Varicocelectomy before assisted reproductive technology: are outcomes improved?

Impact of Varicocele Repair on Assisted Reproductive Technique Outcomes in Infertile Men: A Systematic Review and Meta-Analysis

PURPOSE

In this systematic review and meta-analysis, we investigated assisted reproductive technology (ART) success in infertile men with clinical varicocele and abnormal semen parameters who underwent varicocele repair (VR) before the ART procedure as compared to those who did not.

MATERIALS AND METHODS

A comprehensive search of the Scopus, PubMed, Embase, and Cochrane Library databases was conducted using a specific query string to identify studies examining the impact of VR on ART outcomes, including fertilization rate, clinical pregnancy, pregnancy loss, and live-birth rate, until October 2023. Outcomes were analyzed based on the type of ART. Studies on VR in infertile men with non-obstructive azoospermia and those who underwent ART only due to female factor infertility were excluded from the study.

RESULTS

Out of 1,554 articles reviewed, only 9 met the inclusion criteria for the study. All the included articles were observational studies. The variability in study quality in the included literature resulted in a moderate overall risk of bias. Data analysis showed that for intrauterine insemination, there was no difference in the clinical pregnancy rate (odds ratio [OR] 1.01, 95% confidence interval [CI]: 0.42, 2.45; p=0.97). However, for intracytoplasmic sperm injection (ICSI), men with VR showed a significant improvement in fertilization rate (mean difference 10.9, 95% CI: 5.94, 15.89; p<0.01), clinical pregnancy rate (OR 1.38, 95% CI: 1.07, 1.78; p=0.01) and live-birth rate (OR 2.07, 95% CI: 1.45, 2.97; p<0.01), compared to men who did not undergo VR.

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that VR has a positive impact on pregnancy and live birth rates after ICSI. However, biases like small sample sizes and heterogeneous populations highlight the need for larger, well-designed prospective studies to validate these findings.

[Varicocele and male infertility]

BACKGROUND

Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association française d'urologie (AFU) Comité d'andrologie et de médecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional information. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances.

METHODS

Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023.

RESULTS

Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery.

CONCLUSION

Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.

[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

A comparison of loupe-assisted and non-loupe-assisted subinguinal varicocelectomy

Introduction

Varicocele is a treatable aetiology of male infertility. Magnification with surgical loupe has been associated with improved outcome and reduced morbidity than the conventional technique without magnification.

Objective

To compare the outcomes of two techniques of subinguinal varicocelectomy, with a surgical loupe and without.

Patients and Methods

This was a prospective randomised hospital-based study. Forty-six patients were randomised to two arms - Group A: loupe-assisted subinguinal varicocelectomy (LASV) and Group B: open subinguinal varicocelectomy without Loupe (OSV). They all had their semen and hormonal parameters compared preoperatively and at 3 and 6 months postoperatively. Post-operative complications were also assessed. P < 0.05 was considered statistically significant.

Results

The mean age was 38.28 ± 4.55 years with a range of 27-46 years. The mean age in Group A was 37.35 ± 4.68 and 39.22 ± 4.33 years in Group B. There was an improvement in motility, sperm count and concentration in both the groups at 3 and 6 months (P < 0.05). However, there was no difference in these parameters on comparison of the two groups at 3 and 6 months (P > 0.05). Follicle-stimulating hormone decline was significant in the OSV group at 3 and 6 months, P = 0.010 and 0.021, respectively. There was no difference in other hormonal parameters both at 3 and 6 months (P > 0.05). The pregnancy rate in each arm of study was 4.3%. All complications occurred in Group B.

Conclusion

Both techniques resulted in improvement in seminal fluid parameters. All complications occurred in the arm that had subinguinal varicocelectomy without loupe. Loupe-assisted subinguinal varicocelectomy is safe and effective.

Nomogram for Predicting Semen Parameters Improvement after Microscopic Varicocelectomy in Infertile Men with Abnormal Semen Parameters

Objectives: Information on the prediction of improved semen parameters following varicocelectomy is scarce and mostly contradictory. Therefore, we developed and validated a nomogram to predict whether abnormal semen parameters in infertile men could improve following microscopic varicocelectomy (MSV). Methods: From January 2018 to December 2021, 460 consecutive patients who underwent MSV were included. Of them, 336 patients as a development cohort at the Xiang Hua institution. As a validation cohort, Hu Nan Center (124 patients) was used. Clinicopathologic patient information was recorded. The likelihood ratio test using Akaike’s information criteria was employed as the stopping rule, and multivariate logistic regression was utilized to create a prediction model with regression coefficients. The effectiveness of this prediction model was evaluated based on its ability of discrimination, calibration, and clinical utility. Results: The initial total progressively motile sperm count (TPMSC) and vein diameter were predictors of this model. The model demonstrated strong discrimination for the validation cohort, with an area under the receiver operating characteristic (AUROC) of 0.925 (p < 0.001), and strong calibration (unreliability test, p = 0.522). The decision curve study proved the model’s clinical applicability. Conclusion: According to our research, the improvement of semen parameters in infertile men following MSV was significantly predicted by greater vein diameter and higher initial TPMSC. This nomogram aids in individualized decision-making on the varicocele preoperative treatment plan and may help to enhance the therapeutic result.

Nomogram for predicting spontaneous pregnancy after microscopic varicocelectomy in infertile men with normal hormone

INTRODUCTION

The current challenge for the treatment of varicocele is identifying patients who could benefit the most from surgery. We aimed to develop and validate a nomogram for predicting spontaneous pregnancy following microscopic varicocelectomy in infertile men, based on a large cohort.

METHODS

Two hundred eighty-two consecutive patients who underwent microscopic varicocelectomy from January 2018 to December 2020 were enrolled as participants in the study. Xiang Hua center (206 patients) as a development cohort. Hu Nan center (76 patients) as a validation cohort. Patient clinicopathologic data were recorded. Multivariate logistic regression was used to build a predictive model with regression coefficients. Then, backward stepwise selection was applied, and the likelihood ratio test with Akaike's information criterion was used as the stopping rule. The performance of this predictive model was assessed for discrimination, calibration, and clinical usefulness.

RESULTS

Predictors of this model included the age of female partners, diameter of veins, initial and increased total progressively motile sperm count. The model demonstrated good discrimination with an AUROC of 0.925 (p < 0.001) and calibration (Unreliability test, p = 0.522) in the validation cohort. Furthermore, the model was clinically useful, according to decision curve analysis.

CONCLUSIONS

Our findings indicated that younger female partners, larger diameter of veins, higher initial and increased total progressively motile sperm count were significant predictors of spontaneous pregnancy in infertile men, post microscopic varicocelectomy. This nomogram may assist in individual decision-making on the treatment strategy of varicocele preoperatively and improve the treatment outcome.

Do sclero-embolization procedures have advantages over surgical ligature in treating varicocele in children, adolescents and adults? Results from a systematic review and meta-analysis

We aimed to systematically review complications, and recurrence rate of varicocele treatment by comparing the surgical ligature versus sclero-embolization techniques in children, adolescents and adults. The secondary outcomes were the evaluation of semen parameters and spontaneous pregnancy rate in adults. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05. Twenty studies were included. Incidence of postoperative hydrocele was significantly higher in the surgical ligation group (OR 3.06 95% CI 1.06-8.88, p = 0.04). Incidence of postoperative orchiepidydimitys was significantly higher in sclero-embolization group (OR 0.26 95% CI 0.08-0.85, p = 0.02). Presence of normal spermatozoa was significantly higher sclero-embolization group compared with the surgical ligature group (MD 2.54% 95% CI 0.43-4.65, p = 0.02). No difference was found in overall complications, wound infection, testis pain, surgical site hematoma, total sperm count, sperm motility, pregnancy and recurrence rate. This review confirms that current data does still not support the superiority of one type of treatment over other ones.

The Effect of Sperm DNA Fragmentation on Male Fertility and Strategies for Improvement: A Narrative Review

The inability to conceive due to male infertility is a complex issue with a wide variety of etiologies. Sperm DNA damage can be both a barrier to natural pregnancy and successful assisted reproductive technology (ART). The aim of this narrative review was to describe and highlight the effects of sperm DNA fragmentation and the most recent data on various treatment strategies to decrease sperm DNA damage. Finally, we proposed a management algorithm for couples undergoing ART with increased sperm DNA fragmentation.

Prediction of reproductive function recovery after microsurgical varicocelectomy in men from infertile couples: Clinical and laboratory predictors

The objective was to reveal predictors for fertility recovery after varicocelectomy in subfertile men. This retrospective study recruited 93 men with clinical varicocele and pathozoospermia who underwent microsurgical varicocelectomy. Stepwise discriminant analysis was performed to identify predictors of spontaneous pregnancy (SP) after surgery. 'Clinically significant improvement' (CSI) following varicocelectomy was defined as an increase in total progressively motile sperm count (TPMSC) by at least 12.5 million (calculated from WHO-2010 reference values). 52% of patients showed CSI, and 28% reported SP after surgery. Patients who reported SP (group II), compared to that remained infertile (group I), were younger (27.3 ± 2.9 versus 30.2 ± 4.2 years; p < .01), had less infertility period (24.1 ± 14.0 versus 44.4 ± 32.9 months; p < .05) and had initially higher TPMSC (median (25% -75%) = 34 (11-67) versus 9.5 (0-33) mln; p < .05). The stepwise discriminant analysis showed that male age (coefficient value = -0.157), total sperm motility (0.024) and postoperative increase in TPMSC (0.010) were the significant predictors of SP. The predictive ability, sensitivity and specificity of the discriminant function were 84%, 87%, 76% respectively. This algorithm can be recommended after varicocelectomy in decision-making on natural conception or the ART protocols usage.

Improvement of sperm morphology after surgical varicocele repair

Background

A causative relationship between varicocele and impairment of semen quality has been largely investigated in the context of male infertility, although its clinical benefit remains controversial.

Objective

To investigate the effect of varicocele correction on detailed morphologic microscopic semen parameters in a large homogeneous cohort of patients and to evaluate which factors could predict semen improvement after the surgical treatment.

Materials and methods

An observational, retrospective cohort study was carried out including all patients undergoing surgical treatment for varicocele from September 2011 to March 2020 in the same clinical centre. Enrolled males performed at least one semen analysis before and one after surgical varicocele correction. Primary outcome was the detailed morphologic microscopic sperm evaluation. Secondary outcomes were conventional semen analyses.

Results

A total of 121 males (mean age 24.6 ± 6.1 years) were enrolled. Using detailed morphologic microscopic sperm evaluation, a significant morphological improvement was recorded, with a reduction in head and tail abnormalities. Moreover, a significant increase in sperm concentration (p = 0.015) and percentage of progressive and total motility (p = 0.022 and p = 0.039) were observed after surgery. The multivariate logistic analysis identified the ultrasonography varicocele degree before surgery as a main predictor of the sperm concentration improvement (p = 0.016), with the highest improvement for varicocele of I and II degree.

Discussion

For the first time, the detailed morphologic microscopic sperm evaluation highlights a relevant reduction in sperm abnormalities after varicocele surgery, showing its potential application in clinical practice.

The Comparison of Resistance Index of Testicular Artery Using Color Doppler Ultrasound in Infertile Men Undergoing Varicocelectomy

Background:

Varicocele is one of the leading causes of infertility in men. Resistance index (RI) in testis is a parameter indicating parenchymal perfusion and microvascular functions. Increased RI in the testis of patients with varicocele might be a sign of impairments in microvascularization and a significant decrease in testicular perfusion. In the present study, RI in capsular and intraparenchymal testicular arteries was evaluated in patients with varicocele who underwent varicocelectomy.

Methods:

This prospective cohort study was performed in 2019–2020 in Guilan, Iran. Sixty-six patients were included. Semen analysis was also done before surgeries. Patients with at least one disorder in semen analysis entered the study. RI in testicular arteries was measured by an experienced radiologist before surgeries. Six months after varicocelectomy, all patients underwent the same semen analysis and ultrasound imaging. Data were analyzed using SPSS software. The tests for analysis included McNemar Test and Wilcoxon and p<0.005 was considered as the significance level.

Results:

According to the results, 42 patients (63.6%) had positive changes in sperm analysis after surgeries. Sperm analysis showed a significant increase in number, concentration, morphology, and motility of sperm after surgeries (p<0.001). Further measurements of capsular and intratesticular RI in all patients also indicated a significant decrease (p<0.001).

Conclusion:

Increased RI might be associated with impaired microperfusion in testis followed by impairments in semen. Moreover, mean capsular and intratesticular RI in patients decreased after surgeries and this decrease was significantly more in patients who had improvement in their semen parameters.

Recent advances and controversies in diagnosing and treating male infertility

Interest in male infertility has increased, as it plays an important role in up to 50% of couples struggling with infertility, which is an estimated 48.5 million couples globally. Despite recent advances, diagnosing and treating male infertility remain a significant clinical challenge owing to complex multifactorial pathways and the diversity of treatment options. This review will assess current controversial topics on male infertility such as the use of home-based semen testing, management of subclinical varicocele, and recent advances in the field of sperm proteomics.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

Early male aging or poor clinical consideration for males in IVF centers? An original study

The Italian law 40/2004 allows the use of assisted reproduction techniques only if there are no other effective therapeutic approaches to overcome infertility. According to article 4 paragraph 1, the impossibility of removing the otherwise impeding causes to achieve a pregnancy must be ascertained before the couple undergoes assisted reproduction techniques. On this premises, we sought to evaluate the percentage of couples who underwent or were addressed to assisted reproduction techniques despite a known and potentially treatable male infertility factor in fertility centers in the city of Catania, Italy. To accomplish this, andrologists, urologists and endocrinologists were asked to report the number of couples already addressed to assisted reproduction techniques which they counseled in the trimester April-June 2018 having a under 35-year-old female partner and at least one among the following untreated conditions: (A) oligoasthenoteratozoospermia and FSH <8 mIU/ml, (B) third-degree varicocele (mono or bilateral form), and (C) leukocytospermia or urogenital infections. Of the 320 enrolled couples, 75 (23%) met the criterion A, 45 (14%) the criterion B, and 62 (19%) the criterion C. More than a half couples were addressed to assisted reproduction techniques despite a potentially treatable male infertility factor.

External validation of the post-varicocele repair semen analysis nomogram to predict total motile sperm count: A multicenter study

Total motile sperm count is an important parameter for predicting the probability of natural pregnancy. We have externally validated the Samplaski's post-varicocele repair semen analysis nomogram to confirm the predictive accuracy of total motile sperm count. A total of 300 patients who had undergone varicocelectomy between July 2016 and July 2019 from 4 treatment centres were included in this validation cohort study. The predictive performance of the externally validated nomogram was revealed by applying the Pearson correlation coefficient (R = 0.328; 95% confidence interval (CI) 0.220-0.435; p < .001). Compared to Samplaski's nomogram result (R = 0.581; 95% CI 0.186-0.729), our study also revealed a statistically significant rate. However, it had a relatively lower correlation coefficient rate. Notably, the predicted total motile sperm count was lower than the observed post-varicocelectomy total motile sperm count. The calibration plot revealed that the discrepancy between the predicted and observed total motile sperm count was plausible. However, it had low explanatory power in this nomogram model. This validation study demonstrates that the post-varicocele repair Samplaski's nomogram predicts a relatively lower total motile sperm count than the observed count.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Varicocele Repair Prior to Assisted Reproductive Technology: Patient Selection and Special Considerations

Clinical varicoceles are one of the most commonly identified physical exam abnormalities in men presenting with infertility. Clinical varicoceles can cause impaired spermatogenesis and surgical correction can improve semen parameters in select men. Increasingly, andrologists are performing varicocele repairs prior to intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) to boost male fertility potential. In this review, we evaluated the available literature 1) to determine if varicocelectomy prior to IUI or assisted reproductive technologies proved to improve sperm production or pregnancy outcomes; and 2) to identify who may be the ideal candidate for pre-IUI/ART varicocelectomy. Overall, few studies have explored this topic and little can be concluded about the impact of varicocelectomy prior to IUI. The evidence, however, does support that correcting a clinical varicocele can increase pregnancy outcomes in couples who plan to pursue IVF or ICSI. When selecting patients for varicocelectomy prior to IUI or ART, clinicians should evaluate female age as improvement in semen parameters can take 6 months after varicocelectomy and this duration of time may be deleterious in cases of advanced maternal age when each cycle becomes increasingly important. Overall, the currently limited literature regarding clinical varicoceles correction demonstrates that pregnancy rates can be increased when comparing patients who have undergone varicocelectomy prior to ART with those who had clinical varicocele but did not undergo surgery.

Microsurgical varicocelectomy effect on sperm telomere length, DNA fragmentation and seminal parameters

Varicocele is one of the main causes of male infertility and microsurgical varicocelectomy (MV) seems to be the best procedure for its repair and to reduce testicular oxidative stress (ROS). As ROS causes guanine modifications, we postulated that DNA damage could be more intense in telomeres due to their G-rich nature. We studied the effect of MV on sperm telomere length (TL), single- and double-strand DNA fragmentation (ssSDF and dsSDF) and seminal parameters. Sperm telomeres from 12 fertile donors and 20 varicocele patients before and nine months after MV were labelled using FITC-PNA qFISH (a new method to obtain absolute TL from relative fluorescence intensity using FITC-fluorescent spheres). Both ssSDF and dsSDF were analysed using the alkaline and neutral Comet assays, respectively. The results showed that varicocele and MV had no effect on TL. Seminal parameters, ssSDF and dsSDF of varicocele patients were altered. Although these parameters improved after MV, values did not reach those seen in fertile donors. A good estimation of absolute TL was developed based on FITC-fluorescent spheres. The results showed that TL is not affected by varicocele or surgery. However, MV is able to partially reduce altered seminal parameters, ssSDF and dsSDF values in varicocele patients.

Left spermatic vein reflux after varicocele repair predicts pregnancies and live births in subfertile couples

PURPOSE

Varicocele repair (VR) is proposed to improve fertility in subfertile couples with a poor semen quality. We explored whether the disappearance of a left continuous spermatic venous reflux (SVR) at scrotal colour-Doppler ultrasound (CDUS), an objective evidence for a VR, is predictive for improved fertility outcome in subfertile couples.

METHODS

VR was performed by left internal spermatic vein sclero-embolisation in 88 males seeking a consultation for subfertility. Semen analysis and scrotal CDUS were evaluated before and 6 months after VR. Serum levels of FSH and total testosterone (TT) were obtained at baseline. Telephone interview was used to obtain information about fertility outcome. Significant predictors of pregnancy and live births, selected by univariate analyses, were included into multiple logistic regression models to assess independent associations.

RESULTS

At the adjusted model, independent significant predictors of pregnancy after VR were a disappeared SVR at CDUS (OR = 5.5, 97.5% CI 2.01-15.4; p = 0.0009) and an improved sperm total motile count (TMC) (OR = 5.5, 97.5% CI 1.4-27.9; p = 0.02). Even live births were independently associated with both disappeared left SVR at CDUS (OR = 4.3, 97.5% CI = 1.6-11.8; p = 0.003) and improved TMC after VR (OR = 4.8, 97.5% CI 1.3-24.2; p = 0.02).

CONCLUSION

The still controversial effect of varicocele repair on fertility in subfertile couples may reside on the undefined objective methods to document a successful VR and its effect on couple fertility. The disappearance of a continuous left SVR at CDUS after VR was the objective best predictor for subsequent improved fertility in subfertile couples.

Semen parameter improvements after microsurgical subinguinal varicocele repair are durable for more than 12 months

INTRODUCTION

Varicoceles account for the most common correctable cause of male infertility, with varicocele repair leading to improvements in semen quality. However, there is little evidence to establish the durability of varicocele repair. We analyzed the durability of improvements in postoperative semen parameters following microsurgical subinguinal varicocele repair.

METHODS

We evaluated all men who underwent microscopic subinguinal varicocelectomy from 2015-2019. Patients were included if they desired fertility and had a followup of at least 12 months. We assessed the baseline characteristics of these patients, as well as semen volume, total motile sperm count (TMSC), concentration, percent motility, and morphology. Semen parameters were analyzed at baseline (preoperative) and at approximately three months and ≥12 months postoperatively.

RESULTS

Of 105 men who underwent varicocelectomy, 18 men had a followup of at least 12 months. These men presented with median age of 34.5 (27-38) years for a median followup duration of 14.5 (13-22.5) months. TMSC levels increased from 6.4 (1.1-24.5) million at baseline to 11.1 (2.4-38.4) million at approximately three months and remained similar at 12.5 (1.6-31.5) million at ≥12 months. The study is limited by its retrospective nature and limited sample size.

CONCLUSIONS

Microscopic subinguinal varicocele repairs can result in durable improvements of semen quality beyond one year, as demonstrated by upgrade in median TMSC. Further studies should be performed to confirm our findings.

Effects of Varicocele Treatment on Sperm Conventional Parameters: Surgical Varicocelectomy Versus Sclerotherapy

INTRODUCTION

Varicocele is often associated with impaired sperm parameters. Different procedures have been developed for varicocele treatment. The aim of this study was to evaluate the effects of varicocele treatment on conventional sperm parameters.

MATERIALS AND METHODS

We compared two different techniques of intervention: surgical varicocelectomy and sclerotherapy. We also evaluated the number of varicocele recurrences and the pregnancy rate. We included 102 patients (mean age 29.8 ± 0.8 years) with ultrasound diagnosis of varicocele. We excluded patients whose ultrasound evaluation and/or sperm parameters were not known before and after varicocele correction. We divided the patients (excluding 8 with azoospermia) into two subgroups: surgical varicocelectomy (n = 44) and sclerotherapy (n = 50). For each patient, we compared conventional sperm parameters before and after varicocele correction.

RESULTS

After varicocele correction, we found a significant improvement in sperm concentration, total count and total motility. Considering the two subgroups, baseline sperm parameters did not differ significantly. Sperm concentration and total count increased significantly after varicocele correction by varicocelectomy. Varicocele correction by sclerotherapy resulted in a significant increase in sperm concentration, progressive and total motility. We found varicocele recurrence in 32% of patients who underwent varicocelectomy and in 19.7% of patients undergoing sclerotherapy. The pregnancy rate was higher after sclerotherapy (28%) than after surgical varicocelectomy (13%).

CONCLUSION

Varicocele treatment must be recommended when other causes of infertility have been treated. Our results suggest the use of sclerotherapy for varicocele repair.

LEVEL OF EVIDENCE

2 b.

Treating varicocele in 2018: current knowledge and treatment options

PURPOSE

Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein. The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In this review, the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in pediatric/adolescent subjects.

METHODS

We conducted a Medline and a PubMed search from 1965 to 2018 to identify publications related to varicocele clinical aspects, treatment procedures and treatment outcomes. Keywords used for the search were: "varicocele", "varicocelectomy", "sclerotherapy", "male infertility", "subfertility", and "semen abnormalities".

RESULTS

Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach.

CONCLUSIONS

Varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies.

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.

The Impact of Microsurgical Repair of Subclinical and Clinical Varicoceles on Total Motile Sperm Count: Is There a Difference?

OBJECTIVE

To determine if subclinical varicocele repair produces similar results to palpable varicocele repair.

METHODS

Retrospective review was performed on 190 infertile men who underwent a microsurgical varicocele repair by two surgeons from 2009 to 2017. Improvement in total motile sperm count (TMC) that enables men limited to in vitro fertilization (IVF) or intrauterine insemination (IUI) to undergo IUI or natural conception (upgrade) is clinically meaningful. Using TMC, men were grouped into three pre- and postoperative categories: IVF, (TMC < 5 million), IUI (TMC 5-9 million), or natural pregnancy (TMC > 9 million). Changes in category after varicocele repair were assessed. We compared the proportion of men in each category with clinical varicoceles to those with subclinical varicoceles.

RESULTS

Men with clinical and subclinical varicoceles had improvements in TMC after surgery (change in TMC of 9.3 ± 19.5, 7.7 ± 22.6 million, P < 0.001 for both, respectively). There was no difference in TMC improvement between men with clinical and subclinical varicoceles (P = 0.66). Of men initially limited to IVF, 11% improved to IUI, and 38% to natural pregnancy. Of patients starting in IUI category, 22% transitioned to natural pregnancy category. No difference exists in the proportion of men who "upgraded" between palpable or subclinical varicoceles.

CONCLUSION

Men with subclinical varicoceles have similar, clinically meaningful improvement in TMC after varicocele repair compared with men with palpable varicoceles.

Abnormal Human Sperm Parameters Contribute to Sperm DNA Fragmentation in Men with Varicocele

PURPOSE

This study was performed to evaluate and compare threshold sperm parameters and sperm DNA fragmentation index (DFI), and further analyzed whether sperm DFI could be predicted from sperm parameters in men with varicocele.

MATERIALS AND METHODS

A total of 157 semen samples underwent both semen analysis and sperm DNA fragmentation (SDF) testing in men with varicocele. Sperm parameters were assessed using the World Health Organization guidelines. SDF testing was performed using the Halosperm kit. Sperm parameters and sperm DFI results were compared.

RESULTS

The overall sperm parameter results and sperm DFI showed normal values; however, the morphology value was at the lower limit of normal. High sperm DFI was associated with significantly lower motility and viability (p<0.001, respectively). Sperm motility and morphology were significantly higher in the higher sperm count group compared to the lower sperm count group (p<0.05), while sperm DFI was higher in the lower sperm count group (p<0.05). Sperm count and viability and sperm DFI were significantly associated with the quality of sperm motility (p<0.001). Sperm motility and sperm DFI were significantly different (p<0.001) between normal and abnormal sperm viability groups. Between normal and abnormal sperm morphology groups, sperm count, motility, and sperm DFI showed significant differences (p<0.001).

CONCLUSIONS

In this study, a correlation between SDF and sperm parameters was confirmed in men with varicocele. SDF may be contributing factors to sperm motility, viability, and morphology. Abnormal sperm count, motility, and viability showed high sperm DFI. Therefore, lower sperm parameters were indicative of increasing SDF in men with varicocele.

The varicocele argument resurfaces

A recent series of articles and reviews published in Fertility and Sterility have rekindled the more than half century debate on varicocelectomy. Every one of these articles favored strongly the repair of varicocele for male infertility. Since my review paper on this issue in 2001, published in Human Reproduction Update, and since advent of ICSI in 1993, I had thought that most reproductive physicians felt negatively about the benefit of varicocelectomy. However, more recent urological papers are causing this negative view to be re-evaluated. It is now advocated by some urologists that varicocelectomy improves sperm count and testosterone levels, and even improves the results with ICSI. Thus, it may be appropriate to revisit older studies again and review the newer ones in this never ending controversy. Newer studies are re-opening the door to review and possibly re-instate varicocelectomy. This dilemma may never be fully resolved, but it is important to keep an open mind.

Role of varicocele treatment in assisted reproductive technologies

Objective

In this review, we investigate the advantage of varicocele repair prior to assisted reproductive technologies (ART) for infertile couples and provide cost analysis information.

Materials and methods

We searched the following electronic databases: PubMed, Medline, Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL). The following search strategy was modified for the various databases and search engines: 'varicocele', 'varicocelectomy', 'varicocele repair', 'ART', 'in vitro fertilisation (IVF)', 'intracytoplasmic sperm injection (ICSI)'.

Results

A total of 49 articles, including six meta-analyses, 32 systematic reviews, and 11 original articles, were included in the analysis. Bypassing potentially reversible male subfertility factors using ART is currently common practice. However, varicocele may be present in 35% of men with primary infertility and 80% of men with secondary infertility. Varicocele repair has been shown to be an effective treatment for infertile men with clinical varicocele, thus should play an important role in the treatment of such patients due to the foetal/genetic risks and high costs that are associated with increased ART use.

Conclusion

Varicocele repair is a cost-effective treatment method that can improve semen parameters, pregnancy rates, and live-birth rates in most infertile men with clinical varicocele. By improving semen parameters and sperm structure, varicocele repair can decrease or even eliminate ART requirement.