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

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.

Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction

Varicocele repair is indicated for infertile men with clinical varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from varicocelectomy.

Testicular volume discrepancy is associated with decreased semen quality in infertile Japanese males with varicoceles

Purpose

We retrospectively reviewed infertile Japanese males for testicular volume discrepancies (D) and semen parameters to evaluate whether left grade II-III varicoceles (V) cause testicular damage.

Methods

Seventy-seven patients who had idiopathic male infertility and 88 who had V without other causes of infertility were examined. We excluded cases of azoospermia. Testicular volume was measured using a punched-out orchidometer. D was defined as a size difference of at least 3 ml. The frequency of D was compared between the patients with and without V. The semen parameters were reviewed in association with D and V.

Results

The mean left and right testicular volumes were 19.4 and 20.1 ml, respectively (p < 0.001). D with a smaller left testis was more common in V+ cases than in V- cases (26.1 vs. 13.0%, p = 0.0351). The sperm count and motility were also significantly lower (p = 0.0213 and p = 0.0217, respectively) in the D+ patients with a smaller left testicular volume.

Conclusions

In the patients with V, D was more common than in those without V. The semen parameters were worse if D was present in the patients with V. These results indicated that V could induce testicular atrophy and negatively affect semen quality. Therefore, the ipsilateral reduced testicular volume is considered to be a sign of persisting testicular damage by V.

Varicocèle et infertilité masculine

Introduction

La responsabilité de l’homme dans l’infertilité du couple est établie par plusieurs travaux. Le but de ce travail est de rapporter les aspects cliniques, spermiologiques de la varicocèle et d’évaluer les résultats de la varicocélectomie rétropéritonéale à ciel ouvert.

Patients et méthodes

Il s’agit d’une étude rétrospective évaluant les résultats de la varicocélectomie rétropéritonéale à ciel ouvert, dans le service d’urologie-andrologie du centre hospitalier et universitaire Aristide-Le-Dantec de Dakar, Sénégal. Nous nous sommes intéressés aux patients suivis pour infertilité du couple, porteurs de varicocèle et chez la (les) partenaire(s) de qui aucune autre cause d’infertilité n’a été décelée. Pour l’évaluation des résultats, nous avons comparé les moyennes des paramètres spermatiques pré-et postopératoires en utilisant le test Z (test de comparaison de deux moyennes sur deux séries appariées). Une différence était considérée comme significative si p inférieur ou égal à 0,05.

Résultats

Cinq cent quatorze dossiers ont été retenus au cours de l’exploitation sur une période de six ans (janvier 2005–décembre 2010). L’âge moyen de nos patients était de 36,5 ± 7,3 ans. L’infertilité était primaire dans 62,4 %. L’exploitation des spermogrammes préopératoires a permis de noter que l’oligozoospermie sévère (33,7 %) était associée à des degrés divers à une asthénozoospermie et à une thératozoospermie. Ces patients étaient suivis avec un recul moyen de 22 mois (6–48 mois). L’amélioration des paramètres spermatiques était significative, concernant la concentration et la mobilité des spermatozoïdes. Le taux de grossesses naturelles obtenu dans la série était de 20,8 %. Aucun cas de grossesse naturelle n’a été noté dans le groupe des patients présentant une azoospermie, mais une induction de la spermatogenèse a été notée dans 20,5 % des cas. Près de deux grossesses sur trois (64 %) ont été notées durant les 12 premiers mois postopératoires.

Conclusion

Le traitement chirurgical de la varicocèle permet d’améliorer les paramètres spermatiques, ce qui non seulement permet l’obtention de grossesses naturelles mais également de simplifier les techniques d’Assistance Médicale à la Procréation (AMP) prévues grâce aux nouveaux paramètres.

Effects of anthocyanin extracted from black soybean seed coat on spermatogenesis in a rat varicocele-induced model

Varicocele is the most common cause of primary male infertility and is associated with oxidative stress. The aim of the present study was to investigate the effects of anthocyanin on a rat model of varicocele. Twenty-four male rats were divided into four experimental groups: a normal control group, a varicocele-induced control group and two varicocele-induced groups treated with either 40 or 80mgkg(-1), p.o., anthocyanin for 4 weeks. Varicocele was induced by the partial obstruction of the left renal vein. After 8 weeks, the testes and epididymides from rats in all groups were removed, weighed and subjected to histological examination and semen analysis. Apoptosis in the testes was determined by terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end-labelling (TUNEL) and oxidative stress was assessed by measuring 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels. Although no significant differences in sperm counts were observed among the groups, anthocyanin treatment of the varicocele-induced groups resulted in significantly increased testes weight, sperm motility and spermatogenic cell density (P<0.05). Anthocyanin treatment also significantly decreased apoptotic body count and 8-OHdG concentrations (P<0.05). We suggest that the antioxidant effect of anthocyanin prevented the damage caused by varicocele-induced reactive oxygen species.

Scrotal infrared digital thermography in assessment of varicocele--pilot study to assess diagnostic criteria

The aim of this study was to assess scrotal thermography in diagnostics of varicocele and suggest potential diagnostic criteria. Twelve patients with clinically diagnosed varicocele were examined with scrotal infrared digital thermography, physical examination and ultrasound/doppler. The main outcome measure was evaluation of thermography diagnostic criteria for varicocele. Mean temperature at left pampiniform plexus was ≥ 34 °C in 83%, and at right pampiniform plexus in all cases was ≤ 34 °C. In 92% of patients, temperature at the left testicle was ≥ 32 °C, whereas at the right testicle it was >32 °C in 50% patients. Temperatures between left and right pampiniform plexus and between left and right testicle were significantly different with P < 0.0001 and P < 0.006 respectively. In all patients, temperature difference between pampiniform plexuses was ≥ 0.6 °C. In 92% of patients, temperature at left pampiniform plexus was equal or higher to thigh temperature with the mean temperature difference of 1.1 ± 1.1 °C. Temperature at right pampiniform plexus was colder than the thigh in 92% of patients. This study suggests diagnostic criteria of five thermographic signs to easily diagnose varicocele. Scrotal thermography presents feasible, short and low cost diagnostic method for varicocele. Further study on a larger number of patients and healthy participants is needed to evaluate sensitivity and specificity of this method.

A critical appraisal on the role of varicocele in male infertility

Varicocele is a major cause of male infertility, as it may impair spermatogenesis through several distinct physiopathological mechanisms. With the recent advances in biomolecular techniques and the development of novel sperm functional tests, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele and, therefore, propose optimized ways to prevent and/or reverse them. Up to now, there is still controversy involving the true benefit of varicocele repair in subfertile men as well as in certain specific situations such as concomitant contralateral subclinical varicocele or associated nonobstructive azoospermia. Also, with the continued development of assisted reproductive technology new issues and questions are emerging regarding the role of varicocelectomy in this context. This paper reviews the most recent data available on the pathogenesis, diagnosis, and management of varicocele with regard to male infertility.

Surgical techniques for the management of male infertility

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.

Predictors of sperm recovery and azoospermia relapse in men with nonobstructive azoospermia after varicocele repair

PURPOSE

In this study we determined the recoverability and sustainability of motile sperm in semen of men with nonobstructive azoospermia after varicocelectomy as related to different variables.

MATERIALS AND METHODS

Men with documented infertility for more than 1 year, with nonobstructive azoospermia and clinically palpable varicoceles were included in this prospective noncontrolled study. Participants underwent simultaneous subinguinal microsurgical varicocelectomy and testicular biopsies. Preoperative as well as initial and late followup semen analyses were performed. Outcomes of sperm recovery and relapse of azoospermia were correlated with the variables of patient age, infertility duration, varicocele grade, laterality, follicle-stimulating hormone, testicular volume and testicular histology.

RESULTS

The study included 31 men with a mean ± SD age of 34.9 ± 8.7 years and mean followup of 19.3 ± 3.3 months. Hypospermatogenesis, late maturation arrest, early maturation arrest and Sertoli-cell-only were observed in 13, 6, 2 and 10 patients, respectively. Overall, sperm recovery was evident in 10 of 31 (32.3%) patients (persistent recovery 19.4%, intermittent recovery 6.5%, relapse 6.5%). Sperm were recovered in patients with hypospermatogenesis (7 of 13, 53.8%) and late maturation arrest (3 of 6, 50%). No sperm were recovered in those with early maturation arrest or Sertoli-cell-only. Among the variables only histological patterns demonstrated a significant correlation with recovery (rho = 0.504, p = 0.004). None of variables was significantly correlated with relapse. Bilateral varicocele repair demonstrated a strong yet nonsignificant negative correlation with relapse (rho = -0.612, p = 0.06).

CONCLUSIONS

Varicocelectomy could recover motile sperm in men with nonobstructive azoospermia, palpable varicoceles and hypospermatogenesis or late maturation arrest. No sperm was recovered with early maturation arrest or Sertoli-cell-only. Recovery might be persistent or intermittent, or involve relapse of azoospermia. Testicular histology was the sole parameter significantly correlated with recovery and no predictors of relapse could be identified. This prognostic role of testicular biopsy is imperative in couple counseling.

Testicular symmetry and adolescent varicocele--does it need followup?

PURPOSE

Appropriate management for adolescent varicocele with testicular symmetry is rarely discussed. We examined the natural history of varicocele in patients presenting with testicular symmetry to achieve better understanding of the clinical course.

MATERIALS AND METHODS

Our varicocele registry was queried for adolescent boys who presented with varicocele in association with less than 15% testicular asymmetry and who underwent at least 1 testicular asymmetry assessment 12 or more months later. Patients were stratified into 2 groups based on an initial testicular asymmetry measurement of less than 10% vs 10.0% to 14.9%. Logistic regression modeling was used to analyze the association of Tanner stage, varicocele grade, peak retrograde flow and maximum vein diameter at presentation with increased testicular asymmetry at followup. Kaplan-Meier methodology was applied to compare testicular asymmetry progression rates.

RESULTS

We identified 89 adolescents, of whom 52 (58.4%) and 37 (41.6%) presented with less than 10.0% and 10.0% to 14.9% testicular asymmetry, respectively. Of the patients 37 (41.6%) showed testicular asymmetry progression at a median 18-month followup. The overall 3-year testicular asymmetry progression-free rate was 48% while in patients with peak retrograde flow 30 cm per second or greater it was 23%. On multivariate analysis controlled for age, Tanner stage and varicocele grade a peak retrograde flow of 30 cm per second or greater was associated with worsening testicular asymmetry (OR 4.87, 95% CI 1.6-8.0).

CONCLUSIONS

Adolescents with varicocele and less than 15% testicular asymmetry are at risk for asymmetry during followup. Those with peak retrograde flow 30 cm per second or greater are at increased risk for early asymmetry while those with peak retrograde flow less than 30 cm per second may still show asymmetry but tend to do so after longer followup.

Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis

OBJECTIVES

To determine the effect of surgical varicocele repair in improving testicular Leydig cell function as shown by increased testosterone production.

METHODS

Eligible studies were searched in Medline and the Pubmed database, and cross-referenced as of 31 May 2011 using the terms "varicocele,""testosterone" and "surgery." The database search, quality assessment and data extraction were independently carried out by two reviewers. Only studies including patients with testosterone evaluation before and after surgery were considered for the analysis. A systematic review and meta-analysis was carried out for continues variables using random effect models.

RESULTS

Out of 125 studies, a total of nine were selected, including 814 patients. The combined analysis showed that mean serum testosterone levels after surgical treatment increased by 97.48 ng/dL (95% confidence interval 43.73-151.22, P=0.0004) compared with preoperative levels.

CONCLUSIONS

Surgical treatment of varicocele significantly increases testosterone production and improves testicular Leydig cell function.

Varicocele repair: does it still have a role in infertility treatment?

PURPOSE OF REVIEW

To review the role of varicocele repair in the treatment of male infertility.

RECENT FINDINGS

Since the advent of technologies bypassing boundaries of natural selection, this question may seem outdated. Over the past 20 years, fertility has decreased, and testicular damage (cryptorchidism, tumors) has increased. Thus the exploration of the infertile male is still unavoidable. However, what should be done and assigned to the discovery of a varicocele?The issue raised is whether varicocele found during the review of the infertile couple should be treated or 'ignored'.This study will update significant findings with regards to the pathophysiology of varicocele-induced infertility, such as oxidative stress and role of varicocele in bilaterality of testicular damage. Benefits of varicocele repair in semen analysis and simplifications of assisted reproductive techniques are reported. But reviews of randomized clinical trials have raised doubts about the benefit of varicocele treatment in infertile men.

SUMMARY

We conclude that varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility. Deleterious cofactors, like obesity or smoking, could also be reduced for the benefit of general health and fertility.

Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair

CONTEXT

Varicocele is a common condition, found in many men who present for infertility evaluation.

OBJECTIVE

To assess the effect of varicocelectomy on male infertility.

EVIDENCE ACQUISITION

A literature search was performed using Embase and Medline. Literature reviewed included meta-analyses and randomized and nonrandomized prospective (controlled and noncontrolled) studies. In addition, a new meta-analysis was performed.

EVIDENCE SYNTHESIS

Four randomized controlled trials reporting on pregnancy outcome after repair of clinical varicoceles in oligozoospermic men were identified. Using the random effect model, the combined odds ratio was 2.23 (95% confidence interval [CI], 0.86-5.78; p=0.091), indicating that varicocelectomy is moderately superior to observation, but the effect is not statistically significant. We identified 22, 17, and 5 prospective studies reporting on sperm concentration, total motility, and progressive motility, respectively, before and after repair of clinical varicocele. The random effect model combined improvement in sperm concentration was 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001). The random effect model combined improvement in sperm total and progressive motility were 10.86% (95% CI, 7.07-14.65; p<0.0001) and 9.69% (95% CI, 4.86-14.52; p=0.003), respectively. These results indicate that varicocelectomy is associated with a significant increase in sperm concentration as well as total and progressive motility. Prospective studies also show that varicocelectomy reduces seminal oxidative stress and sperm DNA damage as well as improving sperm ultramorphology. Studies indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques.

CONCLUSIONS

Although there is no conclusive evidence that a varicocele repair improves spontaneous pregnancy rates, varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. The various methods of repair are all viable options, but microsurgical repair seems to be associated with better outcomes.

Glutathione S-transferase M1 and T1 polymorphisms in Turkish patients with varicocele

Several studies have shown that high oxidative stress levels are associated with varicocele. The GST (glutathione S-transferase) family of genes is critical in the protection of cells from oxidative stress because they utilise as substrates a wide variety of products of oxidative stress. The objective of this study was to assess the relationship between genetic polymorphism in GST-M1 and GST-T1 and varicocele using 109 varicocele patients and 123 controls. Varicoceles were clinically graded as Grade 1, Grade 2 and Grade 3. GST-M1 and GST-T1 genes were determined by polymerase chain reaction. Although the GST-M1 null genotype was higher in Grade 3 than in Grade 1, 2 and controls, there were no statistical differences between control group and varicocele groups according to GST-M1 and GST-T1 null genotype. Men with varicocele do not have more GST-M1 and GST-T1 null polymorphisms than men without varicocele. Additional studies are needed to assess the exact mechanism by which the varicocele corresponds to elevated ROS levels.

Varicocele as a risk factor for androgen deficiency and effect of repair

OBJECTIVE

• To determine whether men with varicoceles have lower testosterone levels than those without and to ascertain if testosterone levels increase after varicocelectomy.

PATIENTS AND METHODS

• We measured preoperative testosterone levels in 325 men with palpable varicoceles and in 510 men with vasectomy reversal without varicoceles who served as a comparison group. • The testosterone levels between groups were compared by age. Of the men with varicoceles, 200 had data on both pre- and postoperative testosterone levels, which were compared to assess postoperative changes.

RESULTS

• Men with varicocele had significantly lower testosterone levels than the comparison group, with mean (sd) levels of 416 (156) vs 469 (192) ng/dL (P < 0.001). This difference persisted when analysed by age. • The testosterone levels significantly increased after repair from 358 (126) to 454 (168) ng/dL (P < 0.001). • Of the 70% of patients with postoperative improvement in testosterone levels, the mean (sd) increase in testosterone was 178 (142) ng/dL. The percentage change in testosterone levels was: 30% had no increase, 41% increased by ≤ 50%, 19% increased between by 51-100%, and 10% increased by >100%. • There was no association between change in testosterone level and age, laterality of varicocele, or varicocele grade.

CONCLUSIONS

• Men with varicoceles had significantly lower testosterone levels than the comparison group of men with vasectomy reversal. • Microsurgical varicocele ligation resulted in a significant increase in serum testosterone levels in more than two-thirds of men. • These findings suggest that varicocele is a significant risk factor for androgen deficiency and that repair may increase testosterone levels in men with varicocele and low testosterone levels.

Expression of E-cadherin and α-catenin in a varicocele-induced infertility rat model

The roles of E-cadherin and α-catenin were evaluated in the development of varicocele-induced infertility. Analysis of the association between the expression of E-cadherin/α-catenin and clinical/pathological parameters was performed. Thirty 10-week-old male rats (experimental group) were used for the experiments; the left renal vein was ligated to form a varicocele. The abdomen was incised in 30 rats (control group) and no procedure was performed on 10 rats (baseline group). The weights of the left testis, serum reactive oxygen species (ROS), testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and degenerative changes in the seminiferous tubules after 4 and 8 weeks were recorded. The expression of E-cadherin and α-catenin was evaluated by immunohistochemical (IHC) staining and Western blot analysis. The ROS increased in the 8-week experimental group, compared with the baseline and control groups (P < 0.001 for both). Additionally, FSH significantly increased in the 4- and 8-week experimental group compared with the control groups (P = 0.013 and P = 0.032, respectively). The ratio of degenerative changes in the seminiferous tubules of the experimental groups increased. The IHC staining showed that the expression of E-cadherin and α-catenin decreased in the 4- and 8-week experimental groups. Similar to the IHC staining, the experimental group had decreased reactivity on Western blot analysis. The expression of E-cadherin and α-catenin was significantly associated with the ROS and degenerative changes in the seminiferous tubules. The results of this study suggest that damage to the blood-testis barrier (BTB) is associated with varicocele-induced male infertility, and that ROS may cause damage to the BTB.

The great debate: varicocele treatment and impact on fertility

OBJECTIVE

To evaluate the current literature on the impact and potential mechanisms of varicocele repair on male fertility.

DESIGN

Pertinent articles were identified through computer PubMed search on varicocele repair and male factor infertility. References of selected articles were hand searched for additional citations.

CONCLUSION(S)

Varicocele repair has been shown to reverse a spectrum of effects contributing to men with impaired fertility. Clinical studies on the intervention have illustrated variable effects on postoperative sperm parameters and pregnancy rates (PR). Studies with conflicting results suffer from a significant number of confounding variables such as variable repair technique or lack of controls. Additional studies are warranted on the role of modern microsurgical varicocelectomy given the improvements in assisted reproductive technologies (ART).

Azoospermia and maturation arrest: malfunction of valves in erect poster of humans leads to hypoxia in sperm production site

Maturation arrest (MA) of spermatogenesis is diagnosed on histology as interruption of spermatogenesis before the final stage without impairment of Sertoli or Leydig cells. It is considered a condition of irreversible or absolute infertility. Varicocele, which represents impairment in the testicular venous drainage system, has been shown to be a bilateral disease. Malfunction of the valves increase the hydrostatic pressure in the testicular venous system that exceeds the pressure in the arterial system leading to hypoxia in the testicular microcirculation and in the seminiferous tubules, the sperm production site. Sperm production deteriorates, and ultimately progresses to azoospermia. Our prediction was that MA, if genetic factors are excluded, is the final stage of long standing hypoxia. This would indicate that MA is not always an independent disease entity, but may represent progressive process of deterioration of the testicular parenchyma beyond azoospermia. By histology and electron microscopy, our prediction confirmed, at least partially, that MA is associated with degenerative ischaemic changes in the seminiferous tubules. Adequate treatment of bilateral varicocele by microsurgery or super-selective sclerotherapy of the internal spermatic veins including associated network of venous bypasses, vertically oriented, may resume the flow of oxygenated blood. If irreversible damages did not occur and ischaemia is not too long standing, limited sperm production may be restored, at least partially.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy

PURPOSE

It is generally accepted that men with clinically palpable varicocele are at high risk for a progressive decrease in fertility and testosterone levels with time. Varicocelectomy is thought to improve testicular function or at least halt the accelerated decrease in testicular function associated with varicocele. Substantial controversy exists as to whether varicocelectomy is effective in older men, possibly due to irreversible testicular damage or limited potential for recovery from varicocele induced damage.

MATERIALS AND METHODS

We retrospectively reviewed the records of men who underwent microsurgical subinguinal varicocelectomy, as done by a single surgeon. Demographics, patient questionnaires, operative notes, charts, testosterone and semen analysis were reviewed. Patients were divided into 3 groups based on age at surgery, including less than 30, 30 to 39 and 40 years or greater.

RESULTS

A total of 272 men met study inclusion criteria. In all 3 age groups we noted similar testosterone and baseline semen analysis parameters. There were significant increases in sperm concentration and total sperm count in all age groups. When analysis was restricted to men with baseline testosterone 400 ng/dl or less, there was a mean 110, 133 and 136 ng/dl increase in 21 men who were 40 years old or older, in 30 who were 30 to 39 years old and in 21 who were younger than 30 years, respectively.

CONCLUSIONS

Microsurgical varicocelectomy resulted in significant increases in sperm concentration, total sperm count and testosterone in all age groups studied, including men in the fifth and sixth decades of life. Microsurgical varicocelectomy should be offered to older men for infertility and/or hypogonadism.

Impact de la varicocélectomie chez les patients ayant une azoospermie non obstructive ou une oligozoospermie sévère

But

Évaluer les résultats de la ligature haute rétropéritonéale des veines spermatiques chez les hommes infertiles ayant une azoospermie non obstructive ou une oligozoospermie sévère.

Patients et méthodes

Étude rétrospective colligeant 61 cas de varicocèle dont 46 (75,4 %) ayant une oligozoospermie sévère (groupe I) et 15 (24,6 %) ayant une azoospermie non obstructive (groupe II).

Résultats

Dans le groupe I (oligozoospermie sévère), l’âge moyen des patients était de 35,5 ± 6,4 ans (23–47 ans). La durée moyenne de l’infertilité était de 4,9 ± 3,4 ans (1–13 ans). La varicocèle était bilatérale chez 41 patients (89,1 %) et unilatérale gauche chez cinq patients (10,9 %). Cette varicocèle a été classée de grade I dans deux cas (4,3 %), de grade II dans 39 cas (84,7 %) et de grade III dans cinq cas (10,9 %). En préopératoire, la concentration moyenne des spermatozoïdes était de 1,85 ± 1,4 millions/ml. La mobilité normale à la première heure des spermatozoïdes était en moyenne de 43,3 ± 21,5 %. Les spermatozoïdes de morphologie anormale représentaient 65,05 ± 21,6 % en moyenne. Après varicocélectomie, la concentration moyenne des spermatozoïdes était de 8,3 ± 10,3 millions/ml. La mobilité normale était en moyenne de 47,6 ± 29,2 %, et les spermatozoïdes de morphologie anormale de 50,08 ± 26,9 %. Après un recul moyen de 26,2 ± 11,6 mois, 12 couples (26,1 %) avaient rapporté des grossesses spontanées. Dans le groupe II (azoospermie), l’âge moyen des patients était de 40,8 ± 7,2 ans (27–47 ans). La durée moyenne de l’infertilité était de 6 ± 3,1 ans (3–15 ans). Après varicocélectomie, une induction de la spermatogenèse avec présence de spermatozoïdes mobiles dans l’éjaculat a été observée chez trois patients (20 %). Dans ce groupe, un seul couple avait rapporté une grossesse qui s’est terminée par une fausse couche.

Conclusion

La varicocélectomie chez les hommes infertiles ayant une azoospermie non obstructive peut entraîner une apparition dans l’éjaculat de spermatozoïdes mobiles utilisables dans le cadre d’une assistance médicale à la procréation (AMP). Elle entraîne une amélioration significative de la qualité de la spermatogenèse et de la fertilité en cas d’oligozoospermie sévère. La réalisation de cette intervention chez de tels hommes est donc une option raisonnable.

Conventional progesterone receptors (PR) B and PRA are expressed in human spermatozoa and may be involved in the pathophysiology of varicocoele: a role for progesterone in metabolism

The physiological roles of intracellular progesterone (PRG) receptors (PRs) have been studied intensively in female mammals, while their functions in male are scarce. Conventional PRs were evidenced in our study by Western blotting, concomitantly in healthy spermatozoa and in oligoasthenoteratozoospermic samples without and with varicocoele. Transmission electron microscopy revealed the presence of the PRs on the membrane as well as in the nucleus, mitochondria and flagellum. A reduced expression of the PRs was observed only in varicocoele spermatozoa. Responses to PRG treatment on cholesterol efflux, tyrosine phosphorylation, src and Akt activities, acrosin activity and acrosome reaction in varicocoele spermatozoa were reduced or absent. To further investigate PRG significance in human male gamete, we focused its action on lipid and glucose metabolism. The evaluation of the triglycerides content, lipase and acyl-CoA dehydrogenase activities suggests that PRG through the PRs exerts a lipolytic effect on human spermatozoa. An increase in glucose-6-phosphate dehydrogenase activity was also obtained, evidencing a role for PRG on glucose metabolism. In 'varicocoele' spermatozoa, the PRG did not induce energy consumption. The action of PRs on sperm metabolism is a novel finding that renews the importance of PRG in male fertility. Our results showed that varicocoele may lead to male factor infertility by a mechanism involving a decreased PR expression in human spermatozoa that evidences a detrimental effect on spermatozoa at the molecular level, going beyond the abnormal sperm morphology described to date.

Adolescent varicocele: influence of Tanner stage at presentation on the presence, development, worsening and/or improvement of testicular hypotrophy without surgical intervention

PURPOSE

Testicular asymmetry in adolescents with varicocele can worsen, remain unchanged or decrease on followup. We determined the incidence of testicular asymmetry at presentation by Tanner stage and the correlation between Tanner stage at presentation and subsequent changes in percent asymmetry (ability for catch-up growth or progressive asymmetry) without surgical intervention.

MATERIALS AND METHODS

We retrospectively studied the records of 115 boys with a mean age of 14.1 years (range 9.2 to 20.0) with grade 2 or 3 left varicocele who underwent testicular volume measurement at 2 visits at least that were a minimum of 6 months apart. Of the patients 92% and 8% underwent Doppler duplex ultrasound and orchidometry, respectively. Patients were divided into 2 groups, including those with less than 15% and those with 15% or greater asymmetry. Catch-up growth was defined as less than 15% asymmetry at any subsequent visit.

RESULTS

At presentation 58%, 64%, 67%, 35% and 39% of Tanner 1 to 5 cases showed 15% or greater testicular asymmetry, respectively. When Tanner 1 to 3 cases were combined and compared with Tanner 4 and 5 cases, the difference in initial asymmetry was significant (64% vs 38%, p = 0.007). Although it was not statistically significant, there was a trend toward more catch-up growth for the later Tanner stages, including 27% for Tanner 1 to 3 vs 53% for Tanner 4 and 5 (p = 0.06).

CONCLUSIONS

Slightly more than 50% of children and adolescents referred with varicocele have 15% or greater testicular asymmetry at presentation. Initial asymmetry is statistically more common in cases of earlier Tanner stages (1 to 3). Adolescents with 15% or greater testicular asymmetry who present at higher Tanner stages (4 and 5) show a trend toward a higher incidence of catch-up growth, although it is not significant.

Treatment strategy for the adolescent varicocele

A varicocele is a dilatation of the testicular vein and the pampiniform venous plexus within the spermatic cord. Although rare in pediatric populations, the prevalence of varicoceles markedly increases with pubertal development. Varicoceles are progressive lesions that may hinder testicular growth and function over time and are the most common and correctable cause of male infertility. Approximately 40% of men with primary infertility have a varicocele, and more than half of them experience improvements in semen parameters after varicocelectomy. The decision to treat adolescents with varicocele is a controversial one. The task for pediatricians and urologists is to identify those adolescents who are at greatest risk for infertility in adulthood, in an effort to offer early surgical intervention to those most likely to benefit.

Experience of varicocele management during ipsilateral inguinal herniorrhaphy: a prospective study

BACKGROUND

This was a prospective study to evaluate the experience of varicocele management during ipsilateral herniorrhaphy in an inpatient urology setting.

METHODS

A total of 65 patients with varicocele and inguinal hernia scheduled for herniorrhaphy were included for evaluation. They were categorized into 3 groups. Group 1 (n = 20) had painful varicocele and underwent simultaneous herniorrhaphy and varicocelectomy; group 2 (n = 20) had asymptomatic varicocele and received simultaneous herniorrhaphy and varicocelectomy; and group 3 (n = 25) had asymptomatic varicocele and underwent herniorrhaphy only. We used the Bassini method for herniorrhaphy and inguinal microsurgical varicocelectomy for varicocele. Varicocele was diagnosed by physical examination and further confirmed by Doppler ultrasonography.

RESULTS

The mean follow-up was 30.2 months (range, 6-56 months). Of the 20 subjects in group 1, complete resolution of scrotal pain was noticed in 14 (70%), and 2 (10%) had hydrocele after varicocelectomy. Of the 20 patients in group 2, 1 (5%) had hydrocele after surgery, and no hydrocele was noticed in group 3 after surgery. Mean operation time was significantly longer in group 1 (70.5 + or - 15.2 minutes) and group 2 (69.8 + or - 14.5 minutes) than in group 3 (38.2 + or - 17.2 minutes). One case in group 1 had recurrent varicocele 6 months after surgery. Of the 25 subjects in group 3, 2 (8%) developed painful varicocele during the follow-up period, and both of them had indirect inguinal hernia and lower body mass index.

CONCLUSION

Simultaneous herniorrhaphy and varicocelectomy are suggested for patients who have inguinal hernia and ipsilateral varicocele, but the average operation time is significantly longer and there is a higher rate of hydrocele than with herniorrhaphy only.

Histopathologic patterns of testicular biopsies in infertile azoospermic men with varicocele

In azoospermic infertile men with varicocele, testicular biopsy revealed histopathologic patterns that varied from disorganized spermatogenesis with low or moderate sperm scores to early (primary spermatocytes stage) or late (spermatid stage) arrested spermatogenesis or germ cell aplasia and Sertoli cells only. Diagnostic testicular biopsy can be helpful for accurate management of azoospermic infertile men with varicoceles before surgical repair.

Varicocele repair in patients with nonobstructive azoospermia: a meta-analysis

PURPOSE

Multiple small case series have reported sperm in the ejaculate and spontaneous pregnancies in patients with nonobstructive azoospermia after varicocele repair. We hypothesized that men with favorable testicular histopathology on testis biopsy such as maturation arrest or hypospermatogenesis would have a higher probability of success than those with more ablative pathology, eg Sertoli-cell-only.

MATERIALS AND METHODS

A review of the literature on varicocele repair in patients with nonobstructive azoospermia was performed and 11 publications from the previous 20 years were evaluated. Histopathological data were presented in 8 publications, and were categorized as Sertoli-cell-only, maturation arrest and hypospermatogenesis. Maturation arrest was further differentiated by 4 publications. Early maturation arrest was defined as maturation ending at the secondary spermatocyte and late maturation arrest was defined as maturation ending at the spermatid without spermatozoa present. Success after repair was defined as having sperm in the ejaculate or spontaneous pregnancy.

RESULTS

A total of 233 patients were analyzed. After varicocele repair 91 (39.1%) patients had motile sperm in the ejaculate and 14 spontaneous pregnancies were reported. Success rates in patients with maturation arrest (42.1%) or hypospermatogenesis (54.5%) were significantly higher than in those with Sertoli-cell-only (11.3%, p <0.001 in both groups). Patients with late maturation arrest had a higher probability of success (45.8%) than those with early maturation arrest (0%, p = 0.007).

CONCLUSIONS

Infertile men with nonobstructive azoospermia can have improvement in semen analysis and achieve spontaneous pregnancy after repair of clinical varicoceles. This meta-analysis demonstrates that men with late maturation arrest and hypospermatogenesis have a higher probability of success and, therefore, histopathology should be considered before varicocele repair in men with nonobstructive azoospermia.

Differences in biochemical markers and body mass index between patients with and without varicocele

BACKGROUND

Varicocele is characterized by abnormal tortuosity and dilatation of the veins of the pampiniform plexus within the spermatic cord and is one of the causes of male infertility. This study aimed to evaluate the differences in biochemical markers and body mass index (BMI) between patients with and without varicocele.

METHODS

Between January 2004 and June 2009, 102 patients with varicocele (Group A) were evaluated. Ninety-five age-matched male patients who did not have varicocele were selected as controls (Group B). Varicocele was diagnosed by physical examination and confirmed by Doppler ultrasonography. The range of ages was between 18 and 50 years old. BMI, testosterone, serum alkaline phosphatase, calcium, lactic dehydrogenase, inorganic phosphate, gammaglutamine transpeptidase, uric acid, albumin, iron, cholesterol, triglyceride, alanine aminotransferase, and aspartate aminotrans-ferase levels were measured for all the subjects.

RESULTS

The mean age was 35.4 years in group A and 36.5 years in group B. Of the 102 patients in group A, 20 were grade 1 varicocele, 55 were grade 2 and 27 were grade 3. The BMI (mean +/- SD) of patients with varicocele (22.8 +/- 3.2) was significantly lower than that of patients without varicocele (24.9 +/- 4.1). Patients with varicocele had significantly lower serum levels of cholesterol than patients without varicocele (176.5 +/- 31.1 vs. 187.7 +/- 42.1 mg/dL). There were no significant differences for the other biochemical markers between the groups. Patients with grade 3 varicocele had a lower BMI than patients with grades 1 and 2 varicocele, but this was not significant. No significant differences were found for the other biochemical markers among the patients with grade 1, 2 or 3 varicocele.

CONCLUSION

Patients with varicocele had significantly lower serum levels of cholesterol than those without varicocele. In addition, the prevalence of varicocele was higher in patients with a lower BMI. Our findings suggest that patients with a greater BMI may have advantages in relieving the nutcracker phenomenon, which causes significant varicoceles.

Expression of the Fas-ligand gene in ejaculated sperm from adolescents with and without varicocele

PURPOSE

To assess FasL mRNA levels in ejaculated sperm from adolescent patients with and without varicocele.

METHODS

Semen was obtained by masturbation following 2-4 days of ejaculatory abstinence, from 14 adolescents with varicocele grades II and III (study group), and 20 adolescents without varicocele (control group). Seminal analysis was done according to World Health Organization guidelines and morphology using Kruger's strict criteria. The Fas-ligand (FasL) gene expression was performed using reverse transcription and real-time quantitative polymerase chain reaction (RQ-PCR) analysis, according to the expression level of the housekeeping cyclophilin A gene. A Student's t-test was applied to compare the groups, and Spearman's rank test in order to verify possible correlations (p < 0.05).

RESULTS

Quantitative RQ-PCR demonstrated that the expression of FasL mRNA in sperm from the varicocele group was higher than in the control group. Also, sperm concentration was higher in the controls, when compared to the varicocele group. When submitted to correlation analysis, adolescents with varicocele presented a correlation between sperm concentration and FasL gene expression levels (r = -0.470), not observed in controls.

CONCLUSION

Our results allow us to conclude that, in adolescents with varicocele presenting lower sperm concentration, FasL mRNA levels are higher than in adolescents without varicocele.

Predictors of improved seminal parameters and fertility after varicocele repair in young adults

The aim of our study was to determine hormonal or biochemical markers in patients with clinically palpable left varicocele but without a history of infertility, with especial emphasis on nitric oxide, related with improved seminal parameters after varicocelectomy. Semen samples were obtained from 202 patients with left varicocele grade II or III. Nitric oxide levels in seminal plasma were determined by the Griess technique. Testicular volume was determined ultrasonographically in both testes and hormonal profile was measured. The post-operative sperm concentration increased significantly in patients with normal sperm count or moderate oligozoospermia, but we did not find an increment in sperm count in patients with mild and severe oligozoospermia after surgery. The mean percentage of normal motility significantly increased after surgery, but we did not observe a significant increment in morphologically normal sperm count and testicular volume after varicocele repair. Moreover, we did not find any correlation between nitric oxide concentrations and severity of oligozoospermia, asthenozoospermia or abnormal sperm morphology in this population. It is concluded that in the general male population, varicocele repair is not associated with an improved semen profile in all cases. We did not observe a significant correlation between nitric oxide concentrations and semen profile.

Sperm retrieval and intracytoplasmic sperm injection in men with nonobstructive azoospermia, and treated and untreated varicocele

PURPOSE

We evaluated the impact of varicocelectomy on the sperm retrieval success rate using microsurgical testicular sperm extraction and intracytoplasmic sperm injection in men with clinical varicocele and nonobstructive azoospermia.

MATERIALS AND METHODS

The study included 96 men with complete nonobstructive azoospermia with a history of clinical unilateral or bilateral varicocele. Of the patients 66 previously underwent successful varicocelectomy and 30 had any grade of varicocele at sperm extraction.

RESULTS

Mean patient age was 34.8 and 32.3 years in the treated and untreated groups respectively. There were no differences in mean follicle-stimulating hormone, testicular volume, infertility duration or female partner age between the 2 groups. The proportion of female factor problems in the 2 groups was similar. The distribution of varicocele grade in the treated and untreated groups was not different. The sperm retrieval rate was significantly higher in the treated group (53% vs 30%, OR 2.63, 95% CI 1.05-6.60, p = 0.036). There was no significant difference in the normal 2PN fertilization rate (63.9% vs 53.6%). The rate of high quality embryos and mean number of transferred embryos were similar in the groups. The clinical pregnancy rate in the treated and untreated groups was 31.4% and 22.2%, respectively (p >0.05).

CONCLUSIONS

Our results suggest that varicocele repair significantly increased the sperm retrieval rate in patients with clinical varicocele and nonobstructive azoospermia.

POSTOPERATIVE CHANGES OF SPERM CHROMATIN HETEROGENEITY, USING ACRIDINE ORANGE STAINING, IN VARICOCELE PATIENTS

The aim of this study was to evaluate postoperative changes in sperm chromatin heterogeneity in varicocele patients. In 15 infertile patients with varicocele, sperm parameters including concentration, motility, and morphology were evaluated before and after surgical correction of varicocele. Sperm motion analysis using computer-assisted semen analyzer (CASA) was also performed. To analyze the sperm nuclear proteins, the acridine orange staining method was used. On semen analysis, sperm concentration and motility significantly increased after surgery (p = 0.002, p = 0.003, respectively), although sperm morphology was unaltered postoperatively. CASA parameters, including velocity, linearity, amplitude of lateral head displacement and beat cross frequency were unaltered postoperatively. On the other hand, acridine orange staining significantly increased postoperatively (p = 0.002). Varicocele influences the sperm chromatin condition, as well as sperm concentration and motility.