstinence twice a month. Total sperm concentration (TSC), rapidly progressive motility (SPa), and slow or sluggish motility (SPb) rates were noted. Pain was evaluated by using 10 cm visual analogue scale (VAS). Results. Postoperative TSC and %SPb were significantly higher in both groups (P = 0.01). There was no difference between two groups for preoperative and postoperative TSC, %SPa, % and SPb values. VAS significantly declined in both groups (P = 0.005). This postoperative decline was not significant for intergroup comparison. Conclusions. Our results show that increase in semen quality and decrease in the pain after microsurgery varicocelectomy do not depend on the duration of the preoperative pain.
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Abstract
Varicoceles are an abnormal dilation of the pampiniform plexus of veins within the scrotum. Varicoceles are highly prevalent and can result in a myriad of deleterious effects on male reproduction. Numerous therapeutic options are available for correcting varicoceles, including surgical varicocelectomy and radiographic venous embolization. Varicocele correction is a more cost-effective therapeutic modality than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples. In summary, varicoceles contribute significantly to male reproductive pathology, and varicocele correction is an important option for both clinicians and patients to consider in this era of assisted reproductive techniques.
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139
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Kim KH, Lee JY, Kang DH, Lee H, Seo JT, Cho KS. Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials. Korean J Urol 2013; 54:703-9. [PMID: 24175046 PMCID: PMC3806996 DOI: 10.4111/kju.2013.54.10.703] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 07/10/2013] [Indexed: 11/29/2022] Open
Abstract
Purpose To elucidate the impact of surgical varicocele repair on the pregnancy rate through new meta-analyses of randomized clinical trials that compared surgical varicocele repair and observation. Materials and Methods The PubMed and Embase online databases were searched for studies released before December 2012. References were manually reviewed, and two researchers independently extracted the data. To assess the quality of the studies, the Cochrane risk of bias as a quality assessment tool for randomized controlled trials was applied. Results Seven randomized clinical trials were included in our meta-analyses, all of which compared pregnancy outcomes between surgical varicocele repair and control. There were differences in enrollment criteria among the studies. Four studies included patients with clinical varicocele, but three studies enrolled patients with subclinical varicocele. Meanwhile, four trials enrolled patients with impaired semen quality only, but the other three trials did not. In a meta-analysis of all seven trials, a forest plot using the random-effects model showed an odds ratio (OR) of 1.90 (95% confidence interval [CI], 0.77 to 4.66; p=0.1621). However, for subanalysis of three studies that included patients with clinical varicocele and abnormal semen parameters, the fixed-effects pooled OR was significant (OR, 4.15; 95% CI, 2.31 to 7.45; p<0.001), favoring varicocelectomy. Conclusions Varicocelectomy for male subfertility is proven effective in men with clinical varicocele and impaired semen quality. Therefore, surgical repair should be offered as the first-line treatment of clinical varicocele in subfertile men.
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Affiliation(s)
- Kyu Hyun Kim
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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140
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Chen SS. Predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele. Andrologia 2013; 46:738-43. [PMID: 23889601 DOI: 10.1111/and.12142] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2013] [Indexed: 11/28/2022] Open
Abstract
To examine the predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele, we made a retrospective study. Twenty-one patients who had improved quality of spermatozoon 6 months after RV were designated as group 1, those with no improvement as group 2 (17 subjects) and those who received close surveillance as group 3 (10 patients) were recruited. The predictive factors included were time to recurrent varicocele; semen quality; testicular volume; number of ligated veins; body mass index; serum levels of follicle-stimulating hormone (FSH), luteinising hormone and testosterone; scrotal temperature; and peak retrograde flow (PRF) and maximal vein diameter (MVD) by colour Doppler ultrasound. The quality of spermatozoon improved significantly 6 months after RV in group 1 patients (21, 55.3%), and no improvement in group 2 and 3 patients. Patients in group 1 also had significantly lower FSH and PRF, longer time to recurrent varicocele, higher number of ligated veins and larger testicular volume than the group 2 (17, 44.7%) and group 3 patients. The significant predictive factors of successful RV were lower FSH and PRF; longer time to recurrent varicocele; and larger testicular volume preoperatively and a higher number of ligated veins during redo varicocelectomy.
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Affiliation(s)
- S-S Chen
- Department of Urology, School of Medicine and Shu-Tien Urological Institute, National Yang-Ming University, Taipei, Taiwan; Division of Urology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
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Kulis T, Knezevic M, Karlovic K, Kolaric D, Antonini S, Kastelan Z. Infrared digital thermography of scrotum in early selection of progressive varicocele. Med Hypotheses 2013; 81:544-6. [PMID: 23891041 DOI: 10.1016/j.mehy.2013.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Abstract
Varicocele is frequent but correctable cause of male infertility. Varicocelectomy is the most commonly performed operative procedure for varicocele. Majority of varicocele patients do not have fertility problem, therefore surgical correction is not recommended in all prevalent cases. On the other hand, varicocele is a progressive condition in some cases and individual with varicocele is at risk for developing impairment which can ultimately lead to semen deterioration and consequent infertility. Selection of patients with varicocele that will progress and cause infertility is beyond our current diagnostic capabilities. Diagnostic assessment of varicocele depends on physical examination and scrotal ultrasound/doppler. Infrared digital thermography of scrotum is a non-invasive and objective diagnostic method for early varicocele detection by means of temperature measurement on the scrotal skin surface. The criteria for diagnostic use of scrotal thermography were recently presented. We hypothesize that the infrared digital thermography of scrotum could be the cornerstone in detection of varicoceles that tend to progress with impairment of semen quality and will require surgical correction, among all prevalent varicocele cases.
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Affiliation(s)
- T Kulis
- Department of Urology, University Hospital Centre Zagreb, Medical School, University of Zagreb, Zagreb, Croatia.
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142
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Choi WS, Kim SW. Current issues in varicocele management: a review. World J Mens Health 2013; 31:12-20. [PMID: 23658861 PMCID: PMC3640148 DOI: 10.5534/wjmh.2013.31.1.12] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 12/29/2012] [Indexed: 02/06/2023] Open
Abstract
The most common cause of male infertility is varicocele, and varicocele is the most common correctable cause of male factor infertility. In this article we reviewed the concept of varicocele in terms of its diagnosis, method of treatment, indications for treatment, treatment outcomes, and prognostic factors. Physical examination is an essential diagnostic tool in the evaluation of a patient with a varicocele. However, as it depends on subjective findings, standardization of the physical examination method is needed. Various methods for treatment of varicocele exist, including open surgical, laparoscopic, microscopic surgical, and radiologic treatment such as embolization. Among these treatment approaches, microscopic inguinal or subinguinal varicocelectomy has superior outcomes, with a low complication rate. The influence of the treatment of varicocele on fertility is still a controversial issue and a difficult question to address, because there are limitations to performing a randomized control study, and previous studies had a heterogeneity of subjects and high dropout rate. However, there is robust evidence that varicocelectomy improves semen parameters as a surrogate marker of the potential for fertility. To date, general indications for treatment of varicocele are limited in patients with proven infertility, clinical palpable varicocele, and abnormal semen characteristics. Recently, it was shown that some symptoms other than infertility could be an indication for varicocelectomy because these symptoms are frequently related to deterioration of semen parameters. Varicocele in the adolescent presents a more difficult decision regarding whether to treat. A testicular size discrepancy of more than 20% is helpful for treatment decisions. Various prognostic factors were noted in several studies without, however, a consistent consensus.
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Affiliation(s)
- Woo Suk Choi
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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143
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Hsiao W, Rosoff JS, Pale JR, Powell JL, Goldstein M. Varicocelectomy is associated with increases in serum testosterone independent of clinical grade. Urology 2013; 81:1213-7. [PMID: 23561709 DOI: 10.1016/j.urology.2013.01.060] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 12/28/2012] [Accepted: 01/01/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether the varicocele grade is related to the degree of improvement in serum testosterone levels after varicocelectomy. MATERIALS AND METHODS We performed a retrospective review of men with a total serum testosterone level <400 ng/dL who had undergone microsurgical subinguinal varicocelectomy for infertility and/or hypogonadism. All men had clinically palpable left varicoceles and preoperative and postoperative total serum testosterone levels available. For patients with bilateral varicoceles, the greatest grade on either side was used to stratify the patients. The men with an isolated, left-side, grade I varicocele were not offered varicocelectomy. The changes in the testosterone levels were evaluated, with the results expressed as the mean ± standard error. P ≤.05 was considered statistically significant. RESULTS A total of 59 patients had undergone bilateral varicocelectomy and 19 unilateral varicocelectomy. Overall, an increase in testosterone was seen in 65 of the 78 men (83%) in the present study. The mean follow-up was 7 months. The mean serum testosterone level increased from 308.4 to 417.5 ng/dL, with a mean increase of 109.1 ± 12.8 ng/dL (n = 78). The improvements in the serum testosterone levels were seen regardless of the clinical grade. CONCLUSION Microsurgical varicocelectomy resulted in significant increases in the serum testosterone level, independent of the varicocele grade.
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Affiliation(s)
- Wayland Hsiao
- Center for Male Reproductive Medicine, Weill Cornell Medical College, New York, NY 10065, USA
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144
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Affiliation(s)
- Stamatios Karavolos
- Obstetrics and Gynaecology; The Gateshead Fertility Unit; Queen Elizabeth Hospital; Gateshead; NE9 6SX; UK
| | - Jane Stewart
- Newcastle Fertility Centre at Life; International Centre for Life; Times Square; Newcastle upon Tyne; NE1 4EP; UK
| | - Isaac Evbuomwan
- The Gateshead Fertility Unit; Queen Elizabeth Hospital; Gateshead; NE9 6SX; UK
| | - Kevin McEleny
- Newcastle Fertility Centre at Life; International Centre for Life; Times Square; Newcastle upon Tyne; NE1 4EP; UK
| | - Ian Aird
- The Gateshead Fertility Unit; Queen Elizabeth Hospital; Gateshead; NE9 6SX; UK
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145
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Inci K, Gunay LM. The role of varicocele treatment in the management of non-obstructive azoospermia. Clinics (Sao Paulo) 2013; 68 Suppl 1:89-98. [PMID: 23503958 PMCID: PMC3583153 DOI: 10.6061/clinics/2013(sup01)10] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/19/2012] [Indexed: 02/06/2023] Open
Abstract
The literature on male reproductive medicine is continually expanding, especially regarding the diagnosis and treatment of infertility due to non-obstructive azoospermia. The advent of in vitro fertilization with intracytoplasmic sperm injection has dramatically improved the treatment of male infertility due to nonobstructive azoospermia. Assisted reproduction using testicular spermatozoa has become a treatment of hope for men previously thought to be incapable of fathering a child due to testicular failure. In addition, numerous studies on non-obstructive azoospermia have reported that varicocelectomy not only can induce spermatogenesis but can also increase the sperm retrieval rate; however, the value of varicocelectomy in patients with non-obstructive azoospermia still remains controversial. The purpose of this review is to present an overview of the current status of varicocele repair in men with non-obstructive azoospermia.
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Affiliation(s)
- Kubilay Inci
- Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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Hamada A, Esteves SC, Agarwal A. Insight into oxidative stress in varicocele-associated male infertility: part 2. Nat Rev Urol 2012; 10:26-37. [PMID: 23165400 DOI: 10.1038/nrurol.2012.198] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Varicocele, the leading cause of male infertility, can impair spermatogenesis through several pathophysiological mechanisms. Of these, current evidence suggests that oxidative stress is the central element contributing to infertility in men with varicocele, to which the testis responds by way of heat stress, ischaemia or production of vasodilators, such as nitric oxide. Surgical varicocele repair (varicocelectomy) is beneficial not only for alleviating oxidative stress-associated infertility, but also for preventing and protecting against the progressive character of varicocele and its consequent upregulations of systemic oxidative stress. However, antioxidant therapy in infertile men with surgically treated and those with untreated varicocele is poorly studied, and well-designed trials are needed.
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Affiliation(s)
- Alaa Hamada
- Center for Reproductive Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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147
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Abstract
Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele(s), with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.
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Kroese ACJ, de Lange NM, Collins J, Evers JLH. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev 2012; 10:CD000479. [PMID: 23076888 DOI: 10.1002/14651858.cd000479.pub5] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND A varicocele is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that a varicocele causes male subfertility has been around for more than 50 years now, the mechanisms by which a varicocele would affect fertility have not yet been satisfactorily explained. Neither is there sufficient evidence to explain the mechanisms by which varicocelectomy would restore fertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus (a network of many small veins found in the human male spermatic cord) and impairment of fertility. OBJECTIVES To evaluate the effect of varicocele treatment on live birth and pregnancy rate in subfertile couples where the male has a varicocele. SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (12 September 2003 to January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 1, 2012), MEDLINE (January 1966 to January 2012), EMBASE (January 1985 to January 2012), PsycINFO (to Week 1 2012) and reference lists of articles. In addition, we handsearched specialist journals in the field from their first issue until 2012. We also checked cross-references, references from review articles and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) were included if they were relevant to the clinical question posed. If they reported pregnancy rates or live birth rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolization of the internal spermatic vein) compared to untreated or placebo groups. Two authors independently screened potentially relevant trials. Any differences of opinion were resolved by consensus (none occurred for this review). DATA COLLECTION AND ANALYSIS Ten studies met the inclusion criteria for the review. For one study we had only data from a published abstract. All ten studies only included men from couples with subfertility problems; one excluded men with sperm counts less than 5 million per mL and one excluded men with sperm counts less than 2 million per mL, with or without progressive motility of less than 10%. Two trials involving clinical varicoceles included some men with normal semen analysis. Three studies specifically addressed only men with subclinical varicoceles. Studies were excluded from meta-analysis if they made comparisons other than those specified above. MAIN RESULTS The meta-analysis included 894 men. No studies reported live birth. The combined fixed-effect odds ratio (OR) of the 10 studies for the outcome of pregnancy was 1.47 (95% confidence interval (CI) 1.05 to 2.05, very low quality evidence), favouring the intervention. The number needed to treat for an additional beneficial outcome was 17, suggesting benefit of varicocele treatment over expectant management for pregnancy rate in subfertile couples in whom varicocele in the man was the only abnormal finding. Omission of the studies including men with normal semen analysis and subclinical varicocele, some of which had semen analysis improvement as the primary outcome rather than live birth or pregnancy rate, was the subject of a planned subgroup analysis. The outcome of the subgroup analysis (five studies) also favoured treatment, with a combined OR 2.39 (95% CI 1.56 to 3.66). The number needed to treat for an additional beneficial outcome was 7. The evidence was suggestive rather than conclusive, as the main analysis was subject to fairly high statistical heterogeneity (I(2) = 67%) and findings were no longer significant when a random-effects model was used or when analysis was restricted to higher quality studies. AUTHORS' CONCLUSIONS There is evidence suggesting that treatment of a varicocele in men from couples with otherwise unexplained subfertility may improve a couple's chance of pregnancy. However, findings are inconclusive as the quality of the available evidence is very low and more research is needed with live birth or pregnancy rate as the primary outcome.
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150
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Wang XK, Wang HZ, Fu DJ, Lai MK. Microanatomy of the spermatic cords during microsurgical inguinal varicocelectomy: initial experience in Asian men. Asian J Androl 2012; 14:897-9. [PMID: 23064683 DOI: 10.1038/aja.2012.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and to clarify the location of the vas deferens in Asian men. Fifty-one patients receiving 79 primary microsurgical varicocelectomies performed by a single surgeon from April 2011 to July 2012 were studied. The number of internal and external spermatic veins, testicular arteries and lymphatic channels preserved during the inguinal microsurgical varicocelectomy were recorded. The relationship between the right and left vascular anatomy during bilateral varicocelectomies was evaluated. The data showed that mean numbers of 1.5±0.9 arteries, 5.6±2.2 spermatic veins and 3.6±1.9 lymphatics were identified during the repairs. The internal spermatic arteries were surrounded by a dense complex of adherent veins in 81.2% of the cases. The external spermatic vein or veins were found in 60.8% of the cases. The vas deferens may be contained within the internal spermatic fascia. The results suggest that the number of veins may be highly variable and less than those reported in the English literature, but there is some similarity in the inguinal microanatomy of the right and left spermatic cords. Further research is warranted to clarify our results.
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Affiliation(s)
- Xue-Ke Wang
- Division of Urology, Xiamen Chang Gung Hospital, Xiamen 361028, China.
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