The varicocele

Engineered nanoparticles potentials in male reproduction

BACKGROUND

The escalating prevalence of fertility problems in the aging population necessitates a comprehensive exploration of contributing factors, extending beyond environmental concerns, work-related stress, and unhealthy lifestyles. Among these, the rising incidence of testicular disorders emerges as a pivotal determinant of fertility issues. Current treatment challenges are underscored by the limitations of high-dose and frequent drug administration, coupled with substantial side effects and irreversible trauma inflicted by surgical interventions on testicular tissue.

MATERIAL AND METHODS

The formidable barrier posed by the blood-testis barrier compounds the complexities of treating testicular diseases, presenting a significant therapeutic obstacle. The advent of nanocarriers, with their distinctive attributes, holds promise in overcoming this impediment. These nanocarriers exhibit exceptional biocompatibility, and membrane penetration capabilities, and can strategically target the blood-testis barrier through surface ligand modification, thereby augmenting drug bioavailability and enhancing therapeutic efficacy.

RESULTS AND DISCUSSION

This review concentrates on the transformative potential of nanocarriers in the delivery of therapeutic agents to testicular tissue. By summarizing key applications, we illuminate the strides made in utilizing nanocarriers as a novel avenue to effectively treat testicular diseases.

CONCLUSIONS

Nanocarriers are critical in delivering therapeutic agents to testicular tissue.

Knowledge, Attitude, and Practice Toward Varicocele in Patients with Varicoceles: A Cross-Sectional Study in Chinese Patients

Objective

To explore patients' knowledge, attitude, and practice (KAP) toward varicocele in China and the relationship between treatment selection and KAP.

Methods

This cross-sectional study enrolled varicocele patients at the Third Affiliated Hospital of Soochow University (September to October 2023). Structural equation modeling (SEM) was used to explore the relationship between clinical factors and KAP. A score >mean score for each dimension was defined as adequate knowledge, positive attitude, and proactive practice. The patients were grouped according to varicocelectomy vs no surgery. Univariable and multivariable logistic regression analyses were used to identify the factors independently associated with KAP. A structural equation modeling (SEM) analysis was performed to examine how the KAP dimensions influenced each other.

Results

Among 502 patients, 44.02%, 35.86%, and 20.12% were ≤30, 31-40, and >40 years old, respectively. Those who underwent varicocelectomy (n=407) had significantly higher knowledge (20 (15-22) vs 0 (0-6), P<0.001), attitude (26 (24-26) vs 14 (10-18), P<0.001), and practice (20 (17-24) vs 8 (6-16), P<0.001) than those who did not. A higher proportion of patients with varicocelectomy were <40 years old, more educated, had higher income, and were unmarried compared with those without surgery (all P<0.001). High school or higher education level and varicocelectomy (irrespective of type) were independently associated with adequate knowledge (all P<0.001). Knowledge, college/bachelor's degree education, and varicocelectomy type (irrespective of type) were associated with positive attitudes (all P<0.05). In the SEM, knowledge directly influenced attitude, knowledge directly influenced practice, and attitude directly influenced practice (all P<0.001). Having knowledge of the subject may direct varicocele patients to varicocelectomy.

Conclusion

Chinese patients who underwent varicocelectomy exhibit appropriate KAP regarding varicocele, while non-surgery patients have poorer KAP. These results suggest that patients who did not undergo surgery should nevertheless be properly informed about their disease.

Varicocele and nonobstructive azoospermia

Approximately 15% of men in the general population have varicoceles, and varicoceles are diagnosed in 40% of men presenting for fertility evaluations. One percent of men in the general population are azoospermic, and 15% of men presenting for fertility evaluations are diagnosed with azoospermia. This article aims to review the impact of varicoceles on testicular function in men with azoospermia, the impact of varicocele repair on the semen parameters of azoospermic men, and the impact of varicocele repair on sperm retrieval and pregnancy outcomes when the male partner remains azoospermic after varicocele repair.

Mean platelet volume might be an effective indicator of poor semen quality in varicocele patients

OBJECTIVE

To delve into the relationship between mean platelet volume (MPV) and semen quality in patients with varicocele.

MATERIALS AND METHODS

A total of 246 varicocele patients and 120 healthy adult males were enrolled. Physical examinations and the color Doppler ultrasonography were conducted on patients with varicocele to confirm the diagnosis. Venous blood samples and semen samples were collected from all participants for subsequent analysis. A series of statistical analyses were conducted to assess the relationship between their MPV levels and semen quality. A series of statistical analyses were performed to assess the relationship between MPV and semen quality.

RESULTS

No statistically significant differences were found between body mass index (BMI), sexual hormones, semen volume, platelet count, and right testicular volume in all three groups (health subjects, varicocele without symptoms, and varicocele with infertility). When conducting regression analysis on two groups with varicocele, the results indicated that a lower MPV is associated with a reduced risk of varicocele accompanied by infertility (OR = 0.557 95% CI: 0.432-0.719, P < 0.001). Further correlation analysis in varicocele patients revealed that high MPV had a statistically negative impact on the occurrence of poor semen quality, affecting sperm concentration, progressive motility, and morphology (all P < 0.001). More importantly, when predicting varicocele associated with infertility, MPV demonstrated high diagnostic sensitivity (AUC = 0.745, P < 0.001).

CONCLUSION

Our results indicate that MPV is higher in varicocele with infertility and is closely related to semen quality, which may suggest an accompanying decline in semen quality associated with varicocele. However, these conclusions require further experimental validation.

FDG Uptake Caused by Right Varicocele

ABSTRACT

A 67-year-old man underwent 18 F-FDG PET/CT for lung cancer staging. Interestingly, the PET scan revealed strip-shaped FDG uptake in the right inguinal contoured area, which was later confirmed as a right varicocele through ultrasound imaging.

[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]

OBJECTIVE

To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.

MATERIALS AND METHODS

Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.

RESULTS

The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.

CONCLUSION

Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting

INTRODUCTION

Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy.

METHODS

Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation.

RESULTS

Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207).

CONCLUSION

Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

A comparison between the efficacy and complication of laparoscopic and microsurgical varicocelectomy: Systematic review and meta-analysis

Varicocele is the dilatation of the scrotal veins and may affect sperm count and infertility. It is caused by congenital vein insufficiency or absence of venous valve. The main treatment is by surgery, and currently, there are two minimally invasive choices: laparoscopic and microsurgical varicocelectomy. This systematic review aimed to record randomized clinical trials from various sources using all qualified studies up to June 2022. The assessed outcomes were operation time, hydrocele, hospital stay, change in semen parameter, recurrence rate, and pregnancy rate. The essential data extracted were Jadad score, publication year, age, and sample size. This systematic review consisted of 509 and 512 patients in the laparoscopic and microsurgery group, respectively, taken from 12 out of 281 studies. The result of this systematic review was significant difference in operation time between patients from two groups (weighted mean difference [WMD] -21.40, 95% confidence interval [CI]: -28.90--13.89); length of hospitalization (WMD: 0.38, 95% CI: 0.02-0.74); laparoscopic could significantly increase the risk of hydrocele by 3.30-fold (risk ratio [RR]: 3.30, 95% CI: 1.07-10.12); laparoscopic could significantly increase the recurrence rate by 6.98-fold (RR: 6.98, 95% CI: 3.46-14.08); no significant difference in spontaneous pregnancy between patients in both groups (RR: 0.81, 95% CI: 0.57-1.16); and laparoscopic surgery decreased the occurrence of sperm parameter changes by 40% (RR = 0.40, 95% CI: 0.25-0.62).

Relationship between semen parameters, serum InhB, and INSL-3 levels, and the degree of varicocele

BACKGROUND

Varicocele is an abnormal expansion of the pampininias venous plexus in the scrotum, resulting in impaired sperm production and reduced sperm quality. The exact pathophysiological mechanism leading to varicocele-related infertility has not been fully elucidated. Although treatable, varicocele may lead to male infertility.

OBJECTIVE

To investigate the relationship between semen parameters, serum InhB and INSL-3 levels, and the degree of varicocele in male patients.

METHODS

Serum InhB and INSL-3 were detected. To evaluate the relationship between semen parameters and serum InhB and INSL-3 levels. To evaluate the value of semen parameters and serum InhB and INSL-3 levels in distinguishing disease severity in patients with varicocele.

RESULTS

Serum INSL-3 in patients with varicocele decreased with the severity of the disease. Serum INSL-3 was positively correlated with total sperm count and frequency of normal sperm morphology. There was a weak correlation between serum InhB and semen volume, concentration, and total sperm. Patients with different disease severity were similar within the groups, with partial overlap or similarity between varicocele Grade I and Grade II, and significant differences between Grade III and Grade I and II. Semen volume, concentration, total sperm, normal sperm morphology, and serum InhB and INSL-3 levels could distinguish the degree of varicocele.

CONCLUSION

Semen parameters and the combination of serum InhB and INSL-3 levels in patients with varicocele are closely related to the severity of the disease. Serum INSL-3 is expected to be a potential biomarker for early clinical intervention.

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.

Whole-Exome Sequencing Analysis of Idiopathic Hypogonadotropic Hypogonadism: Comparison of Varicocele and Nonobstructive Azoospermia

As a rare disease leading to male infertility, idiopathic hypogonadotropic hypogonadism (IHH) has strong heterogeneity of clinical phenotype and gene mutation. At present, there is no effective diagnosis and treatment method for this disease. This study is to explore the possible new pathogenic gene of idiopathic hypogonadotrophic hypogonadism and the pathological mechanism affecting its occurrence. We performed a whole-exome sequencing on 9 patients with normosmic idiopathic hypogonadotropic hypogonadism (nIHH), 19 varicocele patients with asthenospermia, oligospermia, or azoospermia, 5 patients with simple nonobstructive azoospermia, and 13 normal healthy adult males and carried out comparative analysis, channel analysis, etc. After preliminary sequencing screening, 309-431 genes harbouring variants, including SNPs and indels, were predicted to be harmful per single patient in each group. In genetic variations of nIHH patients' analysis, variants were detected in 10 loci and nine genes in nine patients. And in co-analysis of the three patient groups, nine nIHH patients, 19 VC patients, and five SN patients shared 116 variants, with 28 variant-harbouring genes detected in five or more patients. We found that the NEFH, CCDC177, and PCLO genes and the Gene Ontology pathways GO:0051301: cell division and GO:0090066: regulation of anatomical structure size may be key factors in the pathogenic mechanism of IHH. Our results suggest that the pathogenic mechanism of IHH is not limited to the central nervous system effects of GnRH but may involve other heterogeneous pathogenic genetic variants that affect peripheral organs.

Structured Examination of the Scrotum and Penis

Primary care pediatricians, family practitioners, and primary care advanced practice clinicians frequently need to examine male adolescent genitalia as part of a comprehensive physical examination. Although this part of the examination may be uncomfortable for clinicians, taking a structured approach to the examination can mitigate clinicians' apprehension as well as enhance their ability to use this evaluation to identify potential pathology for the patient. Familiarity with the male genitourinary examination will also allow clinicians to definitively identify medical urgencies and emergencies for timely intervention. This review will provide the clinician with a structured approach to the male genitourinary examination while highlighting common pathology that may be encountered during the examination. [Pediatr Ann. 2024;53(1):e5-e9.].

[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.

Amplatzer™ Vascular Plugs for Embolisation: A 10-Year Single-Centre Retrospective Study

Our objective was to investigate the indications, effectiveness, and safety of Amplatzer™ Vascular Plugs (AVPs) in clinical practice. To retrospectively identify patients managed with AVPs at the Dijon University Hospital between January 2011 and April 2021, we searched materials vigilance registries and procedure reports. The 110 identified patients underwent 111 procedures with delivery of 202 AVPs into 118 vessels; 84% of the procedures were performed by radiologists with over 10 years' experience and 67% were scheduled. Varicocele, haemostasis, pelvic varicose veins, and arterio-venous dialysis fistulas accounted for 69% of procedures. The technical and clinical success rates were 99% and 97%, respectively. The single major complication was AVP migration in a high-flow internal iliac vein, with no residual abnormalities after successful device retrieval. Several AVPs and/or concomitant injection of coils or liquid agents were used in 80% of cases. The use of AVPs alone occurred chiefly for splenic artery embolisation in trauma patients and for collateral vein occlusion in dysfunctional arterio-venous dialysis fistulas. No cases of recanalisation occurred during the 19 ± 29 month follow-ups. Based on their good safety and effectiveness profile, AVPs deserve to be part of the therapeutic armamentarium of every interventional radiologist.

Bilaterality of varicocele: The overlooked culprit in male infertility. Case series study

OBJECTIVES

Varicocele is the most common correctable cause of male infertility that always has been a debatable subject as regards how it affects fertility and the best way to treat it. Proper assessment of the disease bilaterality is crucial not to miss one side and not to jeopardize treatment outcome. This study aimed to objectively assess varicocele bilaterality in infertile men aiming to improve treatment outcome in this cohort of patients.

METHODS

This prospective study was conducted between January 2019 and January 2022 including infertile males with varicoceles. Assessment of missed concomitant contralateral varicocele done pre-operatively by Color Doppler Ultrasound and intraoperatively by intraoperative Doppler device and measurement of maximal vein diameter of contralateral side.

RESULTS

A total of 329 cases completed the study. A hundred cases (30.4%) were initially referred as unilateral varicoceles and 229 (69.6%) as bilateral varicoceles. After reassessment of the study population, bilaterality of varicocele was found to be as high as 98.5% (324/329). Repeat CDUS strongly correlated with the intraoperative measured varicocele diameter (r = 0.9, p < 0.001). Moreover, sperm parameters showed significant improvement 3 and 6 months post varicocelectomy. Normal pregnancy after 1 year of surgery occurred in 118 cases (35.9%).

CONCLUSIONS

Varicocele bilaterality in infertile men is underreported. Thorough assessment by expert radiologists and andrologists is of paramount importance not to miss significant pathology or hazard treatment outcome.

Predictors of Semen Parameters Decline Following the Microsurgical Varicocelectomy

Objective Varicocele is considered the most common reversible cause of male infertility. However, some men do not clinically improve after surgical repair. We aimed to identify preoperative factors associated with decreased semen parameters and clinical "downgrading" of total motile sperm count (TMSC) following varicocelectomy. Methods We examined men with preoperative laboratory testing and pre- and postoperative semen analyses (SA) who underwent varicocelectomy between 2010 and 2020. Ejaculate volume, sperm motility, sperm concentration, TMSC, and clinical grade of TMSC (in vitro fertilization: <5M sperm, intrauterine insemination: 5-9M sperm, natural pregnancy: >9M sperm) were used to determine postoperative outcomes. Demographic and clinical factors were compared between cohorts. Results Among 101 men who underwent varicocelectomy, 35 (34.7%) had decreased postoperative TMSC with a median follow-up of 6.6 months (interquartile range 3.9-13.6 months). Eleven (10.9%) men experienced TMSC clinical "downgrading" following surgery. Clinical grade III varicocele was significantly associated with decreased sperm motility on postoperative SA (OR 4.1, 95% CI 1.7-10.0, p=0.002), and larger left testicle volume (OR 1.4, 95% CI 1.1-1.8, p=0.02) was associated with clinical "downgrading" after varicocelectomy. Conclusion A small but significant proportion of men experienced a "downgrading" of semen parameters after varicocelectomy. Larger left testis size was associated with clinical downgrading, whereas clinical grade III varicoceles were associated with lower post-treatment sperm motility. These data are critical for preoperative patient counseling.

The learning curve of bilateral laparoscopic varicocelectomy: a prospective study

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

Varicocele Embolization: Interventional Radiologist's Perspective

The goal of this article is to review the patient selection criteria, technical pearls, and outcomes of percutaneous varicocele embolization. This article will provide a brief overview of the history of the procedure, angiographic approach, and materials used in contemporary embolization. The success rates and complications of the varicocele embolization will also be discussed.

The Role and Place of Antioxidants in the Treatment of Male Infertility Caused by Varicocele

The inability to become pregnant for at least 1 year despite regular unprotected intercourse may indicate infertility of one or both partners. This problem affects approximately 10-20% of couples worldwide, regardless of race, with male infertility reported to account for 25-60% of cases. Among the most common pathological causes of male infertility is the presence of varicocele and chronic infections of the male reproductive system. This study was performed using data collected at the Genesis Infertility Treatment Clinic, Bydgoszcz, Poland, between 1 January 2015 and 30 June 2017. A total of 163 men meeting the inclusion criteria were selected and divided into the idiopathic infertility group (78 men) and varicocele-related infertility group (85 men). All patients received treatment with a male fertility supplement containing a combination of 1725 mg of L-carnitine fumarate, 500 mg of acetyl-L-carnitine, 90 mg of vitamin C, 20 mg of coenzyme Q10, 10 mg of zinc, 200 µg of folic acid, 50 µg of selenium, and 1.5 µg of vitamin B12 (Proxeed® Plus, Sigma-Tau, Italy) twice a day for a period of 6 months from the time of the diagnosis of infertility. The treatment resulted in significant improvements in general semen parameters, particularly sperm count, sperm concentration, total motility, and progressive motility. This antioxidant therapy produced a particularly marked therapeutic benefit in patients with Grade III varicocele, with a greater improvement in progressive motility than in men with less severe or no varicocele. The use of the antioxidant preparation examined here seems reasonable in men with idiopathic infertility and as an adjuvant in those with varicocele-related infertility in whom surgical treatment has resulted in no improvement. Its use should be considered particularly in patients with Grade III varicocele who do not wish to undergo surgical treatment or in whom such a treatment is not possible for various reasons.

Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective

A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.

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.

Can preoperative inflammatory markers predict the success of varicocelectomy?

The aim of this study was to evaluate the effect of inflammation on the success of varicocelectomy by using some inflammatory markers. Adult male patients aged ≥18 years who were evaluated for infertility, had abnormal parameters in at least two preoperative semen analyses and underwent subinguinal microscopic varicocelectomy were retrospectively evaluated. The patients were divided into two groups; those showing improvement in semen parameters were determined as Group A and those without improvement as Group B and compared with each other. A total of 102 patients were included in this study. Group A contained 32 (31.4%) patients while Group B had 70 (68.6%) patients. Monocyte/lymphocyte ratio (MLR) and neutrophil/lymphocyte ratio (NLR) were found to be statistically significantly higher in Group B (p = 0.014 and p = 0.028 respectively). Although preoperative sperm concentration and total motile sperm count were higher in Group B, postoperative all semen parameters were significantly higher in Group A. The cutoff points that were determined using the Youden test were <2.02 for NLR (AUC = 0.636, CI = 0.519-0.754; p = 0.028) and <0.22 for MLR (AUC = 0.652, CI = 0.531-0.773; p = 0.014). Pre-varicocelectomy low NLR and MLR values were found to be significant parameters in predicting the success of the surgery.

Reproductive potential repair in men with varicocele

Relevance. In majority of men, varicose veins of the testicle - varicocele - does not cause discomfort and is asymptomatic, and scrotal pain only bothers 10 % of patients. In 2/3 of cases, varicocele is a clinical finding. In this case, varicocele is the most common cause of male infertility. Aim of the study. Recovery of the reproductive potential of patients with varicocele. Materials and Methods. In 219 patients with varicocele, weve carried an ejaculate study out (WHO, 2010) 3, 6, 12 months after surgical treatment of varicocele. We considered the reproductive function restored by normozoospermia in the ejaculate and the onset of pregnancy in the spouse during the follow - up period of 12 months. Results and Discussion. The 2/3 men of the 219 patients with varicocele had ejaculate abnormalities. The age of patients who were diagnosed with pathospermia was 31+11 years. 66 (39.5 %) patients with varicocele had spermatozoa with reduced mobility. After surgical treatment (varicocelectomy according to Marmara), normozoospermia was present almost in every second man. Nevertheless, the number of pregnancies in a married couple was higher than 6 months after varicocelectomy - 24(32.8 %). The surgical method of treatment of varicocele allows to restore the reproductive function of a man in 30 %. In our study, normozoospermia after varicocelectomy was recorded in almost every second patient. Ultrasound changes in the testicle with varicocele are an unfavorable prognosis for the restoration of male fertility. Conclusion. Surgical treatment of varicocele can recover the reproductive potential of almost every second man of reproductive age. Moreover, a greater number of pregnancies six months right after the operation were registered in spouses.

Reproductive potential repair in men with varicocele

Relevance. In majority of men, varicose veins of the testicle - varicocele - does not cause discomfort and is asymptomatic, and scrotal pain only bothers 10 % of patients. In 2/3 of cases, varicocele is a clinical finding. In this case, varicocele is the most common cause of male infertility. Aim of the study. Recovery of the reproductive potential of patients with varicocele. Materials and Methods. In 219 patients with varicocele, weve carried an ejaculate study out (WHO, 2010) 3, 6, 12 months after surgical treatment of varicocele. We considered the reproductive function restored by normozoospermia in the ejaculate and the onset of pregnancy in the spouse during the follow - up period of 12 months. Results and Discussion. The 2/3 men of the 219 patients with varicocele had ejaculate abnormalities. The age of patients who were diagnosed with pathospermia was 31+11 years. 66 (39.5 %) patients with varicocele had spermatozoa with reduced mobility. After surgical treatment (varicocelectomy according to Marmara), normozoospermia was present almost in every second man. Nevertheless, the number of pregnancies in a married couple was higher than 6 months after varicocelectomy - 24(32.8 %). The surgical method of treatment of varicocele allows to restore the reproductive function of a man in 30 %. In our study, normozoospermia after varicocelectomy was recorded in almost every second patient. Ultrasound changes in the testicle with varicocele are an unfavorable prognosis for the restoration of male fertility. Conclusion. Surgical treatment of varicocele can recover the reproductive potential of almost every second man of reproductive age. Moreover, a greater number of pregnancies six months right after the operation were registered in spouses.

Varicocele-Associated Infertility and the Role of Oxidative Stress on Sperm DNA Fragmentation

Varicocele has been extensively described and studied as the most important reversible cause of male infertility. Its impact on semen parameters, pregnancy rates, and assisted reproductive outcomes have been associated with multifactorial aspects, most of them converging to increase of reactive oxygen species (ROS). More recently, sperm DNA fragmentation has gained significant attention and potential clinical use, although the body of evidence still needs further evolution. The associations between sperm DNA damage and a variety of disorders, including varicocele itself, share common pathways to ROS increase. This mini-review discusses different aspects related to the etiology of ROS and its relation to varicocele and potential mechanisms of DNA damage.

Assessment of seminal cystatin C levels in infertile men with varicocele: A preliminary study

Varicocele has been raised as a contributor to male infertility supported by the improvement of sperm parameters after varicocelectomy. Cystatin C (Cys C) has been linked to several cellular changes that are common in male infertility cases associated with varicocele such as apoptosis and autophagy. This preliminary study aimed to assess the seminal levels of Cys C in infertile oligoasthenoteratozoospermic (OAT) men associated with varicocele that have been shown to have spermatic vein vasodilation and active death pathway. Overall, 60 men were investigated being divided into two equivalent groups-infertile OAT men with varicocele who underwent varicocelectomy and healthy fertile men as a control group. These men were subjected to history taking, clinical examination, semen analysis and assessment of seminal Cys C pre and 6 months post-varicocelectomy. The results showed a significant increase of seminal Cys C in infertile OAT men with varicocele than the fertile control (55.57 ± 25.6 ng/ml versus 10.78 ± 1.88 ng/ml, p = .001). Seminal Cys C was a significantly decreased post-operative than its pre-operative level (34.69 ± 14.02 versus 55.57 ± 25.6 ng/ml, p = .01). These results show a potential role of Cys C in varicocele-induced infertility.

Oxidative Stress: A Comprehensive Review of Biochemical, Molecular, and Genetic Aspects in the Pathogenesis and Management of Varicocele

Oxidative stress is a condition due to an imbalance between the concentrations of oxidants and antioxidants, and it is a well-recognized contributor in several male infertility conditions. Varicocele, a common vascular condition, may cause male infertility due to hyperthermia, hypoxia and/or exposure to toxic adrenal and renal metabolites. In this review, the mechanisms by which oxidative stress can affect cellular integrity and functions are described, along with molecular markers of cellular oxidative damage, and the most commonly performed techniques for their detection in seminal fluid. Moreover, we focus on the role of oxidative stress in the pathophysiology of varicocele based on recently published evidence from omics based studies, such as proteomics and genomics. Finally, we discuss strategies for the management of oxidative stress and the clinical guidelines for testing oxidative stress-related sperm DNA fragmentation in this group of patients.

Dracaena arborea (Dracaenaceae) Increases Sexual Hormones and Sperm Parameters, Lowers Oxidative Stress, and Ameliorates Testicular Architecture in Rats with 3 Weeks of Experimental Varicocele

Varicocele is a disease characterized by an abnormal dilation of the pampiniform plexus that drains the testis. The main objective of this work was to evaluate the curative effects of aqueous and ethanolic extracts of Dracaena arborea on some reproductive and antioxidant markers in rats with experimental varicocele. Following varicocele induction, rats (5 per group) were randomly partitioned into untreated varicocele, vitamin E-treated (150 mg/kg), aqueous extract-treated (500 mg/kg), and ethanolic extract-treated (100 mg/kg) animals. Two other groups served as normal and sham-operated. After 2 or 4 weeks of treatments, body and sex organ weights, spermatozoa characteristics, antioxidant status, NO level, sex hormones, and testis histology were measured. Animals with 3 weeks of varicocele showed a significant (p < 0.05–0.001) decrease in body and sex organ weights, total proteins, sperm characteristics, testosterone concentration, SOD, catalase, and total peroxidase activities. An increase in the plasmatic FSH, LH, and testicular MDA and NO concentrations was also recorded. Moreover, marked disorganization of the testicular architecture was observed. Treatment with D. arborea significantly reversed these impairments due to varicocele. For instance, after 4 weeks, treatment with aqueous extract of D. arborea significantly (p < 0.05–0.001) increased testes and epididymis weights, sperm viability (89.12 ± 1.09 vs 68.22 ± 1.42), sperm density (148.50 ± 2.59 vs 110.25 ± 2.51), and sperm motility (68.16 ± 2.39 vs 55.88 ± 3.20) in the left side, compared with varicocele-untreated rats. The extract also significantly (p < 0.05–0.001) decreased malondialdehyde level (2.19 ± 0.04 vs 3.50 ± 0.13) but elevated catalase (0.97 ± 0.03 vs 0.55 ± 0.03), SOD (0.5 ± 0.03 vs 0.15 ± 0.03), and peroxidase (65.80 ± 2.9 vs 40.95 ± 2.44) activities. Present results showed that D. arborea extracts possess antioxidant effects and improve sperm quality in male rats with an existing varicocele.

Varicocele-Mediated Male Infertility: From the Perspective of Testicular Immunity and Inflammation

Background

Varicocele (VC) is present in 35 - 40% of men with infertility. However, current surgical and antioxidant treatments are not completely effective. In addition to oxidative stress, it is likely that other factors such as testicular immune microenvironment disorder contribute to irreversible testicular. Evidence suggests that VC is associated with anti-sperm antibodies (ASAs), spermatogenesis and testosterone secretion abnormalities, and testicular cytokine production. Moreover, inhibition of inflammation can alleviate VC-mediated pathogenesis. The normal function of the testis depends on its immune tolerance mechanism. Testicular immune regulation is complex, and many infectious or non-infectious diseases may damage this precision system.

Results

The testicular immune microenvironment is composed of common immune cells and other cells involved in testicular immunity. The former includes testicular macrophages, T cells, dendritic cells (DCs), and mast cells, whereas the latter include Leydig cells and Sertoli cells (SCs). In animal models and in patients with VC, most studies have revealed an abnormal increase in the levels of ASAs and pro-inflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-alpha in the seminal plasma, testicular tissue, and even peripheral blood. It is also involved in the activation of potential inflammatory pathways, such as the nucleotide-binding oligomerization domain-like receptor family pyrin domain containing (NLRP)-3 pathway. Finally, the development of VC-mediated infertility (VMI) may be facilitated by abnormal permeability of proteins, such as claudin-11, that constitute the blood-testis barrier (BTB).

Conclusions

The testicular immune response, including the production of ASAs and inflammatory factors, activation of inflammatory pathways, and destruction of the BTB may be involved in the pathogenesis of VMI it is necessary to further explore how patient outcomes can be improved through immunotherapy.

Sonographic Evaluation of Pelvic Venous Disorders

ABSTRACT

Pelvic venous disorders are a group of interrelated conditions characterized by venous incompetence. These conditions often manifest with nonspecific symptoms that overlap with many gynecological, gastrointestinal, and urologic diseases. Clinical diagnosis can be difficult, and imaging can play a vital role in differentiating etiology. Sonographic evaluation is often the first step in evaluating these symptoms. Special attention to possible underlying pelvic venous disorders can reveal characteristic findings, support diagnosis, and guide treatment. Here we review pelvic congestion syndrome, nutcracker syndrome, May-Thurner syndrome, and other venous disorders, with a specific focus on sonographic findings and considerations.

Laparoscopic varicocelectomy in male infertility : Improvement of seminal parameters and effects on spermatogenesis

Background

The suitability of laparoscopic varicocelectomy for assisted reproductive technology depends on the improvement of semen parameters. The present study analyzed the improvement of semen parameters following laparoscopic varicocele ligation.

Material and methods

A retrospective study of the laparoscopic varicocele clippings at the Department of Urology of University Hospital of Kiel between the years 2007 and 2019 was conducted. The semen analyses according to WHO standards (sperm count, density, motility and morphology) were conducted before and 12 months after surgery. Screening for surgical complications took place at the time of the follow-up seminal analysis. Included were patients with oligozoospermia, asthenozoospermia and/or teratozoospermia (group 1, OAT) or with nonobstructive azoospermia (group 2, NOA).

Results

This study included data of 27 patients and 22 patients presented preoperative OAT (81%, group 1). Another 5 patients showed NOA (19%, group 2). Data of group 1 showed that semen parameters normalized in 32% of the patients after surgery. Significant improvement in total sperm count (p < 0.005), sperm density (p < 0.005) and total motile sperm count (p < 0.005) was observed. No deterioration of semen parameters was observed. In group 2 we detected spermatozoa in 1 case in the postoperative ejaculate. None of the patients showed complications according to the Clavien-Dindo classification, postoperative hydrocele formation or recurrence of varicocele at the time of control spermiogram.

Conclusion

Laparoscopic varicocelectomy is a valid therapeutic approach to improve semen parameters for further assisted reproductive techniques. Spermatogenesis may be induced for patients with NOA. Normalization of semen parameters can be achieved for patients with OAT.

Surgical procedures for male infertility: an update

PURPOSE OF REVIEW

The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes.

RECENT FINDINGS

Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures.

SUMMARY

Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

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.

Right-sided scrotal varicocele and its association with malignancy: a multi-institutional study

PURPOSE

To determine the prevalence of isolated right-sided varicocele due to an obstructing malignancy in patients with no other evidence of malignancy.

METHODS

This retrospective, multi-institutional study included a text search for right-sided varicocele in consecutive reports of scrotal ultrasound studies performed between 4/22/1999 and 06/24/2018. Diagnosis was confirmed by a radiologist based on the following criteria: pampiniform plexus vein diameter of ≥ 2 mm, which has augmented flow or increases by ≥ 1 mm on Valsalva. Inclusion criteria for adequate follow-up were (1) abdominopelvic CT or MRI performed within 3 months prior to, or any time after, the ultrasound study; or (2) presence of clinical documentation more than 2 years after the ultrasound date. Exclusion criteria were existing cancer diagnosis in the abdomen or pelvis, epididymo-orchitis, intratesticular or intrascrotal mass, and prior scrotal surgery. Images of available CT or MRI studies were reviewed for presence of any explanation of right-sided varicocele.

RESULTS

210 patients with right-sided varicocele met inclusion and exclusion criteria. 118/210 had abdominopelvic CT or MRI in the assigned timeframe. Of these, no patients had malignancy that could account for right-sided varicoceles. Of the 92/210 patients without CT or MRI but with available clinical follow-up, none had a malignancy that could have caused an isolated right-sided varicocele. There was no underlying malignancy to explain the right-sided varicocele in any of the patients, 0/210, 95% CI [0.0-1.4%].

CONCLUSION

No associated malignancy was found in patients with isolated right-sided varicoceles to support additional imaging for malignancy screening.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Efficacy of scroto-inguinal microsurgical varicocelectomy in treating male infertility

Background

Varicocele presents as the most frequent cause of infertility in men. Most reports showed that varicocelectomy has a significant impact on male fertility and reproductive outcome. This study aims to evaluate the safety and effectiveness of scrotal–inguinal microsurgical varicocelectomy in treating male infertility.

Methods

We prospectively studied preoperatively and postoperatively (at 3 and 6 months) 86 consecutive patients diagnosed with varicocele, abnormal semen parameters, and infertility, undergoing scrotal–inguinal microsurgical varicocelectomy. Semen test was performed before surgery and at 3 months and 6 months after surgery. The reproductive events were short-term followed up.

Results

The median age of the patient was 32.9 ± 5.1 (20–43). Two cases (2.7%) had a minor infection of the scrotum incision, who were well treated by appropriate antibiotics. After operation, total sperm count and the percentage of motile sperms at 3 months and 6 months were significantly higher than those pre-varicocelectomy, respectively. In total, 26.7% (23/86) of all couples achieved a spontaneous pregnancy. Late complications such as testicular atrophy, hydroceles, and recurrent varicocele have not occurred.

Conclusions

Scrotal–inguinal microsurgical varicocelectomy is an acceptable method in treating male infertility due to high rate of reproductive outcomes and very low rate of complications.

Seminal inflammasome activity in the adult varicocele

Varicocele has been hypothesized to lead to seminal inflammation, which in turn interferes with sperm function. Thus, the aim of this study was to investigate the role of inflammatory cytokines in the pathogenesis of decreased semen quality observed in adult men with varicocele, and to determine if varicocelectomy corrects these potential alterations. A prospective study was carried out including fifteen control men without varicocele and with normal semen quality and 15 men with varicocele with surgical indication. Men with varicocele grades II or III underwent microsurgical subinguinal varicocelectomy. Controls collected one semen sample and men with varicocele collected one before and one 6 months after the surgery. Semen analysis, sperm function, and seminal lipid peroxidation levels were assessed. Seminal plasma inflammasome activity was evaluated by ELISA assays for IL-1β, IL-18 and caspase-1 and by Western blotting for ASC (apoptosis-associated speck-like protein). Groups were compared by an unpaired Student's T test. Varicocelectomy samples were compared using a paired Student's T test (α = 5%). Men with varicocele had decreased semen quality, and increased seminal IL-1β levels, when compared to control men. Varicocelectomy decreased levels of caspase-1, IL-18, and IL1β. Thus, varicocelectomy improves sperm morphology and decreases seminal plasma inflammatory activity, after a six-month post-operative period.

The impact of ipsilateral testicular atrophy on semen quality and sperm DNA fragmentation response to varicocele repair

Varicoceles adversely impact semen quality and sperm DNA fragmentation, which typically improve with surgical repair. Some men with varicoceles have ipsilateral testicular atrophy due to damage from the varicocele. This study assessed semen quality and the sperm DNA fragmentation index (DFI) response to varicocele repair in men with ipsilateral testicular atrophy (TA) versus men with no testicular atrophy (NTA). Semen parameter values and DFI in both groups were compared preoperatively and postoperatively. The Mann–Whitney U test and the Wilcoxon signed-rank test were used where appropriate. There were 20 men in the TA group and 121 men in the NTA group with no difference in age, varicocele grade, or preoperative semen parameter values between the two groups. The NTA group had a higher preoperative DFI than the TA group. Both groups showed improvement in semen quality postoperatively, only the TA group showed a significant improvement in DFI, whereas the NTA group showed significant improvements in several parameter values and DFI. The change from preoperative to postoperative parameter values when comparing the two groups revealed a difference in total sperm motile count and DFI, with a larger mean improvement in the NTA group than in the TA group. Both TA and NTA groups showed improved semen quality and DFI after varicocele repair, but the NTA group had more improvement than the TA group. However, only total motile count (TMC) and DFI had a significantly greater mean change in preoperative to postoperative response in the NTA group than in the TA group.

[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.

A rare case of right-sided varicocele in right renal tumor in the absence of venous thrombosis and IVC compression

Background

The presence of unilateral right-sided varicocele hints at a serious retroperitoneal disease such as renal cell neoplasm. Such tumors are usually associated with a thrombus in renal vein or spermatic vein. We report a rare presentation of right-sided renal tumor causing right-sided varicocele in the absence of thrombus in renal vein and spermatic vein but due to an anomalous vein draining from the tumor into the spermatic vein as demonstrated by computed tomography angiogram.

Case presentation

A 54-yr-old hypertensive male presented with unilateral grade 3 right-sided varicocele and no other signs and symptoms. Ultrasound examination of his abdomen showed the presence of a mass lesion in the lower pole of right kidney. Computed tomography confirmed the presence of right renal mass, absence of thrombus in right renal vein or inferior vena cava. The angiographic phase of CT scan showed an anomalous vein from the tumor draining into the pampiniform plexus causing varicocele.

Conclusion

The presence of right-sided varicocele should raise a suspicion hidden serious pathological retroperitoneal condition, renal malignancy in particular, and should prompt the treating physician to carry out imaging studies of the retroperitoneum and careful study of the angiographic phase of the CT scan can ascertain the pathogenesis of the varicocele.

Nonsurgical Management of Oligozoospermia

Male infertility secondary to oligozoospermia is surprisingly common. Although a majority of cases are idiopathic, oligozoospermia can be caused by endocrine dysfunction, anatomic abnormalities, medications, or environmental exposures. The work-up includes excluding reversible factors such as hormonal deficiency, medication effects, and retrograde ejaculation and identifying any underlying genetic syndrome and treating reversible medical causes. If no reversible cause is found, appropriate referrals to urology and assisted reproductive technology should be initiated. Lastly, clinicians should be aware of and respond to the psychological and general health ramifications of a diagnosis of oligozoospermia as part of the comprehensive care of men and couples struggling with a diagnosis of infertility.

Efficacy of varicocelectomy for sperm DNA integrity improvement: A meta-analysis

Varicocele is common among male adolescents and adults. Varicocelectomy is the major means of varicocele repair. There is evidence that varicocelectomy could decrease sperm DNA fragmentation. However, studies evaluating the efficacy of varicocelectomy for sperm DNA integrity usually have a small sample size, and there is no up-to-date meta-analysis in this area. The present meta-analysis is to evaluate the efficacy of varicocelectomy for sperm DNA integrity. A literature search was conducted to identify all relevant studies from Medline database (PubMed), Cochrane Library, and OVID Embase from the inception dates to 08 June 2020. A total of 11 prospective studies including 394 cases were included in this meta-analysis. All analysis was performed using Stata version 16.0. In the random-effect model for 11 studies, DNA fragmentation index (%) of clinical varicocele patients decreased by 5.79 (95% CI, -7.39 to -4.19) after varicocelectomy. While after excluding one study with high heterogeneity, from the results of fixed-effect model, DNA fragmentation index decreased by 6.14 (95% CI, -6.90 to -5.37) on average. Sperm DNA integrity of clinical varicocele patients was significantly improved following varicocelectomy. Therefore, it is necessary to include elevated sperm DNA fragmentation index as a molecular indicator for varicocelectomy among clinical varicocele cases.

The effect of varicocele repair for sperm DNA fragmentation: A protocol for systematic review and meta-analysis

INTRODUCTION

Sperm DNA integrity has been considered as one of the important determinants of normal fertilization and embryonic development in natural and assisted pregnancy. It is difficult for men with high levels of sperm DNA fragmentation (SDF) in semen to conceive their partners naturally and assist in conception. The studies have found that the level of SDF in the semen of patients with varicocele (VC) was on the high side. In recent years, the effect of VC surgery on DNA fragmentation index has attracted the attention of researchers. In this study, we will evaluate the effectiveness of VC repair as a way to alleviate SDF and improve male fertility.

METHODS AND ANALYSIS

Electronic databases including English databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library) and Chinese databases (China National Knowledge Infrastructure, China Biology Medicine Database, Wanfang Database, VIP Database) will be searched from their inception to December 2020 to recognize related studies. All the randomized controlled trials of microsurgical varicocelectomy for the management of VC patients will be included. The potential outcome will include improvement in SDF, oxidative stress markers (reactive oxygen species, nitric oxide, and lipid peroxidation products), sperm chromatin compaction, other advanced sperm function characteristics, follow-up of fertility results. We will conduct this study strictly according to the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

The study is a protocol for systematic review and meta-analysis without results, and data analysis will be carried out after the protocol. We will share our findings on April 5th of 2021.

CONCLUSION

This systematic review will provide more evidence to assess whether varicocelectomy is an effective intervention for patients with SDF. The results will be published in a public issue journal and offer the urologists help to make clinical decisions.

ETHICS AND DISSEMINATION

Formal ethical approval is not required in this protocol. We will collect and analyze data based on published research. Since this research does not involve patients, personal privacy will not be affected. The results of this review will be distributed to peer-reviewed journals or submitted to relevant conferences.

PROTOCOL REGISTRATION NUMBER

INPLASY202070119.

Increased Sperm DNA Fragmentation in Infertile Men with Varicocele: Relationship with Apoptosis, Seminal Oxidative Stress, and Spermatic Parameters

This study intends to determine the extent of nuclear sperm injury in patients with varicocele and to investigate its relationship with apoptosis and oxidative stress (OS). Ejaculated sperm samples from 51 patients diagnosed with varicocele and 29 fertile men were examined. According to the guidelines, the patient's sperm samples were classified into varicocele with normal semen parameters (n = 11) and varicocele with abnormal semen parameters (n = 40). Sperm DNA fragmentation was assessed using terminal deoxynucleotidyl transferase dUTP nick end labeling assay. The proportion of both viable and dead spermatozoa with externalized phosphatidylserine (PS) was detected by the bivariate annexin V/6-CFDA staining method. Seminal malondialdehyde (MDA) amounts and antioxidant enzymes activities of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) were measured spectrophotometrically. Sperm DNA fragmentation, viable spermatozoa with externalized PS, and MDA levels were significantly higher in studied subgroups of patients with varicocele, either with normal or with abnormal semen parameters than controls. The seminal antioxidant enzymes activities were significantly reduced in both subgroups of patients with varicocele compared to the controls. The percentage of spermatozoa with fragmented DNA was positively correlated to the MDA level as well as the proportion of viable spermatozoa with externalized PS. However, the decreased seminal antioxidant status was negatively correlated with the increased proportion of sperm DNA fragmentation and apoptotic spermatozoa. Impaired seminal antioxidant profile and increased seminal level of lipid peroxidation may be involved in the pathophysiological mechanisms of cell death-mediated DNA breaks in patients with varicocele.

Capsaicin improves sperm quality in rats with experimental varicocele

Capsaicin is the main capsaicinoid in chilli peppers that have numerous biological and pharmaceutical roles in the body such as antioxidant, anti-inflammatory, anticarcinogenic, analgesic, counterirritant and antiarthritic properties. Numerous studies have shown increased oxidative stress in men with varicocele that is caused by dilation of the spermatic vein and increase of testicular temperature. Therefore, we aimed to assess the effect of Capsaicin on sperm parameters in rats with experimental varicocele. At first, we induced varicocele in 30 Wistar rats and, verify varicocele model only in 10 rats by assessment of sperm parameters, oxidative stress, DNA damage and persistent histone after 2 months. Of the remaining 20 varicocelised rats, half of them were treated with 2.5 mg/kg Capsaicin for two months and the other half served as control. Then, sperm tests were assessed, and the results showed that Capsaicin can restore the mean of sperm oxidative stress (38.78 ± 3.75 versus 58.37 ± 4.34; p < .05), sperm concentration (60.14 ± 7.66 versus 34.87 ± 5.78; p < .05) and motility (62.43 ± 3.10 versus 41.22 ± 5.11; p < .05) in varicocelised rats treated with Capsaicin compared to varicocelised rats that were not treat. Therefore, Capsaicin possibly with reduction of oxidative stress level could improve mean of sperm concentration and motility in varicocele condition.

Endoplasmic Reticulum Stress (ER Stress) and Unfolded Protein Response (UPR) Occur in a Rat Varicocele Testis Model

Using a surgically induced varicocele rat model, we show here strong evidence that the misfolded/unfolded protein response that is part of the stress response of the endoplasmic reticulum (ER) is activated in the varicocele testis (VCL), leading to the induction of apoptosis. To support this hypothesis, it is observed that the spliced variant of the X-box protein 1 (XBP1s), resulting from the activation of the inositol-requiring enzyme 1 (IRE1) membrane sensor, is significantly more represented in VCL testicular extracts. The activation of the IRE1/XBP1s pathway is also supported by the observation that the VCL testes show an increase phosphorylation of the c-Jun-kinase (JNK) known to be one intermediate of this pathway and an increased level of caspase-3, the terminal apoptotic effector, partly explaining the apoptotic status of the VCL testis.