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

Significant alterations of 6-keto prostaglandin F1a and NO levels in spermatic vein plexus patients with varicocele

To investigate the level variation of correlative factors between the spermatic vein plexus and peripheral blood in patients with varicocele, a total of 22 patients diagnosed with varicocele were enrolled in the study. All patients were performed a testicular artery-sparing microsurgical varicocelectomy. During the operation, a blood sample from the left spermatic vein plexus and a peripheral blood sample were collected. A radioimmunoassay was used to determine the 6-keto prostaglandin F1a (6-keto-PGF1a ). A colorimetric method was performed to determine the NO. The enzyme immunoassay method was used to determine the creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT. The mean age of all patients was 29.3 ± 7.8 years. Compared with the level of 6-keto-PGF1a and NO in the peripheral blood, 6-keto-PGF1a and NO were significantly increased in left spermatic vein plexus (347.3 (230.8-415.1) versus 99.7 (80.4-119.9) pg/ml and 192.3 ± 178.5 versus 107.1 ± 73.6 μmol/L, p < .05). There were no differences in the level of creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT between the peripheral blood and left spermatic vein plexus (p > .05). The 6-keto-PGF1a and NO concentrations in left spermatic vein plexus were significantly higher than that in peripheral blood patients with varicocele.

Thiol-disulphide homoeostasis as an oxidative stress marker in men with varicocele

Oxidative stress is the most common factor leading to infertility in men with varicocele. Reactive oxygen species and other markers of oxidative stress are measured to predict the extent of oxidative stress. Thiol groups are important antioxidants and essential molecules protecting organism against the harmful effects of reactive oxygen species. Thiol-disulphide homoeostasis is a unique, easy and new method to demonstrate oxidative stress. The aim of this study was to determine thiol-disulphide homoeostasis as an oxidative stress marker in infertile men with varicocele. The hormonal profile and parameters of thiol-disulphide homoeostasis were studied in 46 infertile men with varicocele, 70 fertile men with varicocele and 37 fertile controls. Infertile men with varicocele had significantly higher disulphide concentrations and disulphide/native thiol, disulphide/total thiol and native/total thiol ratios than those of fertile men with varicocele and fertile controls. According to these results, the blood plasma of patients with varicocele contains excessive oxidative stress, even in men with normospermia, and therefore, thiol-disulphide homoeostasis may be useful as an oxidative stress marker in men with varicocele.

Effect of in vitro vitamin E (alpha-tocopherol) supplementation in human spermatozoon submitted to oxidative stress

The aim of this study was to evaluate the antioxidant effect of in vitro supplementation with vitamin E in human spermatozoon incubated with an oxidative stress inducer. In this study, semen samples from 30 patients were collected and with one aliquot we performed semen analysis according to WHO. The remaining volume was divided into four aliquots: group C: incubated with BWW medium; group I: incubated with 5 mmol 1-1 hydrogen peroxide; group A: incubated with 40 μmol 1-1 vitamin E; and group AI: incubated with both them. After incubations, sperm functional analyses were performed and included: evaluation of oxidative stress, acrosome integrity, mitochondrial activity and DNA fragmentation. Groups were compared using a Friedman test with Bonferroni post hoc (α = 5%). In this study, we observed that in group I there was a decrease in acrosome integrity and mitochondrial activity, and an increase in DNA fragmentation, when compared to group C. Group AI showed an increase in acrosome integrity and mitochondrial activity when compared with group I. Based on our findings, we conclude that the vitamin E supplementation had a positive effect in protecting human spermatozoon from induced oxidative stress.

Role of varicocele treatment in assisted reproductive technologies

Objective

In this review, we investigate the advantage of varicocele repair prior to assisted reproductive technologies (ART) for infertile couples and provide cost analysis information.

Materials and methods

We searched the following electronic databases: PubMed, Medline, Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL). The following search strategy was modified for the various databases and search engines: 'varicocele', 'varicocelectomy', 'varicocele repair', 'ART', 'in vitro fertilisation (IVF)', 'intracytoplasmic sperm injection (ICSI)'.

Results

A total of 49 articles, including six meta-analyses, 32 systematic reviews, and 11 original articles, were included in the analysis. Bypassing potentially reversible male subfertility factors using ART is currently common practice. However, varicocele may be present in 35% of men with primary infertility and 80% of men with secondary infertility. Varicocele repair has been shown to be an effective treatment for infertile men with clinical varicocele, thus should play an important role in the treatment of such patients due to the foetal/genetic risks and high costs that are associated with increased ART use.

Conclusion

Varicocele repair is a cost-effective treatment method that can improve semen parameters, pregnancy rates, and live-birth rates in most infertile men with clinical varicocele. By improving semen parameters and sperm structure, varicocele repair can decrease or even eliminate ART requirement.

Superoxide Anion Production by the Spermatozoa of Men with Varicocele: Relationship with Varicocele Grade and Semen Parameters

Purpose

To investigate the pathophysiological role of superoxide anion and total reactive oxygen species (ROS) production by the spermatozoa of men with varicocele and its relationship with varicocele grade and semen parameters.

Materials and Methods

This prospective study included 34 men with grade II–III varicocele, regardless of their fertility status. The control group consisted of 13 healthy men. Semen characteristics were examined according to the 2010 World Health Organization criteria. The swim-up method was used for sperm preparation. Total ROS and superoxide anion production was assayed by luminol- and lucigenin-dependent chemiluminescence (CL), respectively.

Results

The men with varicocele had significantly higher total ROS and superoxide anion levels than the healthy control subjects (2.9±0.4 relative light unit (RLU) vs. 2.4±0.1 RLU, p=0.001 for luminol-dependent CL and 2.8±0.4 RLU vs. 2.3±0.2 RLU, p=0.002 for lucigenin-dependent CL). Cases of grade III varicocele had significantly higher superoxide anion and total ROS levels than grade II cases and control subjects (p<0.001). Superoxide anion and total ROS levels were negatively correlated with all semen parameters.

Conclusions

The superoxide anion levels produced by spermatozoa were significantly higher in varicocele patients than in control subjects. ROS production was related to increased varicocele grade, impaired semen concentration, and abnormal morphology in men with varicocele. Our findings suggest that superoxide anion overproduction may be an important step in the cascade of ROS-related damage to spermatozoa, resulting in impaired semen parameters in patients with varicocele.

Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study

PURPOSE

The purpose of this study is to compare the effect of bilateral versus unilateral varicocelectomy on seminal response and spontaneous pregnancy rates in infertile male patients with left clinical and right subclinical varicocele.

METHODS

A total of 358 infertile men with left clinical and right subclinical varicocele were randomized to group that underwent bilateral (n = 179) and group that underwent unilateral microsurgical subinguinal varicocelectomy (n = 179). Baseline data regarding male age, female partner age, grade of varicocele body mass index, bilateral testicular volume and serum follicle-stimulating hormone, luteinizing hormone, total testosterone levels and infertility duration and semen parameters were gathered. One year after the surgery, semen parameters including sperm volume, sperm concentration, normal sperm morphology, progressive motility and sperm DNA fragmentation index were recorded and any pregnancy was also documented via telephone calls and hospital visits.

RESULTS

We found the baseline characteristics were comparable between the two groups. The seminal parameters had significant improvements 1 year postoperatively in both groups. However, the bilateral group showed significantly greater improvements than the unilateral group in sperm concentration, normal sperm morphology and progressive motility. Besides, the pregnancy rate was statistically higher in the bilateral group after the surgery (42.5 versus 26.0%, bilateral versus unilateral group).

CONCLUSION

In conclusion, our study indicated that bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele, which is associated with greater improvements in sperm concentration, normal sperm morphology and progressive motility and spontaneous pregnancy rate after the surgery.

Varicoceles: prevalence and pathogenesis in adult men

Varicocele, or dilation of the pampiniform venous plexus, affects up to 15% of men. However, few of these men encounter problems with fertility. This discrepancy between men with varicocele and the number of adversely affected men has led to abundant research to identify the mechanisms for formation of varicocele as well as the pathologic mechanisms by which varicoceles affect fertility potential. In this review, we discuss the prevalence of varicocele in adults, the anatomic features of varicocele, the leading theories as to how varicocele can negatively affect fertility potential, and finally, the current literature on the impact of varicocele on testosterone production.

Therapeutic efficacy and safety of laparoscopic surgery versus microsurgery for varicocele of adult males: A meta-analysis

OBJECTIVES

This study aimed to systemically evaluate the efficacy and safety of laparoscopy versus microsurgery in the surgical therapy of varicocele in male adults.

METHODS

Relevant literature, published between January 1995 and October 2012, were searched in Pubmed/Medline database, OVID, EMBASE, Chinese Biology Medicine disc (CBMdisc), CNKI, CEBM\CCD, and Cochrane database. The newly published papers were also manually searched. Randomized controlled trials (RCT) related to the surgical interventions of varicocele were included, and full texts were obtained. Each study was evaluated with the Cochrane Risk of Bias tool. Two investigators collected data independently to produce the meta-analysis.

RESULTS

Five RCTs met the inclusion criteria and included 554 patients. Data were merged by the RevMan5.1 software. The sperm concentration increased significantly after surgery (WMD = 4.28; 95% CI = 4.16, 6.99; P < .00001, Z = 7.72). There was no significant difference in the postoperative hospital stay between laparoscopy and microsurgery (WMD = 0.24, 95% CI = 0.44, 0.93; P = .49, Z = 0.69). The operation time of laparoscopy was significantly shorter than that of microsurgery (WMD = 40.31, 95% CI = 37.77, 42.86; P < .00001, Z = 31.03). The incidence of hydrocele reduced significantly after microsurgery as compared to laparoscopy (WMD = 0.05, 95% CI = 0.01, 0.27; P = .0005, Z = 3.49). The postoperative recurrence rate after microsurgery was significantly lower than that after laparoscopy (WMD = 0.10, 95% CI = 0.04, 0.25; P < .00001, Z = 5.01).

CONCLUSION

No significant differences were found between microsurgery and laparoscopy for the increase of sperm concentration and operation time. Compared to the laparoscopy group, the microsurgery group had lower postoperative incidence of hydrocele and recurrence rate, but longer in the operation time.

Subinguinal microsurgical varicocelectomy vs. percutaneous embolization in infertile men: Prospective comparison of reproductive and functional outcomes

Background

Varicocele is a condition characterized by dilated, tortuous veins within the pampiniform venous plexus of the scrotal sac. Presence of varicocele is associated with an increased risk of alteration of semen parameters. The objective of this study was to compare the current standard in varicocele treatment procedures: sub-inguinal microscopic ligation to percutaneous embolization in terms of semen parameters improvement, fertility, and morbidity at the university hospital of Toulouse (France). Seventy six patients with clinical varicocele, alteration of semen parameters and infertility, underwent either procedure (microsurgery in 49 case performed by a single surgeon and embolization in 27 cases) and were prospectively analyzed. Outcome measures were: semen parameters, spontaneous pregnancies, pain, side effects, recovery time and overall satisfaction. All patients were contacted in January 2015 in order to determine reproductive events.

Results

Preoperatively, there was no difference in clinical and biological items between the two groups. Postoperatively, on the overall population, there was a significant improvement of sperm concentration at 3, 6, 9 and 12 months (p = <0.001, <0.001, 0.012, 0.018) and sperm motility at 6 months (p = 0.002). The sperm concentration was higher at 6 months in the percutaneous embolization group (13.42, vs. 8.1×10⁶/ml; p = 0.043). With a median follow-up of 4 years, 27 pregnancies occurred (spontaneous pregnancy rate of 35.5%).

There was no significant 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

Our study shows that percutaneous embolization seems to be an equivalent alternative to sub-inguinal microscopic ligation in term of sperm quality improvement, pregnancy rate, and overall satisfaction with a slight advantage on post-operative morbidity.

Genetics and epigenetics of varicocele pathophysiology: an overview

Varicocele is found in approximately 20% of adults and adolescents and in 19-41% of men seeking treatment for infertility. It is associated with a decrease in sperm count as well as sperm motility and morphology. The currently accepted description of the pathophysiology of varicocele does not explain all its clinical manifestations; therefore, other factors such as genetic and epigenetic changes, associated with the environment, might be involved in causing infertility and decrease in sperm quality. It has been reported that the varicocele-induced deterioration of testicular function is progressive and interferes with fertility; hence, early and efficient assessment of the genetic manifestations in patients would be important for developing future medical interventions. Chromosomal disorders, mutations, polymorphisms, changes in gene expression, and epigenetic changes have all been reported to be associated with varicocele. Several studies are underway to unravel the genetic basis of this disease, as it is important to understand the origin and the aggravating factors to ensure appropriate guidance and intervention. Here, we review the available literature regarding the genetic and epigenetic changes associated with varicocele, and how these alterations are related to the different clinical manifestations of the disease.

Significant predictive factors for subfertility in patients with subclinical varicocele

We made a retrospective study to determine useful parameters for predicting subfertility in patients with subclinical varicocele (SV). One hundred and fifty men with SV and 17 age-matched men without SV were divided into three groups: Group 1, subfertile patients (n = 15); Group 2, fertile patients (n = 135); and Group 3, control patients (n = 17). Their age, body mass index (BMI), semen analysis, scrotal temperature, testicular volume, resistive index (RI), pulsatility index (PI) and peak retrograde flow (PRF) were compared. Subfertile patients (Group 1) with SV had significantly lower testicular volume and higher scrotal temperature, RI, PI and PRF than fertile men with SV (Group 2) and the control group (Group 3). Elderly men (>50 years, n = 30) with SV had a significantly higher incidence of bilateral SV than young men with SV (10/30; 33.3% vs. 12/120; 10%). There was no difference in age and BMI among the three groups. Patients with SV and RI >0.55 ml/s, PI >0.99 ml/s, total testicular volume <27 cc, scrotal temperature >34.9°C and PRF >29 cm/s have higher incidence of subfertility. Patients with SV may suffer from subfertility regardless of age. Close follow-up with colour Doppler ultrasound may be beneficial.

Comparison of response to treatment of unilateral and bilateral varicocelectomy

BACKGROUND/AIM

We aimed to compare the results of unilateral and bilateral varicocele surgery.

MATERIALS AND METHODS

In two referral hospitals, the data of 180 patients who were treated with unilateral and bilateral microscopic varicocelectomy were retrospectively analyzed. Sperm parameters and spontaneous pregnancy rates were compared in patients who underwent bilateral and unilateral microscopic varicocelectomy.

RESULTS

The mean age was 29.6 (17-46) years. While 82 patients underwent unilateral varicocelectomy (Group I), 98 patients underwent bilaterally varicocelectomy (Group II). Forty (48.8%) spontaneous pregnancies occurred in Group I and 59 (60.2%) in Group II. When we analyzed sperm parameters, the rate of increase in the number of sperm in spermiograms was 17% in Group I and 27.5% in Group II. The rate of increase in sperm mobility was 58.5% and 50% in Group I and II, respectively. The improvement rate in sperm morphology was 46.3% in Group I and 56.1% in Group II. There were no significant differences between all these parameters.

CONCLUSION

In light of our results, although pregnancy rates seemed to be higher in patients who underwent bilateral varicocelectomy, these results were not statistically significant. Improvement rates in sperm parameters were similar between the patients who underwent unilateral and bilateral varicocelectomy.

[Comparison of subinguinal microsurgical varicocelectomy vs percutaneous embolization in infertile men]

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.

Aberrant expressions of stem cell factor/c-KIT in rat testis with varicocele

BACKGROUND/PURPOSE

Varicocele (VC) is considered by the World Health Organization as the main cause of male infertility. Studies have shown that VC can affect spermatogenesis and then result in male infertility. But the exact mechanism by which VC affects spermatogenesis is still unclear. Stem cell factor (SCF) and c-KIT receptor are crucial molecules during spermatogenesis in testis. This study aims to investigate whether SCF/c-KIT signaling is involved in the pathophysiology of VC on spermatogenesis.

METHODS

Rat models of VC were built (n = 13), and sham-operated rats were used as controls (n = 8). The seminiferous tubules of the testis were observed with hematoxylin and eosin staining, expression of SCF was analyzed via enzyme-linked immunosorbent assay and Western blot, and expression of c-KIT was assessed with Western blot and immunofluorescence.

RESULTS

Compared with controls, the seminiferous epithelium was disorganized and had significantly fewer cells in the testes of rats with VC. Expression of SCF increased in testes of VC rats, while expression of c-KIT was decreased.

CONCLUSION

These results suggest that sperm counts in seminiferous epithelium are affected by VC, and the SCF/c-KIT system is aberrantly expressed in VC testis, which could be involved in male infertility caused by VC.

Alterations in the proliferative/apoptotic equilibrium in semen of adolescents with varicocele

PURPOSE

To verify if the presence of varicocele (grades II and III) with and without seminal alterations, using the 5^th centile cutoff values in table A1.1 of the World Health Organization (WHO, 2010) manual, alters the seminal plasma levels of proteins DNASE1 (deoxyribonuclease-1) and IGFBP7 (Insulin-like growth factor-binding protein 7), which are related to apoptosis regulation and cell proliferation, respectively, demonstrating that these proteins are important for correct spermatogenesis.

METHODS

This cross sectional study was performed at the Sao Paulo Federal University Paulo between May 2014 and April 2016. A total of 61 male adolescents were included in this study, of which 20 controls without varicocele (C), 22 with varicocele and normal semen analysis (VNS) and 19 with varicocele and altered semen analysis (VAS). Seminal plasma from each patient was used for Western blotting analysis of individual protein levels. Values of each protein were normalized to a testicular housekeeping protein (PARK7-protein deglycase DJ-1).

RESULTS

Levels of IGFBP7 protein are increased in varicocele. Levels of DNASE1 are progressively decreased in varicocele (lower in varicocele and normal semen analysis, lowest in varicocele and altered semen analysis) when compared to adolescents without varicocele. DNASE1 levels are positively correlated with sperm concentration and morphology (correlation values of 0.400 and 0.404, respectively; p values of 0.001 and 0.001, respectively).

CONCLUSION

In conclusion, in adolescents, seminal plasma levels of IGFBP7, responsible for proliferative activity, are increased in varicocele grades II and III, and DNASE1, responsible for apoptosis regulation, are lower in varicocele, lowest in varicocele and low semen quality. These proteins demonstrate molecular alterations brought upon by varicocele. Moreover, DNASE1 is capable of discriminating a varicocele that causes alterations to semen quality from one that does not. We propose that the initial response of varicocele is to increase proliferative activity which, if followed by regulation of apoptosis, may lead to the ejaculation of a population of sperm that are in accordance with WHO cutoff values but, in the presence of dysregulated apoptosis, leads to lower sperm concentration and morphology.

Clinical Outcomes of Varicocele Repair in Infertile Men: A Review

Varicoceles are a major cause of impaired spermatogenesis and the most common correctable cause of male infertility. They are found in approximately 40% of men with primary infertility and 80% of men with secondary infertility, although they also occur in 12% of men with normal semen parameters. The presence of a varicocele does not always affect spermatogenesis, as it has been reported that only 20% of men with documented varicoceles suffer fertility problems. However, varicocele repair appears to have beneficial effects in men with impaired semen parameters and palpable varicoceles. Currently, the main procedures employed for varicocele repair are microsurgical subinguinal or inguinal varicocelectomy, laparoscopic varicocelectomy, and radiological percutaneous embolization. Microsurgical varicocelectomy appears to be the optimal treatment in most cases, whereas the other procedures are useful only in specific cases. After treatment, it typically takes 3 to 6 months for patients' semen parameters to improve; thus, other therapies, including assisted reproductive technology, should be considered if infertility persists after this interval, especially in older couples. Controversies still remain regarding how varicoceles in certain subgroups, such as adolescents or men with azoospermia, should be treated. Due to their relatively high prevalence rate among the general population, varicoceles can occur concomitantly with other conditions that cause impaired spermatogenesis. Further studies are necessary in order to identify the patients who are most likely to benefit from treatment. In this review, we sought to summarize the issues currently associated with varicocele treatment in infertile men.

Spermatogenesis in humans and its affecting factors

Spermatogenesis is an extraordinary complex process. The differentiation of spermatogonia into spermatozoa requires the participation of several cell types, hormones, paracrine factors, genes and epigenetic regulators. Recent researches in animals and humans have furthered our understanding of the male gamete differentiation, and led to clinical tools for the better management of male infertility. There is still much to be learned about this intricate process. In this review, the critical steps of human spermatogenesis are discussed together with its main affecting factors.

The role of testicular artery in laparoscopic varicocelectomy: a systematic review and meta-analysis

PURPOSE

We performed this meta-analysis to evaluate the efficacy and safety of artery preserving versus artery non-preserving in laparoscopic varicocelectomy.

METHODS

All publications up until October 2015 were searched in PubMed, EMBASE, Ovid, Web of Science, and Cochrane library. Randomized controlled trials (RCTs) and cohort studies (CSs) that compared the difference in two operative approaches in laparoscopic varicocelectomy were included. Statistical analysis was performed using Stata version 12.0.

RESULTS

A total of four RCTs and ten CSs involving 503 cases with artery preserving and 911 cases with artery non-preserving met our inclusion criteria. Meta-analysis showed that artery preserving had higher recurrence rate [risk ratio (RR) = 2.91, 95 % confidence interval (CI) 1.83-4.61; P = 0.000], lower incidence of hydrocele formation (RR = 0.18; 95 % CI 0.08-0.42; P = 0.000), and prolonged operating time [standard mean difference (SMD) = 1.27; 95 % CI 0.17-2.37; P = 0.023], compared with artery non-preserving in laparoscopic varicocelectomy. The results were similar in postoperative catch-up growth (RR = 1.00; 95 % CI 0.86-1.17; P = 0.985) and testicular atrophy (RR = 0.36; 95 % CI 0.09-1.54; P = 0.169). Besides, no significant difference was found in sperm concentration, motility, and normal morphology between two groups, as well as on postoperative pregnancy rate (RR = 0.95; 95 % CI 0.65-1.40; P = 0.809).

CONCLUSION

With the advantages of less recurrence, easier operating and less time spending, and comparable results in other respects, artery non-preserving is preferable to artery preserving in laparoscopic varicocelectomy, although there is a relatively high incidence of hydrocele formation. Considering the limitation of included studies, more large-scaled RCTs are required to confirm the present findings.

Randomised clinical trial of comparing effects of acupuncture and varicocelectomy on sperm parameters in infertile varicocele patients

The aim of the study was to evaluate the effect of the acupuncture treatment on sperm parameters and pregnancy rates in patients with primary infertility. Between January 2008 and May 2010, 30 men with the primary infertility (one year of unprotected intercourse, healthy wife) and varicocele with normal hormone levels and abnormal semen analysis were randomised into two groups. Group 1 underwent subinguinal microscopic varicocelectomy, and Group 2 underwent acupuncture treatment twice a week for 2 months. Both groups were evaluated with semen analysis at 6 months after the treatment. Patients in both groups evaluated with telephone calls and e-mail in terms of pregnancy. The mean age of the patients was 27.2, and groups were comparable regarding the age (P = 0.542). The pre-treatment sperm concentration, motility and morphological characteristics were similar in both groups. Sperm concentration and motility improved significantly in both groups after the treatment. Increase in sperm concentration was higher in the acupuncture group compared to the varicocelectomy group (P = 0.039). The average follow-up was 42 months, and pregnancy rates were emphasised 33% in both groups. Acupuncture treatment in primary infertile varicocele patients with semen abnormalities seems to be effective and has comparable results with the varicocelectomy treatment.

Increased Body Mass Index in Men With Varicocele Is Associated With Larger Spermatic Vein Diameters When Supine

OBJECTIVE

To evaluate the association of body mass index (BMI) and spermatic vein diameters (SVDs) in men treated for varicocele.

SUBJECTS AND METHODS

One hundred fourteen men who underwent scrotal color duplex ultrasounds prior to microsurgical varicocelectomy were classified as normal (BMI = 18.5-24.9), overweight (25-29.9), or obese (≥30). SVDs were measured with and without Valsalva, standing and supine. SVD, pre- and postoperative semen analyses (SA) were compared.

RESULTS

Forty-six (40.4%) men had normal BMI, 54 (47.3%) were overweight, and 14 (12.3%) were obese. Higher BMI was associated with smaller left testis volume and larger left SVD when supine (with and without Valsalva). The association was absent when standing. Men with higher BMI had smaller differences between their left SVD Valsalva diameters when standing vs supine. There were no differences among BMI classes for right SVD measurements, preoperative SA, and postoperative SA improvement.

CONCLUSION

Increased BMI is associated with larger left SVD while supine, suggesting that increased abdominal pressure while recumbent may contribute to varicocele pathology in this population. Interestingly, as in the general population, a majority of the men were overweight.

Adolescent Varicoceles and Infertility

Varicoceles are associated with testicular atrophy and abnormal spermatogenesis. Varicocele-related testicular damage is thought to be progressive in nature. Adult varicoceles are common in men with infertility, and varicocele repair in this population has demonstrated improved semen parameters and paternity outcomes. However, without solid objective endpoints (reproducible semen analyses, paternity), the indications for adolescent varicocele repair remain controversial. Given the controversy surrounding adolescent varicocele management, it is not surprising that surveys of pediatric urologists have revealed a lack of consensus on diagnostic approaches, treatment decisions, and operative approaches.

Efficacy of Varicocele Repair in Different Age Groups

OBJECTIVE

To compare semen parameters and spouse pregnancy rates after varicocele repair in 2 age groups.

MATERIALS AND METHODS

Mean changes in spermatozoa concentration, motility, and morphology after varicocele repair in 83 patients were compared between patients aged 30 years or younger (group 1) and those older than 30 years (group 2). Spouse pregnancy rates were compared between the 2 age groups.

RESULTS

The mean sperm concentration increased significantly in both groups (P <.05). The percentage of motile sperm increased from 48.2% to 56.6% in group 1 and from 47.2% to 53.2% in group 2 one year after varicocele repair. The increase in motility was statistically significant for both groups (P <.05), but there was no statistically significant difference in the increase in sperm motility between the 2 groups (P = .01). The percentage of sperm with abnormal morphology decreased significantly in both groups 12 months postoperatively (from 62.7% to 59.6% in group 1 and from 61.3% to 58% in group 2; P = .03). However, there was no statistically significant difference in the improvement in sperm morphology between the 2 groups (P >.05). The pregnancy rates in the patients' spouses were 51.1% and 44.7% in groups 1 and 2, respectively. This difference was not statistically significant (P = .9).

CONCLUSION

There was no statistically significant difference in semen parameter improvement and spouse pregnancy rates after varicocelectomy in the 2 age groups.

Effect of Varicocelectomy on the Frequency of Nocturnal Sperm Emissions

The aim of this study was to investigate the frequency of nocturnal sperm emissions (NSE) in varicocele patients after varicocele surgery. A total of 127 patients, 96 varicocele (Group 1) and 31 patients with inguinal hernia (Group 2) were included in this study. Mean age, laterality of surgical procedures, spermiogram results, marital status, and postoperative serum hormone levels were noted for all patients. Two groups were compared in terms of Beck depression score (BDS) and anxiety scores (AS). The frequency of NSE and libido changes in the patients during 10 days postoperatively was evaluated. The number of the patients who had NSE and increased libido were significantly higher in the varicocelectomy group when compared with the control group. No significant difference was noted between the groups in terms of BDS, AS, and serum hormone levels. No association was reported between BDS, AS, and serum hormone levels and the presence of NSE in Group 1. The incidence of NSE was higher in younger men. Increased libido was significantly associated with NSE in Group 1. Cord dissection during surgery may be a factor on increased frequency of NSEs in varicocele patients.

Is Varicocelectomy Useful for Subfertile Men with Isolated Teratozoospermia?

OBJECTIVE

To evaluate the effect of microsurgical varicocelectomy on sperm morphology in subfertile men with isolated teratozoospermia and a clinically palpable varicocele.

MATERIALS AND METHODS

A retrospective review was performed of men with isolated teratozoospermia who had undergone microsurgical varicocelectomy. Semen analyses following varicocelectomy were performed at 2- to 3-month intervals. Responders to the varicocelectomy were defined as those who fulfilled the following criteria in semen analysis: (1) an improvement in percentage of normal forms to ≥4% and (2) normal results for all other semen parameters.

RESULTS

A total of 80 patients underwent unilateral varicocelectomy (n = 49) or bilateral varicocelectomy (n = 31) (mean age of 36 ± 0.4 years, range 24-44). After a mean postoperative follow-up period of 6.8 months, the mean percentage of normal sperm forms increased from 0.9% to 3.5% (P < .001), and the mean sperm motility improved from 50.5% to 56.6% (P = .004). The number of responders to the surgery was 16 (20%), and their mean percentage of normal forms increased from 1.3% to 9.1%. The mean preoperative and postoperative semen volume and sperm concentration were not different (P > .05). No differences were observed in age, current smoking status, body mass index, or grade of varicocele between responders and nonresponders.

CONCLUSION

Varicocelectomy might be an option for treating subfertile patients with isolated teratozoospermia and a clinically apparent varicocele. However, patients should be advised that the surgery helps in limited patients only because more patients did not benefit from the surgery.

Microscopic Retroperitoneal Varicocelectomy With Artery and Lymphatic Sparing: An Alternative Treatment for Varicocele in Infertile Men

OBJECTIVE

To compare the therapeutic effect of arterial and lymphatic sparing microscopic retroperitoneal varicocelectomy (MRV) with that of microscopic subinguinal varicocelectomy (MSV) for treatment of varicocele in infertile men.

METHODS

We conducted a prospective and controlled study to evaluate the therapeutic efficacy of MRV and MSV for treatment of varicocele in infertile men. A total of 80 patients were randomly chosen to undergo MRV (n = 40) or MSV (n = 40) treatment. All patients were followed up at 3, 6, and 12 months after surgery. Semen parameters, pregnancy, recurrence, and complications were examined.

RESULTS

Mean operation time in the MRV group was significantly shorter than that in MSV group (38.92 ± 5.67 min vs 91.35 ± 15.08 min), and the number of observed spermatic veins in MRV group was significantly less than that in MSV group (3.59 ± 0.76 vs 18.22 ± 2.83). Sperm count and motility were significantly improved at 12 months follow-up in both groups compared with preoperative values, and the sperm count in the MRV group at 3 months was significantly higher than that in MSV group. Moreover, the incidence of scrotal edema was higher in the MSV group, although natural pregnancy rate was not significantly different between 2 groups at 1-year follow-up (42.1% vs 44.7%).

CONCLUSION

MRV with artery and lymphatic sparing is a simple and effective technique for treatment of varicocele in infertile men.

Embolization of left spermatic vein in non-obstructive azoospermic men with varicocele: role of FSH to predict the appearance of ejaculated spermatozoa after treatment

PURPOSE

Varicocele repair in non-obstructive azoospermia (NOA) was occasionally associated to ejaculated spermatozoa independently from clinical and laboratory measures. We performed a prospective study in infertile men affected by NOA and left side varicocele to find whether or not the appearance of ejaculated spermatozoa after varicocele repair is predicted by baseline measures.

METHODS

Patients with NOA and grade II, or grade III left side varicocele were submitted to hormone analysis and to scrotal color Doppler ultrasound (CDU). Azoospermia was confirmed in 23 patients aged 25-47 years who were than submitted to varicocele repair through a retrograde internal spermatic vein embolization. Patients were re-evaluated after 6 months.

RESULTS

Six months after varicocele repair 12 patients (52.2 %) were still azoospermic (Group 1) while 11 patients (47.8 %) reported ejaculated spermatozoa (Group 2) [sperm count: 1.3 × 10(6)/mL; 0.5 × 10(6)/mL-1.6 × 10(6)/mL (median 25th-75th centiles)]. Serum baseline FSH was lower in Group 2 compared to Group 1 (p = 0.012), while no differences between groups were revealed for all other clinical and laboratory parameters. ROC analysis indicated that baseline FSH level predicted the appearance of ejaculated spermatozoa after treatment [AUC = 0.811; 95 % Confidence Interval (CI) 0.6-0.9; p = 0.0029]. A cut-off level of FSH <10.06 mIU/mL identified 82.0 % of cases with ejaculated spermatozoa with a specificity of 81.8 % and a sensitivity of 83.3 %.

CONCLUSION

Selected patients with NOA may show ejaculated spermatozoa after a non-invasive repair of a left side varicocele, therefore avoiding testicular sperm extraction. Baseline serum FSH was a valuable predictor for ejaculated spermatozoa after treatment.

Evaluation and Management of the Adolescent Varicocele

PURPOSE

Varicocele is one of the most common genital conditions referred to pediatric urologists. Most adolescents with varicocele are asymptomatic and their fertility future (and surgery benefit) is largely unknown. This review assesses varicocele evaluation, management and indications for repair, as well as types and success of varicocelectomy.

MATERIALS AND METHODS

A systematic literature review was performed on Embase™, PubMed® and Google Scholar™ for adolescent varicocele. Original research articles and relevant reviews were examined, and a synopsis of these data was generated for a comprehensive review of clinical adolescent varicocele management.

RESULTS

The prevalence of adolescent varicocele is similar to the adult population. While ultrasound is the most sensitive method for determining testicular volumes, orchidometer measurement may be adequate to gauge significant discordance. Significant hypotrophy of the affected testis with poor total testicular volume may indicate a testis at risk and warrant surgical repair. Similar findings have been noted with an associated high peak retrograde venous flow. Testicular hypotrophy often resolves following surgery but may also improve spontaneously if followed through adolescence. Continued scrotal pain despite adequate support or serial abnormal semen analysis in Tanner stage V boys is an indication for varicocelectomy. Artery and lymphatic sparing techniques (microscopic subinguinal or laparoscopic) are associated with the lowest risk of recurrence and complications.

CONCLUSIONS

Overtreatment and under treatment are medically and financially costly. Abnormal serial semen analysis with or without testicular hypotrophy is an indication for varicocele repair. If observation remains the treatment, followup with an adult urologist should be encouraged until paternity is achieved.

Elastography to assess the effect of varicoceles on testes: a prospective controlled study

Varicoceles are the most common and treatable cause of male infertility. The pathophysiology of varicoceles primarily includes elevated temperature, adrenal hormone reflux, gonadotoxic metabolite reflux, altered testicular blood flow, antisperm antibody formation and oxidative stress. The diagnosis of a varicocele is mainly clinical. However, a Doppler ultrasound is used to obtain clinical data and to more accurately measure testicular size. Acoustic radiation force impulse (ARFI) is an additional technique to simultaneously show different areas with different densities in a colour-coded image and a B-mode or greyscale image. This can be used for structural analysis of testicular tissue and has become an additional method for detecting pathologic tissue alterations. We enrolled 30 patients who had clinically diagnosed with left varicoceles and male infertility (Group 1). All patients were evaluated by history taking, physical examination, a spermiogram and an endocrine profile. Thirty control patients (Group 2) were randomly chosen from patients who had applied to an andrology clinic for infertility; their physical examinations and laboratory results showed normal findings. Mean elastography results were significantly different between the groups, and significantly lower in patients who had varicoceles. The relationship between hormonal profiles and elastography parameters was calculated as statistically significant negative correlations between FSH and elasticity. Additionally, a negative correlation was determined between varicocele grade and elasticity of testes. In conclusion, our prospective study showed that ARFI imaging may be more useful than palpation for determining early damage of testicular structure by varicoceles.

Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: A randomized clinical study

BACKGROUND

Varicocele is the most common correctable cause of infertility. We analyzed the outcomes of single incision laparoscopic varicocelectomy (SIL-V) in comparison with conventional transperitoneal varicocelectomy (CTL-V).

METHODS

Patients with clinically palpable varicocele treated by laparoscopic varicocelectomy were randomly allocated into two groups: SIL-V and CTL-V group. The primary outcome measures were improvement in semen parameters and resolution of testicular pain. Secondary outcome measures included operating time, postoperative pain scores, time to return to normal activity, patient satisfaction and postoperative complications.

RESULTS

Eighty patients completed the study. No vascular or intestinal complications occurred during both procedures. All patients were discharged 24 h postoperatively. The parameters measuring the success of varicocelectomy had improved for the majority of patients with no significant difference between the two groups. There was significantly longer operating time in SIL-V group (44.6 ± 5.4 min) than in CTL-V group (41.3 ± 8.5 min) (P = 0.03). The difference in operating time was lost when bilateral procedures were compared (P = 0.21). The mean VAS scores for pain at 3, 24 and 48 h postoperatively were significantly lower in SIL-V group (P = 0.02, P = 0.03 and P < 0.001 respectively). Time to return to normal activity was significantly shorter in SIL-V (P < 0.001). Patient satisfaction was significantly higher in SIL-V group (P < 0.01). Postoperative complications were comparable in both groups.

CONCLUSION

SIL-V is a safe and effective straightforward alternative to the well-established and accepted CTL-V. The tendency toward decreased postoperative pain, rapid return to normal activity and the high patients' satisfaction rate regarding cosmetic results are potential benefits of SIL-V procedure.

CLINICAL TRIAL

(NCT02335385).

Does L-carnitine therapy add any extra benefit to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study

OBJECTIVE

To evaluate if addition of L-carnitine therapy to standard varicocelectomy adds any extra benefit in terms of improvement in semen parameters or deoxyribonucleic acid (DNA) damage.

MATERIALS AND METHODS

One hundred patients enrolled in this study and were randomly divided into 2 groups (50 patients in each group). In group 1, standard inguinal varicocelectomy and, in group 2, standard inguinal varicocelectomy plus oral antioxidant therapy (oral L-carnitine, 250 mg 3 times a day) were performed for 6 months. For all patients, routine semen analysis and DNA damage test of spermatozoa (by 2 methods of terminal deoxynucleotidyl transferase dUTP nick end labeling and protamine damage assay) were performed at baseline and at 3 and 6 months postoperatively.

RESULTS

In both groups, the improvement in semen analysis parameters and DNA damage was observed, but there was not any statistically significant difference between the 2 groups in these parameters, although the slope of improvement in DNA damage was slightly better in group 2 (that was not statistically significant).

CONCLUSION

We observed that addition of 750 mg of L-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefit in terms of improvement in semen analysis parameters or DNA damage.