Differences in the clinical characteristics of primarily and secondarily infertile men with varicocele

Microsurgical varicocelectomy efficacy in treatment of men with primary and secondary infertility (retrospective study)

INTRODUCTION AND OBJECTIVES

Varicocele is the most common treatable cause of male infertility. The study aimed to compare varicocelectomy efficacy in men with primary (PI) and secondary infertility (SI).

PATIENTS AND METHODS

Medical records of 100 men suffering from PI and SI and having varicocelectomy at the Republican Specialized Scientific-Practical Medical Center of Urology were retrospectively selected and analyzed. Patients were divided into 2 groups. Group I included 58 men with PI and Group II 42 men with SI. Preoperative clinical characteristics and semen parameters before and after varicocelectomy were analyzed and compared between groups.

RESULTS

Analysis revealed that the mean age of patients of group I was significantly lower (p<0.001) and the duration of infertility was accurately shorter (p<0.01) than those of group II. Main semen parameters increased significantly in group I (e.g., sperm concentration increased by 50%, from 62.2 ± 8.7 to 93.5 ± 10.0 M/ml, and total motile sperm count increased by 113%, from 76.7±17.1 to 163.4±27.8 M p<0.05), while in group II only rate of progressive motile sperm increased significantly (by 107%, from 13.5± .6 to 28.0±5.2% p<0.05). We identified a significant difference in varicocelectomy efficacy between group I and group II in change of total motile sperm count (by 113% vs 74% respectively, p<0.01). We also revealed a discrepancy between groups in correlation ratio (r) between initial and post-surgical percent of progressive motile sperm.

CONCLUSIONS

Patients with SI were older and had longer infertility period. Varicocelectomy resulted in significant semen parameters improvement in patients with PI. In patients with SI, only a percent of progressively motile sperm improved significantly. It indicates that advanced male age and long infertility duration may have a negative impact on varicocelectomy success.

A case of hypogonadtropic hypogonadism due to hypophysitis discovered by secondary male infertility

Introduction

The main causes of secondary male infertility are varicocele and aging. It is rarely caused by adult-onset hypopituitarism. The onset of hypopituitarism is often due to brain tumors, trauma, surgery, or congenital disorders.

Case presentation

A 29-year-old man was admitted to the hospital with complaints of decreased libido and semen volume, which lasted for 4 months. He had no abnormalities in adolescence and has a 2-year-old child. Blood tests showed low luteinizing hormone and follicle-stimulating hormone, and semen tests showed azoospermia. Magnetic resonance imaging T1-weighted images showed swelling and enhancement effect of the pituitary gland, and lymphocytic hypophysitis was suspected. After an Insulin-thyroid-stimulating hormone releasing hormone-luteinizing hormone-releasing hormone test, a decrease in luteinizing hormone/follicle-stimulating hormone secretion was considered. We diagnosed hypogonadotropic hypogonadism due to lymphocytic hypophysitis. Currently, the patient is being treated with a hormone replacement therapy.

Conclusion

We experienced a case of hypogonadotropic hypogonadism due to lymphocytic hypophysitis discovered by secondary infertility.

Varicocele is underdiagnosed in men evaluated for infertility: Examination of multi-center large-scale electronic health record data

Varicocele is the most common reversible cause of male infertility, affecting up to 20% of healthy men and 40% of men with primary infertility. The objective of this study was to investigate the prevalence of varicocele in men evaluated for infertility, and to determine rates of subsequent varicocele repair. Since reproductive endocrinologists are the first specialists seen for male infertility care in North America, we hypothesized that varicocele would be underdiagnosed when compared to its reported prevalence among men with infertility. TriNetX, a large, multicenter electronic health record (EHR) database was queried to establish a cohort of all men (above 18 years of age) with a diagnosis of male infertility. This cohort was used to identify those with ensuing varicocele diagnosis. Men who received varicocelectomy or venous embolization after a diagnosis of varicocele were then identified. Out of 101,309 men with a diagnosis of male infertility in the network, only 9768 (9.6%) had a diagnosis of varicocele. Mean age of men with varicocele was 34. Varicocelectomy or venous embolization was performed in 1699 (20.2%) and 69 (0.76%) of men with varicocele, respectively. In this cross-sectional EHR study, varicocele was underdiagnosed in men evaluated for infertility when compared with prior epidemiological studies.

Association of Alcohol Intake and Semen Parameters in Men With Primary and Secondary Infertility: A Cross-Sectional Study

Alcohol consumption has commonly been associated with semen parameters. However, the association between alcohol intake and semen parameters in primary and secondary infertile men remains unclear. In this study, 776 infertile men from China were grouped according to alcohol intake: abstainers, moderate drinkers (<9 units/week, up to approximately 100 g of ethanol) and heavy drinkers (≥9 units/week). Semen parameters, including semen volume, sperm concentration, total sperm count, progressive motility and normal morphology were investigated. Alcohol consumption and other lifestyle factors were assessed by questionnaire. Logistic regression models were applied. There was no significant association between alcohol consumption and semen parameters in men with primary infertility. Smaller testis volumes and lower sperm concentrations were found among moderate and heavy drinkers in the secondary infertility group than among abstainers. After adjustment for potential confounders, men with secondary infertility and heavy alcohol consumption had a higher risk of abnormal sperm concentrations (OR = 3.72; 95% CI, 1.04, 13.37). These findings suggest that alcohol intake may decrease sperm concentrations in men with secondary infertility, whereas no association was found in men with primary infertility. It may be beneficial for clinicians to advise male patients with secondary infertility who are seeking fertility treatment to avoid heavy alcohol consumption.

Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men

In a prospective study, the outcomes of microsurgical varicocelectomy in men with primary versus secondary infertility were compared. Ninety-two infertile men with a varicocele were included. They were classified into those with primary infertility (n = 57) and secondary infertility (n = 35). Clinical data, semen parameters and scrotal ultrasound finding were available for all patients and microsurgical varicocelectomy was performed on all of them. Spontaneous pregnancy rates and improvement in semen parameters in those men with primary versus secondary infertility were recorded 1 year after surgery. Preoperatively, there was no significant difference in the mean semen parameters in both groups (p > 0.05) and the mean semen parameters showed no significant difference between men with primary and secondary infertility. After microsurgical varicocelectomy, the mean semen parameters improved significantly in both group (p < 0.05 for each), but there were no significant difference in mean semen parameters between men with primary versus secondary infertility (p > 0.05 for each). After adjustment for patient and partner ages, the pregnancy rate at the end of the follow-up period did not significantly differ between the primary (24/57, 42.1%) and secondary (11/35, 31.4%) infertility group (Pearson's Chi-squared = 1.05). We concluded from this study that semen parameters and pregnancy rates after microsurgical varicocelectomy were similar between men with primary and secondary infertility.

Significant predictive factors for subfertility in patients with subclinical varicocele

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

Epidemiology of varicocele

Varicocele is a common problem in reproductive medicine practice. A varicocele is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, especially regarding its effect on male infertility. We have conducted a systematic review of studies evaluating the epidemiology of varicocele in the general population and in men presenting with infertility. In this article, we have identified some of the factors that can influence the epidemiological aspects of varicoceles. We also recognize that varicocele epidemiology remains incompletely understood, and there is a need for well-designed, large-scale studies to fully define the epidemiological aspects of this condition.

Left-sided grade 3 varicocele may affect the biological function of the epididymis

OBJECTIVE

Varicocele is present in approximately 30-40% of men evaluated for infertility and in 10-20% of the general male population, but the association between varicocele, compromised semen quality and male infertility remains unclear. This indicates that varicocele may impair spermatogenesis or in some other way mitigate sperm quality. Better understanding of criteria for the selection of men who will benefit from varicocele repair would improve the clinical management of men with impaired semen quality and varicocele.

MATERIAL AND METHODS

To further understand the effect of varicocele repair by embolization in men with grade 3 varicocele, 50 men referred for infertility with varicocele were evaluated before and after embolization.

RESULTS

There was a significant improvement in total sperm count (25.5 ± 4.7 million to 78 ± 11 million, p < 0.001) and sperm motility (slowly and rapidly progressive) (31.5 ± 2.9% to 45 ± 2.5%, p < 0.001) after spermatic vein embolization, comparing baseline to 3 month post-treatment follow-up data. Furthermore, alpha-glucosidase (specific epididymis-derived protein) increased from 61.7 ± 5.7 U to 84.7 ± 7.0 U (p < 0.05) and sperm droplets decreased from 14.2 ± 1.5% to 11.0 ± 1.0% (p < 0.05).

CONCLUSION

The results indicate improved epididymal function and suggest that left-sided grade 3 varicocele may affect the epididymis in addition to effects on the testis.

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.