Testicular volume, scrotal temperature, and oxidative stress in fertile men with left varicocele

Role of varicocele repair in the era of assisted reproductive technologies: Lessons from 2000 cases of microsurgical varicocele repair

Backgrounds

In an era of advanced maternal age, there is less conclusive evidence regarding the treatment outcomes of varicocele repair for assisted reproductive technology (ART). Progress in basic research on varicocele is notable whereas there are many clinically relevant points to discuss.

Methods

Based on our experience with more than 2000 cases of microsurgical varicocele repair, we focused on the effectiveness of varicocele repair, pathophysiology, surgical approaches, contributions to ART, sperm DNA fragmentation, and varicocele-associated azoospermia in this review with the aim of identifying clearer directions for basic and clinical research on varicocele.

Results

Microsurgical low ligation for varicocele repair is expected to remain the gold standard for surgical therapy. Based on the findings from a number of systematic reviews and meta-analyses, negative opinions regarding the efficacy of microsurgical varicocele repair in male infertility treatment have become virtually nonexistent. However, the majority of evidence regarding surgical indications and effectiveness pertains to improvements in semen parameters or non-ART pregnancy rates.

Conclusions

Further understandings regarding to pathophysiology of varicocele will likely be gained through comprehensive genetic, transcriptomic, and epigenetic analyses using blood and testicular samples from humans and we hope to develop new diagnostic methods and pharmacotherapy.

Three-dimensional morphometry of the testis in dog using design-unbiased stereology

Testis is considered the main organ of the male reproductive system. Dogs are used as a suitable experimental model of testicular diseases in humans. From the veterinary aspect, several disorders have been reported to affect the testis in dogs. Thus, the objective of the present study was to investigate the morphometrical features of the dog testis using design-based stereology. The testes of six male dogs were used. Isotropic, uniform random sections were obtained and processed for light microscopy. Testicular total volume and the fractional volume of the seminiferous tubules, interstitial tissue and germinal epithelium were measured using the Cavalieri's estimator and the point counting system. Germinal epithelial surface area was estimated using test lines, and total length of seminiferous tubules was analysed using the counting frames. The total volume of testis was calculated 13.64 ± 1.94 cm3 . The relative volume fractions of the seminiferous tubules, interstitial tissue and germinal layer expressed as a percentage of total testicular volume were found to be 75.87 ± 6.11%, 23.68 ± 5.15% and 64.15 ± 4.82%, respectively. The surface area of the germinal layer was 915.25 ± 150.48 cm2 . The thickness of germinal layer was estimated to be 96.18 ± 10.72 μm. The total length of seminiferous tubules measured 290.8 ± 35.86 m. No statistical difference in investigated parameters was found between the left and right testes (p > 0.05). Our data might contribute to the male reproductive knowledge, help develop experimental studies in this field and possibly lead to advancement in the diagnosis and treatment of testicular diseases in the dog.

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 Oxidative Stress in Varicocele

According to the official statistics of the World Health Organization, at least 48 million couples and 186 million people suffer from infertility. Varicocele has been recognized as the leading cause of male infertility and can affect spermatogenesis and cause testicular and epididymal disorders through multiple diverse pathophysiological processes. Reactive oxygen species (ROS) produced by oxidative stress have been reconciled as an important pathogenic factor throughout the course of varicocele. Testis respond to heat stress, hypoxia, and inflammation at the cost of producing excessive ROS. High levels of ROS can lead to infertility not only through lipid peroxidation or DNA damage, but also by inactivating enzymes and proteins in spermatogenesis. This review studies the oxidative stress and its role in the pathophysiology and molecular biology of varicocele in the context of a decline in fertility.

Assessment of MUSASHI 1 and MUSASHI 2 expression in spermatozoa and testicular tissue

MUSASHI (MSI) family plays the main role in the spermatogenesis process. The purpose of this study was the assessment of sperm MSI1 and MSI2, and sperm functional tests in infertile men (n = 30) with varicocele and fertile men (n = 30). Furthermore, MSI1 and MSI2 proteins were assessed in testicular tissue of azoospermic men (n = 9) as well as epididymal spermatozoa and testis of mice. Expression of MSI1 and MSI2 was assessed at RNA and protein levels in human spermatozoa. Sperm concentration and motility were significantly lower, while abnormal sperm morphology, lipid peroxidation, DNA fragmentation and protamine deficiency were significantly higher in men with varicocele compared to fertile individuals. Any significant difference was not observed in the expression of MSI1 and MSI2 mRNA between the two groups. Unlike MSI1 protein that was not detectable in humans, the relative expression of MSI2 protein was similar in varicocele and fertile individuals. The expression level of both Msi1 and Msi2 proteins was also observable in mouse spermatozoa. No significant relationship was observed between sperm functional parameters with expression of these genes. The data of this study demonstrated that although MSI1 and MSI2 play important roles during spermatogenesis, their relative expression in spermatozoa was not affected by varicocele.

Contribution of pre-varicocelectomy color Doppler ultrasonography finding to surgery and its correlation with semen parameters

BACKGROUND

This study aimed to determine the contribution of color Doppler ultrasonography (CDUS) performed before varicocelectomy to the success of surgical treatment and to evaluate the correlation between CDUS findings and semen parameters.

METHODS

A total of 84 patients diagnosed with grade 3 left varicocele in our clinic between 2016 and 2018 were evaluated. The patients in whom the decision for varicocelectomy was based on only physical examination (PE) findings and abnormal semen analysis (SA) were defined as Group 1, while the patients undergoing varicocelectomy based on PE, CDUS and SA findings were defined as Group 2. The patients diagnosed with varicocele based on PE and CDUS findings who were included in a followup protocol due to normal semen parameters were defined as Group 3.

RESULTS

In Group 1, there was a total of 28 patients and the mean number of ligated internal spermatic veins was 4.53 (range, 2-10). In Group 2, there was a total of 30 patients and the number of ligated internal spermatic veins was 3.76 (range, 1-8). No statistically significant difference was found between Group 1 and 2 in terms of the number of internal spermatic veins ligated during varicocelectomy. No statistically significant correlation was found between semen parameters and the number of veins ligated during varicocelectomy in Group 1 and 2 and between semen parameters and CDUS findings group 2 and 3.

CONCLUSIONS

In patients with primary grade 3 varicocele, diagnosed by physical examination there is no need for additional imaging in primary cases.

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

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

Effect of varicocelectomy and/or mast cells stabilizer on sperm DNA fragmentation in infertile patients with varicocele

This study aimed to assess the effect of varicocelectomy and/or mast cells (MCs) stabilizer on sperm DNA fragmentation in infertile men with varicocele (Vx). Overall, 120 infertile patients were randomized to three equal treatment arms; patients that underwent varicocelectomy, patients on 1 mg ketotifen twice daily for three months, and patients that underwent varicocelectomy followed with 1 mg ketotifen twice daily for three months. These patients were subjected to history taking, clinical examination, semen analysis, and estimation of sperm DNA fragmentation index (DFI). After 3 months, all investigated groups showed significant improvement regarding the mean total sperm count, sperm concentration, total sperm motility, and sperm normal forms percentage compared with the pre-treatment data. As well, the mean sperm DFI was significantly improved compared with the pre-treatment data; in men that underwent varicocelectomy (34.6% vs. 28.3%), in men on MC stabilizer only (33.4% vs. 27.8%), and in men that underwent varicocelectomy followed by MC stabilizer (34.3% vs. 25.1%). Sperm DFI improvement percentages showed the highest improvement in men that underwent varicocelectomy followed with MC stabilizer compared with the other two groups (26.8% vs. 18.2%, 16.8%). Sperm DFI improvement percentages showed significant increases in the infertile patients with Vx grade III compared to Vx grade II in all investigated groups. It is concluded that in infertile men associated with Vx and high sperm DFI, surgical repair followed with MCs stabilizer significantly improve sperm DFI compared with either surgical repair or MCs stabilizer alone.

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

Background

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

Results

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

There was no significant difference between procedures on the sperm quality, pregnancy rate, and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (p = 0.002) and less postoperative pain (p = 0.007).

Conclusion

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

Relationship of spermatozoal DNA fragmentation with semen quality in varicocele-positive men

The aim of the study was to assess the semen quality and levels of spermatozoal nuclear DNA fragmentation in subfertile subjects clinically diagnosed with varicocele, subfertile subjects without varicocele and healthy fertile controls. Semen samples were obtained from 302 subjects. Of them, 115 were healthy fertile controls having normal semen characteristics, 121 subfertile men diagnosed with varicocele, both, clinically and on ultrasonography, while 66 subjects were subfertile with no varicocele. Spermatozoal concentration, percentage motility, morphology and DNA fragmentation were measured. In the study population, deterioration in semen quality-decreased spermatozoal concentration, percentage motility and normal morphology was seen in subfertile subjects, especially with varicocele. Highest spermatozoal DNA fragmentation was observed in varicocele-positive subjects as compared with varicocele-negative subjects and healthy fertile controls. Significant negative correlation was seen between spermatozoal DNA fragmentation and concentration (r = -0.310), motility (r = -0.328) normal morphology, WHO method (r = -0.221) and Tygerberg strict criteria (r = -0.180) in the varicocele-positive subfertile subjects. In conclusion, this study suggests existence of a negative relationship between spermatozoal DNA fragmentation and semen quality in varicocele-positive subfertile subjects.

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.

Insight into oxidative stress in varicocele-associated male infertility: part 1

Varicocele is recognized as the leading cause of male infertility because it can impair spermatogenesis through several distinct pathophysiological mechanisms. Current evidence supports oxidative stress as a key element in the pathophysiology of varicocele-related infertility, although these mechanisms have not yet been fully described. Measurement of the reactive oxygen species and other markers of oxidative stress, including the levels of the antioxidant enzymes catalase and superoxide dismutase, can provide valuable information on the extent of oxidative stress and might guide therapeutic management strategies. The testis can respond to varicocele-associated cell stressors, such as heat stress, ischaemia or production of vasodilators (for example, nitric oxide) at the expense of the generation of excessive reactive oxygen species. These responses have their own implications in exacerbating the underlying oxidative stress and on the subsequent infertility.

Selenium, copper and zinc in seminal plasma of men with varicocele, relationship with seminal parameters

Varicocele has been associated with decrease in seminal parameters. Selenium (Se), copper (Cu), and zinc (Zn) are trace elements essential for normal spermatogenesis of mammals and play a critical role as antioxidant defense system enzymes. Se, Cu, and Zn are associated with sperm quality in fertile and infertile men. However, there is little information about Se, Cu, and Zn concentrations in semen in patients with varicocele and its association with seminal parameters. The purpose of this study was to determine the concentrations of Se, Cu, and Zn in semen of patients with varicocele and the relationship with seminal parameters. Total Reflection X-Ray Fluorescence was used for the fist time in the seminal fluid analysis. The concentration of selenium in men with varicocele was smaller than the normozoospermic group, while no differences were observed for both concentrations of zinc and copper. A significant positive correlation between zinc and selenium concentration was observed. Selenium in seminal plasma correlates with a good spermatozoa concentrations, motility, and morphology. Additionally, a significant positive correlation was observed between zinc levels and sperm count. In conclusion, a decrease in selenium concentration was associated with detriment of seminal parameters. A study should be conducted to evaluate the benefits of both zinc and selenium supplementation to improve seminal parameters in patients with varicocele.

Nationwide survey to evaluate the prevalence of varicoceles in South Korean middle school boys: a population based study

OBJECTIVE

We carried out a nationwide epidemiological study to evaluate the prevalence and effect of varicoceles on testicular volume in South Korean adolescents. We also investigated the correlation between varicoceles and body mass index (BMI).

METHODS

In this prospective study, physical examinations were carried out to assess the presence and severity of varicoceles in middle school boys from six regions of South Korea. Testicular volume, height and weight of all boys were measured. The prevalence of varicoceles was assessed. The associations between age, testicular volume, BMI, and the presence and severity of varicoceles were examined.

RESULTS

A total of 1938 boys with a mean age of 14.1 years (range 13-16 years) were screened. A varicocele was found on the left side in 295 (15.2%) boys and on the right side in 8 (0.4%) boys. Bilateral varicoceles were found in 17 (0.9%) individuals. Of the subjects with a left varicocele, 151 (51.2%), 80 (27.1%) and 64 (25.1%) boys had a grade 1, 2 or 3 varicocele, respectively. The prevalence of varicoceles did not increase with age. The proportion of boys with testicular size discrepancies increased with the severity of the varicocele. After adjusting for age, BMI had a negative correlation with the presence of varicoceles.

CONCLUSIONS

The prevalence of varicoceles in South Korean middle school boys is 16.5%. The presence of varicoceles seems to have a negative effect on testicular growth. BMI has a significant inverse relationship with the occurrence of varicoceles.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.