Microsurgical varicocelectomy for isolated asthenospermia

Is It Time for Andrology and Endocrinology Professionals in Assisted Reproduction Centers?

Epidemiologists indicate that about half of the couple's infertility cases are due to a male factor. Despite this, the role of andrologists or endocrinologists in assisted reproductive technique (ART) centers is still underestimated. According to our literature review, this reduces the chance of a thorough clinical evaluation of the male partners, which, sometimes consists only in a mere semen analysis, usually performed by laboratory technicians. A more complete diagnostic process could lead to the identification of potentially treatable causes of infertility, the recognition of diseases that require immediate treatment, and to the discovery of genetic diseases and, therefore, transmissible to the offspring. It can also increase the success rate of ART resulting in less psychological and financial burden for both public health resources and infertile couples. The presence of medical personnel with andrological and endocrinological skills in the ART centers represents the first step in creating 'precision medicine'. We hope that the guidelines of the various scientific societies will clearly contemplate this possibility.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Bibliometrics and visualisation analysis of literature on varicocele: From 2002 to 2021

Varicocele is a common disease in men, with a global incidence of approximately 25%. A comprehensive and systematic analysis of the knowledge map on it will help in assessing frontier research and identify knowledge gaps. In total, 4103 articles published from 2002 to 2021 in 1066 journals were included. They represent the current research status worldwide, potential hotspots and future research directions. In the past decades, the number of publications and citations of varicocele-related studies have increased steadily. Academic institutions in the United States played a leading role in varicocele research. The country, institution, journal and author with the most publications were the United States (779), Cleveland Clinic Foundation (132), Andrologia (246) and Agarwal A (106), respectively. The most frequently used keywords were Varicocele (1620), Male Infertility (944), Varicocelectomy (288), Testis (245), Sperm (166), Oxidative Stress (144), Azoospermia (119), Semen Analysis (118), Laparoscopy (116) and Adolescent (97). Currently, the main focus of current varicocele research is its surgical treatment method and effect on sperm quality. The frontier research hotspot is the specific mechanism of varicocele-induced decrease in sperm quality.

The benefits of varicocele repair for achieving pregnancy in male infertility: A systematic review and meta-analysis

Introduction

Varicocele is one of the most common treatable causes of male infertility. However, the decision to perform varicocelectomy before starting a fertility program remains controversial. This study aimed to thoroughly review and analyze the benefit of varicocele repair and its impact on the success rate of a fertility program.

Materials and methods

A systematic literature search was performed using MEDLINE, Cochrane Library, and Wiley Library. The primary outcome was the pregnancy rate, and the secondary outcomes were live birth rate and surgical sperm retrieval success rate. Outcomes were compared between men who underwent treatment for a varicocele and those that did not. The pooled analysis data are presented as odds ratios with 95% confidence intervals.

Results

A total of 31 articles were included in the meta-analysis. The pregnancy rate was significantly higher in the treated group (odds ratio = 1.82; 95% confidence interval: 1.37-2.41; P < 0.0001) along with the live birth rate (odds ratio = 2.80; 95% confidence interval: 1.67-4.72; P = 0.0001). The further subgroup analysis revealed a higher pregnancy rate in treated men with azoospermia, subnormal semen parameters, and normozoospermia (P = 0.04, P = 0.0005, and P = 0.002, respectively), while the live birth rate was only significantly higher in the treated men with subnormal semen parameters and normozoospermia (P = 0.001 and P < 0.0001). Treated varicocele also led to a higher sperm retrieval rate in azoospermic patients (odds ratio = 1.69; 95% confidence interval: 1.16-2.45; P = 0.006).

Conclusions

Varicocele repair increased the pregnancy and live birth rates regardless the semen analysis result, along with the sperm retrieval success rate in azoospermic men. Thus, varicocele repair may be beneficial prior to joining a fertility program.

A review of varicocele treatment and fertility outcomes

Varicoceles are reported to be present in a significant proportion of men presenting with subfertility and are more common amongst this group than in the general population. Opinion still remains divided amongst clinicians managing male factor infertility as to whether varicoceles alter the probability of spontaneous conception and/or pregnancy and live birth rates after fertility treatment. The debate as to whether varicoceles should be treated or not has intensified in recent years. This is due to the concerns regarding the impact of varicoceles on not only conventional semen parameters, but also the potential effects that they may have at the cellular level (an increase in circulating reactive oxygen species (ROS) resulting in sperm DNA fragmentation, even when conventional semen parameters are within the normal reference ranges). It has been suggested that treating the varicocele may result in improvements in the semen parameters, the fertilization and pregnancy rates for both spontaneous pregnancy as well as following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. ICSI can still be used for Assisted Reproduction Treatment (ART) in the presence of suboptimal semen parameters. However, it is an invasive and expensive technique with potential adverse effects on the offspring. As far as we are aware, there are no randomized controlled trials comparing the clinical/cost effectiveness of varicocele treatment versus the immediate use of ICSI on pregnancy rates. Previous modelling exercises are old and do not take into consideration current practices and trends such as rising female age and time to pregnancy. The conflicting advice that patients sometimes receive, challenges our commitment to evidence-based practice. The only way to resolve the controversy is to undertake an appropriately powered randomized trial, assessing clinical- and cost-effectiveness and the time to pregnancy following varicocele treatment and comparing this to a no treatment group.

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.

[Initial experience in microsurgical treatment of varicocele: Comparative analysis with conventional macrosurgical varicocelectomy]

INTRODUCTION

Varicocele is the most common cause of male infertility and the standard treatment is varicocelectomy. Having recently started performing microsurgical varicocelectomy (MV) in our centre, the objective of this study is to determine the differences in clinical outcomes and laboratory findings between MV and the conventional varicocelectomy (CV).

MATERIAL AND METHODS

This is a comparative study between MV and CV in our centre between 01/2013 and 12/2016. We included patients with clinical varicocele and altered seminal parameters. We analyzed the following variables: age, laterality, grade of varicocele, testicular volume, surgical technique used, seminogram parameters prior to and after surgery and recurrence.

RESULTS

Between 01/2013 and 12/2016 46 varicocelectomies were performed in our centre, excluding from the study 12 patients due to lack of follow-up. Of the remaining 34, 19 (55.9%) underwent CV and 15 (44.1%) MV. There were no significant differences between the baseline characteristics of both groups. The preoperative sperm count was 30.1±35.6 10⁶/mL for MV vs. 25.6±19.9 10⁶/mL for CV (P=.64) and progressive sperm motility (a+b) was 17.7±13.6% vs. 16.5±10.1% respectively (P=.77). Postoperative sperm count was 29.16±33 10⁶/mL for MV vs. 45.6±55.5 10⁶/mL for CV (P=.32) and progressive motility (a+b) was 26.4±20.1% vs. 27.7±20.4% respectively (P=.85). We observed a tendency towards recurrence in the CV group (26.3%, vs. 6.7% for MV), although not statistically significant (P=.15).

CONCLUSIONS

Despite the learning curve with MV, we obtained improvements in seminal analysis similar to those with CV. Even though not statistically significant, there was a tendency to less recurrence in the MV group, consistent with what is already described in medical literature.

Indications and outcomes of varicocele repair

Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.

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.

Varicocele management for infertility and pain: A systematic review

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Critical appraisal of conventional semen analysis in the context of varicocele

Varicocele is present in approximately 15% of men, and, although it is the most commonly diagnosed cause of male infertility, nearly two-thirds of men with varicoceles remain fertile. It was decided to make use of the current evidence obtained from the previous meta-analyses between 2004 and 2015 as well as available articles covering this field, preferably randomized controlled articles dealing with the topic of semen analysis before and after repair. Two important meta-analyses were discussed as well as other articles dealing with the topic of semen analysis before and after varicocelectomy. The evidence suggests that all semen parameters improve after varicocele repair. Based on the available evidence, it is clear that there is a benefit in treating men with a palpable varicocele. One can expect that all semen parameters will improve within 3 months after repair.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

Prognostic factors for successful varicocelectomy to treat varicocele-associated male infertility

The present study identified prognostic factors for successful varicocelectomy for the treatment of varicocele-induced male infertility. All varicoceles were diagnosed and graded by physical examination and ultrasound. Pre- and postoperative analysis of semen specimens measured sperm density, morphology and motility. 'Responder' and 'non-responder' status was determined by semen analyses at 3, 6 and 12 months postoperatively. Varicocele Grades 1, 2 and 3 were found in 16, 36 and 28 patients, respectively; 49 patients (61.3%) were responders based on improved seminograms. Significant postoperative increases were noted in sperm density (from 18.20 ± 14.76 × 10(6) to 32.36 ± 24.81 × 10(6)mL(-1); P<0.001), sperm morphology (from 57.21 ± 17.35% to 62.66 ± 15.18%; P=0.006) and percentage motility (from 29.89 ± 14.71% to 50.92 ± 19.30%; P<0.001). Multivariate logistic regression indicated that age (odds ratio (OR) 0.56; P<0.001) and preoperative sperm density (OR 1.22; P=0.001) had significant unfavourable and favourable associations, respectively, with the likelihood of successful varicocelectomy. Furthermore, a preoperative sperm density of 12 × 10(6)mL(-1) as a cut-off point was able to predict successful varicocelectomy with a sensitivity of 77.6% and specificity of 77.4% (area under the curve=0.85; P<0.001; 95% confidence interval 0.76-0.92). Age and preoperative sperm density are prognostic factors for successful varicocelectomy. The results of the present study may allow clinicians to predict surgical improvement in fertility in patients with varicocele.

Varicocele: How this condition and its management affects men's health

Varicocele is a relatively common condition that can impact men’s health in various ways. Unfortunately, its prevalence and the availability of various different methods of repairing it might lead to unnecessary treatment. An understanding of the various ways that this condition can impact men’s health is necessary in order to manage it appropriately. At present, there is substantial evidence to support varicocele repair in men who present with infertility, abnormal semen parameters, clinical varicocele and a female partner with normal fertility (or one with a potentially correctable abnormality). Varicocele repair appears to improve seminal fluid quality and might improve pregnancy rates. It might also have a role in managing men with non-obstructive azoospermia. Varicocele can also be a cause of scrotal pain that is usually of a dull character. Varicocele repair is an effective method of managing this type of pain, especially once proper measures have been taken to exclude other possible causes of orchalgia. Conservative measures are generally not effective in managing varicocele-related scrotal pain. There is growing evidence to suggest that varicocele repair might have a role in improving the serum testosterone level in men with hypogonadism, especially in the subfertile population. Well-designed prospective studies are needed to support the utilization of varicocele repair in managing these patients, as well as in preventing testicular dysfunction on a prophylactic basis.

Current issues in varicocele management: a review

The most common cause of male infertility is varicocele, and varicocele is the most common correctable cause of male factor infertility. In this article we reviewed the concept of varicocele in terms of its diagnosis, method of treatment, indications for treatment, treatment outcomes, and prognostic factors. Physical examination is an essential diagnostic tool in the evaluation of a patient with a varicocele. However, as it depends on subjective findings, standardization of the physical examination method is needed. Various methods for treatment of varicocele exist, including open surgical, laparoscopic, microscopic surgical, and radiologic treatment such as embolization. Among these treatment approaches, microscopic inguinal or subinguinal varicocelectomy has superior outcomes, with a low complication rate. The influence of the treatment of varicocele on fertility is still a controversial issue and a difficult question to address, because there are limitations to performing a randomized control study, and previous studies had a heterogeneity of subjects and high dropout rate. However, there is robust evidence that varicocelectomy improves semen parameters as a surrogate marker of the potential for fertility. To date, general indications for treatment of varicocele are limited in patients with proven infertility, clinical palpable varicocele, and abnormal semen characteristics. Recently, it was shown that some symptoms other than infertility could be an indication for varicocelectomy because these symptoms are frequently related to deterioration of semen parameters. Varicocele in the adolescent presents a more difficult decision regarding whether to treat. A testicular size discrepancy of more than 20% is helpful for treatment decisions. Various prognostic factors were noted in several studies without, however, a consistent consensus.

Varicocele in adolescence: where are we now?

The exact pathophysiology of varicocele and the subsequent alteration of spermatogenesis has been the subject of much debate. Despite an enormous amount of literature on the subject, the appropriate management of varicocele in the adolescent patient population has not yet been clearly elucidated. While not every male with varicocele will be subfertile, the possibility potentially lends credence to early diagnosis for those in whom treatment will have an impact.

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.

Review of current varicocelectomy techniques and their outcomes

OBJECTIVES

• To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique • To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery.

PATIENTS AND METHODS

• A PubMed English literature review of literature from 1995 to present.

RESULTS

• Pregnancy rates were highest with microsurgical subinguinal technique • Varicocele recurrence rates were lowest with microsurgical subinguinal technique • Hydrocele formation rates were lowest with microsurgical inguinal technique • Surgical complications were highest in the laparoscopic technique • Varicocelectomy by itself or in conjunction with IVF is cost effective

CONCLUSIONS

• Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes • Varicocelectomy is a cost effective treatment modality for infertility • Further research is needed to explore new developments in varicocelectomy.

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).

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.