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

Imaging and interventional therapy for varicoceles

Varicocele is a common treatable cause of testicular pain, male infertility, and Leydig cell dysfunction. Scrotal ultrasonography has become the modality of choice in the diagnosis and post-treatment follow-up of varicocele. Visualization of dilated veins and reflux into the pampiniform plexus enables accurate diagnosis. Although the pathophysiology of varicocele in testicular dysfunction remains unclear, numerous studies have established significant improvement in the seminal parameters and pregnancy rates after varicocele repair. Interventional therapy is a minimally invasive effective treatment option for primary and salvage varicocele repair. This review discusses sonographic criteria used in the pre- and post-procedural evaluation of varicocele and various interventional techniques for varicocele treatment.

Varicocele-caused progressive damage in bilateral testis and sertoli cell-only syndrome in homolateral testis in rats

Background

We aimed to investigate whether varicocele (VC) in rats can cause Sertoli cell-only syndrome (SCOS).

Material/Methods

Forty adolescent SD rats were randomly divided into 4 groups: 4-weeks control group, 4-weeks experimental group, 12-weeks control group, and 12-weeks experimental group. Left varicocele models were introduced by partially ligating left kidney veins for the experimental groups, and the sham surgery groups as controls were executed with exactly the same surgery as in the experimental groups except for the ligation. Rats in control and experimental groups for 4 and 12 weeks were killed after laparotomy at 4 and 12 weeks, respectively, the testes were taken out and fixed in fixative containing 4% polyformaldehyde, then were stained by hematoxylin and eosin (HE). The density and viability of sperm were analyzed by computer-aided sperm analysis.

Results

Compared with rats in 4-weeks and 12-weeks control group, histological structures of bilateral testes in both experimental groups were impaired, most of them showing as focal focuses. The pathological changes of testes in rats of the 12-weeks experimental group were bilateral, and included atrophy of seminiferous tubules, turbulence of spermatogenic cells in seminiferous tubules, defluvium of most spermatogenic cells, abortion of spermatogenesis, and degradation of spermatogenic epithelia. One rat in the 12-weeks experimental group was shown having SCOS, with the spermatogenic cells in seminiferous tubules completely flaked, degraded, or absent, and only Sertoli cells lined the seminiferous tubules.

Conclusions

Laboratory VC caused progressive impairment of homolateral testes, and SCOS could be induced when the damage was severe. Our results indicate that asthenozoospermia, azoospermia, and SCOS can be prevented by the earlier treatment of VC.

Analysis of inter-examination differences in sperm nuclear vacuoles among male patients with infertility

We analyzed the inter-examination differences in sperm nuclear vacuoles among male patients with infertility. We enrolled 56 male patients with infertility who underwent multiple semen analyses and high-magnification observation of the sperm head. A total of 162 ejaculates were evaluated. The average patient age was 34.5 years. Following the conventional semen analysis, the nuclear vacuoles in motile spermatozoa were evaluated at 3700-6150 × magnification on an inverted microscope equipped with differential interference contrast optics. A large sperm nuclear vacuole (LNV) was defined as one or more vacuoles with a maximum diameter exhibiting > 50% width of the sperm head. We compared the differences in the proportion of spermatozoa with LNVs between two consecutive semen samples before treatment. Treatment-related differences in the number of LNVs were also analyzed. Student's t-test was used to perform the statistical analyses. No differences were observed in any semen parameters between the first and second ejaculates. On high-magnification microscopy, the proportion of spermatozoa with LNVs was 23.5% and 29.4% (p = 0.0220) in the first and second ejaculates, respectively in 33 patients. Among the 18 patients who underwent varicocele repair using a microsurgical subinguinal approach, the proportion of spermatozoa with LNVs at baseline, three, and six months after surgery was 27.7%, 12.0% (p = 0.0132 versus baseline), and 10.3% (p = 0.0226 versus baseline), respectively. After three months of medical treatment for male infertility in 28 patients, the proportion of spermatozoa with LNVs slightly decreased from 33.3% to 28.6% (p = 0.1276); however, it was not statistically significant. In conclusion, when multiple ejaculates were obtained, in the subset of male patients with infertility, the proportion of spermatozoa with LNVs could be different. The number of LNVs decreased following varicocele repair.

Angiogenesis inhibition impairs testicular morphology in experimental left varicocele rat model

INTRODUCTION

It has been reported that varicocele might promote angiogenesis. However, it is not clearly identified how angiogenesis affect testicular morphology or spermatogenic activity. The objective of the study is to investigate the effect of spironolactone, as an angiogenesis inhibitor, on the ipsilateral testis morphology in left varicocele-induced rats.

MATERIALS AND METHODS

Twenty four adult (12-14 mo), male Wistar albino rats were randomly assigned to four groups (n=6, for each): 1. Control group, 2. Sham-operated group, 3. Experimental left varicocele group and, 4. Spironolactone (20mg/kg/day)-treated experimental left varicocele group. Histopathological findings in rat testis were investigated.

RESULTS

Microvessel density increased in varicocele group and spironolactone inhibited angiogenesis neither by antimineralocorticoid, nor by antiandrogenic effect. However, spermatogenesis impaired in spironolactone treated varicocele group.

CONCLUSION

Angiogenesis seems to be a protective process in varicocele. Spironolactone treatment, probably by inhibiting angiogenesis, impairs testicular morphology.

Multiple determinations of sperm DNA fragmentation show that varicocelectomy is not indicated for infertile patients with subclinical varicocele

Varicocele is one of the most common causes of low semen quality, which is reflected in high percentages of sperm cells with fragmented DNA. While varicocelectomy is usually performed to ameliorate a patient's fertility, its impact on sperm DNA integrity in the case of subclinical varicocele is poorly documented. In this study, multiple DNA fragmentation analyses (TUNEL, SCD, and SCSA) were performed on semen samples from sixty infertile patients with varicocele (15 clinical varicoceles, 19 clinical varicoceles after surgical treatment, 16 subclinical varicoceles, and 10 subclinical varicoceles after surgical treatment). TUNEL, SCD, and SCSA assays all showed substantial sperm DNA fragmentation levels that were comparable between subclinical and clinical varicocele patients. Importantly, varicocelectomy did improve sperm quality in patients with clinical varicocele; however, this was not the case in patients with subclinical varicocele. In summary, although infertile patients with clinical and subclinical varicocele have similar sperm DNA quality, varicocelectomy should only be advised for patients with clinical varicocele.

Low body mass index might be a predisposing factor for varicocele recurrence: a prospective study

We investigated the possible relationship between body mass index (BMI) score and varicocele recurrence in an infertile patient population. A total of 255 primary infertile male patients (138 with varicocele and 117 for control) were included in this study. Height and weight measurements, clinical examination for varicocele, determination of serum hormone levels and spermiogram were performed in all cases. The BMI score was calculated, and patients with varicocele were operated with subinguinal technique and re-examined for recurrences. The varicocele group had significantly lower weight and the BMI score than the control group (P < 0.001). Varicocele recurrences were found in 22 patients (16% of them) after the operations. The BMI score was significantly lower in the recurrent group than in the nonrecurrent and control groups (P < 0.001). 73% of the recurrent, 50% of the nonrecurrent and 25% of the control group patients' BMI scores were under 25 kg m(-2) (P < 0.001). In logistic regression analysis, the BMI score was found as a determinant for varicocele recurrence (P = 0.027; OR: 1.25). It is concluded that BMI score lower than 25 kg m(-2) significantly increases the recurrence rate after varicocele operation, and it can be used as an objective indicator for microsurgical varicocelectomy.

Review of Azoospermia

Azoospermia is classified as obstructive azoospermia (OA) or non-obstructive azoospermia (NOA), each having very different etiologies and treatments. The etiology, diagnosis, and management of azoospermia were reviewed and relevant literature summarized. Differentiation between these two etiologies is of paramount importance and is contingent upon thorough history and physical examination and indicated laboratory/genetic testing. OA occurs secondary to obstruction of the male reproductive tract, and is diagnosed through a combination of history/physical examination, laboratory testing, genetics (CFTR for congenital OA), and imaging studies. NOA (which includes primary testicular failure and secondary testicular failure) is differentiated from OA by clinical assessment (testis consistency/volume), laboratory testing (FSH), and genetic testing (karyotype, Y chromosome microdeletion, or specific genetic testing for hypogonadotropic hypogonadism). For obstructive azoospermia, management includes microsurgical reconstruction when feasible using microsurgical vasovasostomy or vasoepididymostomy. Microsurgical epididymal sperm aspiration with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is utilized for those cases not amenable to reconstruction. NOA management includes medical management for congenital hypogonadotropic hypogonadism and microdissection testicular sperm extraction with IVF/ICSI for appropriate candidates based on laboratory/genetic testing. Overall, this important review provides an updated summary of the most recent available literature describing etiology, diagnosis, and management of azoospermia.

Should older patients be offered varicocoele correction to improve their fertility?

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.

Molecular mechanisms involved in varicocele-associated infertility

Varicocele is a pathologic enlargement of the pampiniform venous plexus within the spermatic cord, a condition that is a common cause of impaired sperm production and decreased quality of sperm. While varicocele is the most common surgically correctable risk factor for male infertility, not all males with varicocele experience infertility. In fact, most men with varicocele have normal spermatogenesis. Despite its prevalence, the molecular mechanisms of varicocele and its effect on testicular function are yet to be completely understood. We postulate that men with varicocele-associated infertility could have preexisting genetic lesions or defects in molecular mechanisms that make them more susceptible to varicocele-mediated testicular injury affecting spermatogenesis.

Influence of preoperative pain duration on microsurgical varicocelectomy outcomes

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.

The varicocele

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.

Is methylenetetrahydrofolate reductase (MTHFR) gene A1298C polymorphism related with varicocele risk?

Varicocele is one of the main reasons for male infertility the exact aetiology of which remains unclear. Methylenetetrahydrofolate reductase (MTHFR) is important for DNA synthesis and methylation, which has a key role during spermatogenesis. Numerous literature suggests that the MTHFR polymorphism may be genetic risk factors for male infertility. In this study, we evaluated C677T and A1298C MTHFR gene polymorphism frequency in patients with varicocele and normal men. A total of 107 varicocele patients and 109 fertile healthy individuals were included. Genotyping of the MTHFR gene in C677T and A1298C base pairs carried out by using real-time PCR technique and afterwards, the statistical analysis accomplished. There is a statistical difference for the frequency of 1298AA genotype in patients with varicocele compared with normal controls (P = 0.0051, OR = 2.2750). Instead, subsequently, 1298/A allel frequency in patient group was significantly higher in comparison with control group (P = 0.0174). According to our results, 1298AA genotype in MTHFR gene raises the risk of varicocele approximately 2.3 times more compared with men carrying other genotypes. The results show that genetic factors have an important role in the molecular basis of varicocele.

Is there any relationship between mean platelet volume and varicocele?

Mean platelet volume (MPV) is a parameter that is obtained from an automatic haemogram device during routine blood count and measures platelet reactivity. Increased platelet volume has been considered to be a risk factor for vascular diseases. The aim of this study was to evaluate the relationship between the presence of varicocele and the MPV, platelet count (PLT) and platelet distribution width (PDW) values. We included 264 patients with a diagnosis of varicocele in Group 1, and 220 patients with no varicocele in Group 2. The varicocele diagnosis was performed both with physical examination findings and colour Doppler ultrasonography (CDU). Mean platelet volume values were statistically significantly high (P < 0.001) whereas PLT and PDW values were statistically significantly low (P = 0.011), (P = 0.008) in the varicocele group compared with the control group respectively. However, no significant correlation was found between MPV and PDW in patients diagnosed with varicocele and the varicocele grade on examination and spermatic vein diameter on CDU. Mean platelet volume, which is used widely to measure the size of platelets and indicates platelet reactivity, can provide guidance in the investigation of varicocele pathophysiology and the relevant vascular pathologies.

[Varicocele and infertility: where do we stand in 2013?]

While the incidence of clinical varicocele is common in infertile men (about 40%), the reasons why varicocele may affect sperm parameters is still unclear. In addition, the improvement of fertility after treatment of varicocele is also a subject of debate. The purpose of this review is to get new insight into the physiopathology of varicocele, its impact on sperm parameters and the effectiveness of varicocele treatment on fertility. Treatment is likely to be effective in infertile men with clinical varicocele and impaired spermatogenesis. Even if it does not systematically lead to an improvement in sperm parameters, it may prevent further sperm degradation. In case of non-obstructive azoospermia, few studies reported a slight improvement in the process of spermatogenesis. The critical role of an adequate methodology in order to establish clinical guidelines needs to be stressed. Indeed, the huge intra-individual variability in sperm production makes the usual analysis of sperm parameters inadequate to measure treatment effectiveness. Regarding the assessment of conception, it requires not only well designed and properly sized studies but also a multivariate analysis for weighing predictive factors of success. Thus, an active scientific research is needed to better identify pathogenic agents and appropriately assess the impact of varicocele treatment.

Predictive factors of successful microdissection testicular sperm extraction

Azoospermia in men requires microsurgical reconstruction or a procedure for sperm retrieval with assisted reproduction to allow fertility. While the chance of successful retrieval of sperm in men with obstructive azoospermia approaches >90%, the chances of sperm retrieval in men with non-obstructive azoospermia (NOA) are not as high. Conventional procedures such as fine needle aspiration of the testis, testicular biopsy and testicular sperm extraction are successful in 20-45% of men with NOA. With microdissection testicular sperm extraction (micro-TESE), the chance of successful retrieval can be up to 60%. Despite this increased success, the ability to counsel patients preoperatively on their probability of successful sperm retrieval has remained challenging. A combination of variables such as age, serum FSH and inhibin B levels, testicular size, genetic analysis, history of Klinefelter syndrome, history of cryptorchidism or varicocele and histopathology on diagnostic biopsy have provided some insight into the chance of successful sperm retrieval in men with NOA. The goal of this review was to evaluate the preoperative factors that are currently available to predict the outcome for success with micro-TESE.

Azoospermia due to spermatogenic failure

This article summarizes the current literature regarding azoospermia caused by spermatogenic failure. The causes and genetic contributions to spermatogenic failure are reviewed. Medical therapies including use of hormonal manipulation, whether guided by a specific abnormality or empiric, to induce spermatogenesis are discussed. The role of surgical therapy, including a discussion of varicocelectomy in men with spermatogenic failure, as well as an in-depth review of surgical sperm retrieval with testicular sperm extraction and microdissection testicular sperm extraction, is provided. Finally, future directions of treatment for men with spermatogenic failure are discussed, namely, stem cell and gene therapy.

Predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele

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.

Infrared digital thermography of scrotum in early selection of progressive varicocele

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.

Clinical and subclinical varicocele incidence in patients with primary varicose veins requiring surgery

BACKGROUND

The purpose of this study was to analyze the incidence of clinical and subclinical varicocele in patients with primary varicose veins requiring surgery.

METHODS

A total of 100 patients with primary varicose veins requiring surgery were evaluated. Clinical varicocele was found in each patient through physical examination. Each patient was also evaluated with ultrasound because of evidence of subclinical varicocele.

RESULTS

Among the patients with varicose veins, 28 had no clinical sign of varicocele, whereas the remaining 72 had varicocele with different clinical levels (72%). Doppler ultrasound revealed that 32 patients had no reflux flow, whereas the other 68 had different grades of reflux flow (68%).

CONCLUSIONS

Clinical or subclinical varicocele may be highly present in patients with severe venous disease. However, these types of varicoceles do not cause infertility in most patients. Nevertheless, infertility may occur in subsequent years, especially in young patients who have venous disease and undergo surgery, and they should be aware of this condition.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Current issues in varicocele management: a review

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.

Varicocelectomy is associated with increases in serum testosterone independent of clinical grade

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.

Varicocele repair for nonobstructive azoospermia

PURPOSE OF REVIEW

To evaluate the role of varicocelectomy in the management of patients with varicoceles and nonobstructive azoospermia and to review predictors of successful outcomes.

RECENT FINDINGS

Several small, retrospective, noncontrolled studies have documented return of sperm to the ejaculate in up to 56% of men with nonobstructive azoospermia (NOA) following varicocele repair. Additionally, a recent meta-analysis has reported a 6% spontaneous pregnancy rate in amongst NOA patients who underwent varicocele repair, regardless of surgical technique. Although these observations are promising, evidence for whether or not varicocele repair significantly improves spermatogenesis within an impaired testicle is conflicting. No clear predictors of success following varicocele repair have been identified, but a certain level of spermatogenesis on testicular biopsy appears to be necessary for a desirable outcome after varicocele repair.

SUMMARY

The role of varicocelectomy for the treatment on NOA is controversial. Prospective, controlled studies are needed in order to define the true benefit of varicocele repair in men with NOA, in terms of improvement in semen parameters, testicular sperm retrieval rates, and pregnancy outcomes.

Reproducibility and reliability of semen analysis in youths at risk for infertility

PURPOSE

There are few normative data on semen analyses in youths at risk for but not presenting with infertility. Standard practice among infertility specialists includes evaluation of 2 separate semen samples, given the degree of within subject variability. We hypothesized that males transitioning from pediatric to adult care who are at risk for infertility would similarly have this variability.

MATERIALS AND METHODS

We retrospectively reviewed patients with a history of cryptorchidism or varicocele who submitted 2 semen samples for evaluation of fertility potential. The within subject coefficient of variation and intraclass correlation coefficient were calculated for each semen parameter to evaluate reproducibility and reliability, respectively.

RESULTS

A total of 79 subjects were studied. Mean ± SD age was 18.8 ± 1.2 years (range 17.8 to 24.7). The within subject coefficient of variation was high for each semen parameter, ranging from 36% for volume and motility to 82% for total motile count. Intraclass correlation coefficient for a single semen analysis ranged from 0.55 for motility to 0.88 for total count. Intraclass correlation coefficient for total motile count was 0.78 (95% CI 0.67-0.85), consistent with substantial reliability.

CONCLUSIONS

Although we observed within patient variability of individual semen analysis parameters, overall there was substantial agreement between consecutive semen analyses in this population at risk for infertility, particularly regarding total motile count, which is the most important determinant of fertility from a semen analysis. Therefore, it is possible to appropriately classify some young men based on the result of a single measurement as they transition from pediatric to adult care.

Causes and classification of male infertility in Korea

OBJECTIVE

The aim of this study is to investigate the various causes of male infertility using multiple approaches.

METHODS

Nine-hundred-twenty infertile male patients were analyzed at their first visit with one physician between January 1 and December 31, 2009. All patients were subjected to physical examination, semen analysis and azoospermic patients underwent hormonal testing, chromosomal tests, and testicular biopsy. Semen analysis was based on the definition of the World Health Organization.

RESULTS

Among the 920 patients, 555 patients (60.3%) had semen results within the normal range, 269 patients (29.2%) within the abnormal range, and 96 (10.5%) were diagnosed with azoospermia. Varicoceles were diagnosed in 84 of the 555 normal-range patients (15.1%) and in 113 of the 269 abnormal-range patients (42.0%). Of the 96 patients with azoospermia, 24 patients (25%) were diagnosed with obstructive azoospermia, 68 patients (71%) with non-obstructive azoospermia, and 4 patients (4%) with retrograde ejaculation.

CONCLUSION

Various causes of male infertility have been reported and diverse treatment methods can be adopted for each cause. In this regard, research must be conducted on a larger number of patients to accurately assess the various causes of infertility in Korean patients and to investigate various infertility treatment methods.

Microsurgical varicocelectomy: a review

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.

Evaluation of FSH, LH and testosterone levels in different subgroups of infertile males

Gonadotropins (FSH, LH) and testosterone are the prime regulators of germ cell development. Abnormal spermatogenesis is often associated with altered serum gonadotropins and testosterone. FSH, LH and testosterone levels were estimated in 96 infertile men of whom 35 were azoospermic, 35 were oligozoospermic, 11 were with varicocele and 15 were with histopathological abnormalities like hypospermatogenesis, spermatid arrest and sertoli-cell only syndrome. Results showed statistically significant (p<0.05), increase in the mean FSH and LH levels in all the infertile males studied when compared with the fertile controls (n=35). However, there is no significant difference in the mean levels of testosterone between the infertile and fertile men.

Comparison of before and after varicocelectomy levels of nitric oxide in seminal fluid of infertile men

Background

Since nitric oxide (NO) has an oxidant activity, lower levels following a varicocelectomy may result in better functioning sperm, improved semen quality and consequently higher fertility rates. However, this procedure should be examined in more detail.

Objectives

Accordingly, this study was performed to compare the before and after varicocelectomy levels of NO in the seminal fluid of infertile men.

Patients and Methods

In this before and after comparative study, 20 consecutive patients attending a training hospital in Tehran, Iran were recruited. All of these men had primary or secondary infertility accompanied with a varicocele. A semen sample was collected from the men in two phases, first before their varicocelectomy and two months after their operation.

Results

NO levels differed significantly across the study and the mean (± standard deviation) levels of NO in the patients were 30.59 ± 10.35 µM/L and 21.48 ± 32.14 µM/L in the before and after phases of the study, respectively (P = 0.009).

Conclusions

According to the results obtained in this study, it may be concluded that in future, levels of NO should be taken into consideration together with other parameters for the evaluation of patients who are affected by varicoceles, to determine probable therapeutic responses.

Inguinal and genital anomalies

Problems of the groin and genitalia are a common presenting complaint in both pediatrician's offices and emergency departments. The authors endeavor to provide a comprehensive review of the most common inguinal and genital anomalies encountered by the pediatrician, with a special focus on examination and management.

The effect of magnified bilateral varicocele ligation on semen quality and the natural paternity rate in subfertile men, based on the sum of varicocele grading

Objective

To evaluate the effect of magnified bilateral varicocele ligation on the semen quality and natural paternity rate in subfertile men, based on the sum of varicocele grading.

Patients and methods

In a prospective longitudinal study, 78 patients (mean age 36.5 years, range 21–56) with a total of 156 varicoceles underwent bilateral varicocele ligation. Patients included had bilateral, primary and clinically palpable varicoceles, with a normal hormonal profile and abnormal semen; patients excluded had unilateral varicocele, or were recurrent cases, had infraclinical varicocele or had a genetic abnormality. Patients were classified into five groups (A–E), based on the findings of a physical examination; A included 13 patients with grade sum II (I + I), B included 21 with grade sum III (II + I), C included 25 with grade sum IV (II + II) or (III + I), D included 11 with grade sum V (III + II) and E included eight with grade sum VI (III + III). The follow-up was scheduled at 3, 6 and 12 months to assess semen variables and the natural paternity rate; 16 patients continued to a 36-month follow-up. Data were analysed statistically using a paired t-test to compare the mean sperm variables before and after surgery, with P < 0.05 considered to indicate significant differences.

Results

Of the 78 patients, 74 completed the follow-up at 3 months and only seven missed the 6-month follow-up. Overall, the mean sperm density, total sperm motility and sperm morphology increased from 13.44 to 26.48 × 10⁶/mL, 27.4% to 53% and 41.4% to 65.0%, respectively; the differences were statistically significant for all variables (P < 0.001). For each group separately there were significant improvements for both sperm density and motility, but for sperm morphology there were significant improvements in all groups except E, where the improvement was not correlated with those in the other groups. The paternity rate (by natural pregnancy) at 2 years was 26.9%, and this increased to 41% within 3 years.

Conclusion

Magnified bilateral varicocele ligation based on the sum of varicocele grading significantly improved semen quality and the natural paternity rate in subfertile men.

Varicocele is associated with erectile dysfunction: a population-based case-control study

INTRODUCTION

While many studies have been conducted investigating the efficacy of varicocele treatment on fertility, the literature is comparatively sparse concerning the association between varicocele, varicocelectomy, and erectile dysfunction (ED).

AIM

This study aimed to estimate the associations between varicocele, varicocelectomy, and ED using a population-based dataset.

METHODS

This study used data from the Longitudinal Health Insurance Database 2000 in Taiwan. A total of 32,856 cases and 98,568 randomly selected controls were included in this study. Conditional logistic regression analyses were used to examine associations between ED and having been previously diagnosed with varicocele or having underwent a varicocelectomy.

MAIN OUTCOME MEASURE

The odds of prior varicocele or having underwent a varicocelectomy between cases and controls.

RESULTS

Of the sampled patients, the prevalence of prior varicocele was 3.3% and 1.2% for cases and controls, respectively (P < 0.001). Conditional logistic regression analysis suggested that the odds ratio (OR) of being previously diagnosed with varicocele for cases was 3.09 (95% confidence interval [CI] = 2.67-3.49) when compared with controls after adjusting for monthly income, geographic location, hypertension, diabetes, coronary heart disease, hyperlipidemia, hypogonadism, obesity, and alcohol abuse/alcohol dependence syndrome. Furthermore, cases were 1.92 (95% CI = 1.52-2.43) times more likely to have undergone a varicocelectomy than controls. Furthermore, subjects aged between 18 and 29 had the highest ORs for prior varicocele among cases when compared with controls (OR = 5.20; 95% CI = 3.27-8.28).

CONCLUSION

This investigation succeeded in identifying an association between both varicocele and ED. We also realized that varicocele patients who underwent a varicocelectomy had lower magnitudes of association with ED than those who did not.

The hemodynamic approach to evaluating adolescent varicocele

During adolescence, the risk of developing a varicocele increases. Prevalence is less than 1% in boys aged younger than 10 years, but approaches that of the general adult population (about 15%) during puberty. For adolescent males with varicoceles, surgical risk factors have not yet been clearly delineated and clinical severity correlates poorly with prognosis. Fortunately, the widespread use of Doppler ultrasonography is transforming the diagnostic work-up for this demographic. A continuous reflux detected by color Doppler ultrasound (CDUS) is thought to have a negative prognostic value and evidence suggests that a peak retrograde flow above 38 cm per second is a powerful predictor of lack of spontaneous improvement in adolescent patients with ≥ 20% asymmetry between testes. CDUS also enables the detection of varicocele resulting from reflux in the deferential vein adjunctive to a refluxing internal spermatic vein; a causality that accounts for approximately 15% of cases. In addition to a diagnostic role, hemodynamic parameters can be used to predict the risk of persistence or worsening asymmetry. Although further studies are necessary to validate single parameters, it seems that the more severe the reflux, the greater the likelihood that the patient will develop testicular asymmetry.

What every gynecologist should know about male infertility: an update

PURPOSE

Our article reviews the evolving concepts in the field of male infertility for gynecologists and other health professionals involved in the care of men and women experiencing difficulty in having a child. The increased knowledge will help in the better management and treatment of infertile couples.

METHODS

Review of literature through Pubmed, Science Direct, Online Library.

RESULTS

Gynecologists are often the first healthcare providers to assess an infertile couple. Because half of all infertility problems stem from male factors, it is crucial for the gynecologist to remain updated on the main conditions that cause male infertility as well as current diagnostic tools and treatment options, including conventional strategies and assisted reproductive techniques.

CONCLUSIONS

Extraordinary advances have been achieved in the field of male infertility over the past several years and many old concepts are now challenged. Therefore, it is imperative that male infertility physicians should update the gynecologists about the recent advances in the work-up of infertile men in terms of diagnosis and management. Such convention will help improve the standards of care for the infertile couple and enhance the cooperation between male and female reproductive endocrinologists.