Effects of bioflavonoids in the management of subclinical varicocele

Oxidative Stress and Varicocele-Associated Male Infertility

Despite being regarded as one of the most common causes of male subfertility, the pathophysiology of varicocele remains largely unknown. Recently, oxidative stress (OS) is proposed to be the mediator in how varicocele may negatively impact fertility. The imbalance of reactive oxygen species (ROS) and seminal antioxidants results in damage to sperm DNA and lipid membrane. There is evidence demonstrating higher OS level in men with varicocele which is also positively correlated with clinical grading of varicocele. Moreover, a number of studies have revealed the negative correlation between OS and conventional semen parameters. Furthermore, various interventions have shown their potential in alleviating OS in men with varicocele-associated infertility. Although direct evidence on improving pregnancy rate is not available at the moment, varicocelectomy has demonstrated promising results in relieving OS. Oral antioxidants represent another option with a favourable safety profile. The supplement can be used alone or as adjunct to varicocelectomy. However, most of the studies are hampered by heterogenous dose regime and high-level evidence is lacking.

Role of total motile sperm count in the evaluation of young men with bilateral subclinical varicocele and asthenospermia

INTRODUCTION

In comparison to its clinical analogue, the subclinical varicocele represents a questionable entity and specific guidelines for the optimal management are lacking. In our previous study of patients with subclinical varicocele, we showed that bilateral condition is associated with risk of dyspermia. In the present study, we evaluated the risk of deterioration of semen quality in men with bilateral disease and impaired motility according to WHO criteria.

MATERIALS AND METHODS

Men with bilateral subclinical varicocele, not desiring fatherhood at the time of presentation, were included in study. During initial evaluation, the number of Total Motile Sperm Count (TMSC) was calculated and the patients' age, total testicular volume (TTV), maximum venous size and mean resistive index (RI) of the intratesticular arteries were recorded. We classified the participants in five classes according to the TMSC reading: class A-: TMSC < 5 x 106, class A: TMSC between 5-10 x 106, class B: TMSC between 10-15 x 106, class C: TMSC between 15-20 x 106, and class D: TMSC > 20 x 106 per ejaculate. The participants were seen after 6 months for a repeat spermiogram and physical examination. If clinical varicocele was diagnosed or a new abnormality in the spermiogram was noted, the participants were excluded from the study. The remaining patients were allocated to two groups according to the repeat TMSC reading: patients sub-classified into a lower class (group 1), and patients remaining at the same class (group 2). A comparative analysis was performed between two groups.

RESULTS

Nineteen men were included. Nine patients were subclassified (group 1). Three patients moved to A- class (< 5 x 106). Ten patients remained in the same class having no deterioration (group 2). Comparing the two groups, no statistically significant difference was recognized for age, TTV, maximum venous size on both sides, and mean RI (p > 0.05). However, the initial reading for TMSC was 14.57 x 106 in group 1, and 22.84 x 106 in group 2, respectively. This difference was statistically significant (p < 0.05). Additionally, in a paired analysis there was a significant difference in TMSC after 6 months (p < 0.05), too. Summary Conclusions: Young men with bilateral varicocele and asthenospermia seem to be at risk of deterioration in their semen quality after a follow-up of 6 months. The measurement of TMSC can unmask patients at risk, whereas men with the lowest readings seem to be at highest risk for deterioration. The possibility of a worsening sperm quality should be considered in the appropriate clinical context.

Varicocele repair in patients prepared for intracytoplasmic sperm injection: To do or not to do?

PURPOSE

This study sought to evaluate the impact of varicocele repair on intracytoplasmic sperm injection outcomes.

PATIENTS AND METHODS

A prospective comparative study was conducted at the Assisted Reproduction Unit, International Islamic Center for Population Studies and Researches, Al-Azhar University. This study included 100 non-azoospermic infertile men with a history of varicocele who were scheduled for intracytoplasmic sperm injection, half of them had already undergone prior subinguinal varicocelectomy at least 12 months prior to ICSI without clinically evident recurrence (treated group 1), and the other half has any grade of an unrepaired clinical varicocele (untreated group 2) at sperm injection. All cases were clinically evaluated and eligible for analysis by using inclusion and exclusion criteria. ICSI outcomes compared between the two groups, including fertilisation rate, embryo development rate and pregnancy outcome.

RESULTS

Our study did not show any significant difference between treated and untreated groups regarding the mean values of fertilisation (0.7759 ± 0.2708 vs. 0.7119 ± 0.3057, p = 0.2708), embryo development (0.7759 ± 0.2708 vs. 0.6991 ± 0.3211, p = 0.1990) or different embryo grades. There was no statistically significant difference between groups regarding pregnancy occurrence rates (p = 0.0928).

CONCLUSION

Infertile men scheduled for ICSI do not seem to benefit from varicocele repair as regard to the outcomes of ICSI.

An update on the role of medical treatment including antioxidant therapy in varicocele

Varicocele-associated male infertility has classically been managed using surgery or assisted reproductive techniques. With increasing evidence of oxidative stress as a pathophysiological factor in varicocele-associated infertility, medical therapy especially antioxidants might become a treatment option with lower risks. We reviewed the existing literature on the role of various medical agents in the management of male infertility attributed to varicoceles. Medical therapy is typically evaluated in three different situations such as (a) comparison of two drugs or one drug with placebo, (b) comparison of drugs versus surgery, and (c) comparison of drugs as adjuvant therapy with surgery versus drug therapy alone. Due to heterogeneity of data and lack of well-conducted studies, there is insufficient data to recommend routine use of medical therapy for men with varicocele-associated infertility and surgery remains the treatment of choice. Pregnancy and live birth rates are usually not reported in most studies and mere improvement in sperm parameters or antioxidant capacity is insufficient to support its routine use. Antioxidant therapy is a potential option due to its theoretical benefit, data from preclinical studies, and lack of major side effects. Adjuvant therapy with antioxidants after surgical repair of varicocele may improve the outcome and is a potential area for further research.

Insight into oxidative stress in varicocele-associated male infertility: part 2

Varicocele, the leading cause of male infertility, can impair spermatogenesis through several pathophysiological mechanisms. Of these, current evidence suggests that oxidative stress is the central element contributing to infertility in men with varicocele, to which the testis responds by way of heat stress, ischaemia or production of vasodilators, such as nitric oxide. Surgical varicocele repair (varicocelectomy) is beneficial not only for alleviating oxidative stress-associated infertility, but also for preventing and protecting against the progressive character of varicocele and its consequent upregulations of systemic oxidative stress. However, antioxidant therapy in infertile men with surgically treated and those with untreated varicocele is poorly studied, and well-designed trials are needed.

The effect of micronized purified flavonoid fraction on the prevention of testicular pathologies in adolescent rats with experimentally induced varicocele

PURPOSE

We investigated the effect of micronized purified flavonoid fraction on the prevention of testicular pathologies following varicocele induction.

MATERIALS AND METHODS

A total of 66 adolescent (6-week-old) male Wistar rats were included in study. Rats were divided into 7 groups, including group 1--control, group 2--sham operation, group 3--left varicocele induced, group 4--varicocele induced, varicocelectomy done 4 weeks later and micronized purified flavonoid fraction administered for 4 weeks, group 5--varicocele induced and micronized purified flavonoid fraction administered for 8 weeks, group 6--varicocele induced and beginning 4 weeks later micronized purified flavonoid fraction administered for 4 weeks, and group 7--varicocele induced and varicocelectomy done 4 weeks later. Before sacrifice bilateral real-time testicular microvascular perfusion of all rats was measured using the PeriFlux System 5000 PF 5010 LDPM Unit (Perimed, Järfälla, Sweden). All testes were graded according to the Johnsen scoring system. To assess apoptosis caspase-3 levels were measured.

RESULTS

Testicular weight in group 3 was markedly decreased and the extent of seminiferous tubular damage was significantly increased compared with the other groups. Bilateral testicular blood flow and the number of apoptotic germ cells were greater in group 3. Significantly higher Johnsen scores and a meaningful decrease in the apoptotic index were detected in groups 4 to 7 compared with group 3.

CONCLUSIONS

We observed favorable effects of micronized purified flavonoid fraction on the regression of testicular damage secondary to varicocele.

Risk factors for progressive deterioration of semen quality in patients with varicocele

OBJECTIVE

To assess the risk factors for progressive deterioration of semen quality (PDSQ) in adult patients with varicocele.

METHODS

A total of 32 men with left varicocele and impaired semen quality (group 1) and 30 age-matched patients with left varicocele and normal semen quality (group 2) were recruited for the present study. All the subjects received conservative treatment, and the parameters for evaluation every 12 months included semen quality, peak retrograde flow (PRF) and spontaneous venous reflux by color Doppler ultrasonography, body mass index, serum concentration of follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, testicular volume and discrepancy, grade of varicocele, and scrotal temperature.

RESULTS

The mean follow-up time was 63.2 months (range 60-66). The patients in group 1 had a significantly greater PRF, lower testicular volume, greater testicular volume discrepancy, lower testosterone level, higher scrotal temperature, and greater follicle-stimulating hormone level than those in group 2 at first. The semen quality deteriorated in 28 subjects (87.5%) in group 1, but in only 6 patients (20%) in group 2 during follow-up. Furthermore, the 6 subjects with PDSQ in group 2 had greater PRF and scrotal temperature than those without.

CONCLUSION

The rate of PDSQ was significantly greater in the varicocele patients with an initially abnormal semen quality than in those with initially normal semen quality (87.5% vs 20%). Furthermore, the varicocele patients with initially normal semen quality who had greater PRF and scrotal temperature might have a greater risk of PDSQ.

Effects of micronised purified flavonoid fraction on pain, semen analysis and scrotal color Doppler parameters in patients with painful varicocele; results of a randomized placebo-controlled study

AIM

Aim of this study is to evaluate the effects of micronised purified flavonoid fraction (Daflon(®)) on pain, semen analysis and color Doppler parameters in patients with painful varicocele.

MATERIALS AND METHODS

Forty varicocele patients whom have normal sperm concentration (>20 million/ml) were involved in the study. The patients were divided into two groups such as Daflon (n = 20) and placebo (n = 20) group. Pain score, semen analyses and Doppler sonography were performed in all patients before and after the treatment.

RESULTS

In the first group, mean pain scores at 1, 3, 6 and 12 months were 1.80 ± 1.32, 1.15 ± 0.93, 1.05 ± 0.95 and 0.95 ± 0.89, respectively, all were significantly lower (P < 0.001 for each) than baseline (5.25 ± 1.07). While semen volume, total sperm count, sperm concentration and morphology were not changed significantly, the motility of sperm increased significantly (P = 0.015) due to decrease in grade 1 sperms at the 6th month in the first group. Reflux time of left spermatic vein during the Valsalva maneuver decreased significantly (P < 0.001).

CONCLUSIONS

Results of this study suggest the safety and efficacy of Daflon in the treatment of varicocele-associated pain. However, these results of the present study must be confirmed by randomized placebo-controlled studies by using different drug doses and durations before making any recommendation for the use of Daflon.