Effect of age and grade on surgery for patients with varicocele

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

PURPOSE

The purpose of this meta-analysis is to study the impact of varicocele repair in the largest cohort of infertile males with clinical varicocele by including all available studies, with no language restrictions, comparing intra-person conventional semen parameters before and after the repair of varicoceles.

MATERIALS AND METHODS

The meta-analysis was performed according to PRISMA-P and MOOSE guidelines. A systematic search was performed in Scopus, PubMed, Cochrane, and Embase databases. Eligible studies were selected according to the PICOS model (Population: infertile male patients with clinical varicocele; Intervention: varicocele repair; Comparison: intra-person before-after varicocele repair; Outcome: conventional semen parameters; Study type: randomized controlled trials [RCTs], observational and case-control studies).

RESULTS

Out of 1,632 screened abstracts, 351 articles (23 RCTs, 292 observational, and 36 case-control studies) were included in the quantitative analysis. The before-and-after analysis showed significant improvements in all semen parameters after varicocele repair (except sperm vitality); semen volume: standardized mean difference (SMD) 0.203, 95% CI: 0.129-0.278; p<0.001; I²=83.62%, Egger's p=0.3329; sperm concentration: SMD 1.590, 95% CI: 1.474-1.706; p<0.001; I²=97.86%, Egger's p<0.0001; total sperm count: SMD 1.824, 95% CI: 1.526-2.121; p<0.001; I²=97.88%, Egger's p=0.0063; total motile sperm count: SMD 1.643, 95% CI: 1.318-1.968; p<0.001; I²=98.65%, Egger's p=0.0003; progressive sperm motility: SMD 1.845, 95% CI: 1.537%-2.153%; p<0.001; I²=98.97%, Egger's p<0.0001; total sperm motility: SMD 1.613, 95% CI 1.467%-1.759%; p<0.001; l2=97.98%, Egger's p<0.001; sperm morphology: SMD 1.066, 95% CI 0.992%-1.211%; p<0.001; I²=97.87%, Egger's p=0.1864.

CONCLUSIONS

The current meta-analysis is the largest to date using paired analysis on varicocele patients. In the current meta-analysis, almost all conventional semen parameters improved significantly following varicocele repair in infertile patients with clinical varicocele.

Nomograms for Predicting Postoperative Sperm Improvements in Varicocele Patients

Background

Varicocele is a condition that seriously affects male fertility. It can cause pathological changes in the testicles and affect their spermatogenesis and endocrine function.

Objective

To formulate nomograms to predict sperm improvements after microscopic varicocelectomy.

Design setting and participants

A retrospective analysis was conducted on varicocele patients who met the research criteria and were enrolled from March 2020 to June 2022. They were divided into a development and a validation cohort in a 2:1 ratio.

Outcome measurements and statistical analysis

Data on preoperative testicular atrophy index, bilateral testicular elastic modulus, testosterone, pre- and postoperative 6-mo total sperm count, sperm concentration, and sperm vitality were collected. An increase of ≥25% is considered a postoperative improvement in sperm parameters. Predictive nomograms were constructed through forward stepwise LR regression, based on independent risk factors filtered by univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis, calibration curve, and decision curve analysis were employed to assess the performance of the models.

Results and limitations

The areas under the curve of nomograms for predicting the postoperative improvement of total sperm count, sperm concentration, and sperm vitality were 0.915, 0.986, and 0.924 respectively. The nomogram models demonstrated good predictive performance. The single-center sample size was a limitation of this study.

Conclusions

In this study, we developed effective predictive nomogram models for anticipating postoperative improvements in sperm quality among varicocele patients. These models offer a significant value in providing accurate predictions of surgical outcomes. However, it is crucial to conduct further external validation.

Patient summary

In this study, a predictive nomogram model was constructed for assessing the improvement of sperm quality in varicocele patients after surgery. The model offered satisfactory results.

Color Doppler ultrasound imaging in varicoceles: Is the difference in venous diameter encountered during Valsalva predictive of palpable varicocele grade?

Objective

The clinical grading system for varicoceles is subjective and dependent on clinician experience. Color Doppler ultrasound (US) has not been standardized in the diagnosis of varicoceles. We aimed to determine if US measurement of varicocele could be predictive of World Health Organization (WHO) varicocele grade.

Methods

Men who presented for either scrotal pain or infertility to a tertiary men's health clinic underwent physical examination, and varicoceles were graded following WHO criteria (0=subclinical, 1, 2, 3). US was used to measure largest venous diameter in the pampiniform plexus bilaterally at rest and during Valsalva maneuver. Receiver operator characteristic curve analysis was used to determine if resting diameter, diameter during Valsalva, or change in diameter between at rest and during Valsalva provided the highest sensitivity and specificity for determining clinical grade. Threshold values for diameter were determined from these receiver operator characteristic curves.

Results

A total of 102 men (50 with clinical varicocele and 52 with subclinical varicocele) were included. Diameter at rest was the best ultrasonographic discriminator between subclinical and clinical varicoceles (area under the curve [AUC]=0.67) with a diameter threshold of 3.0 mm (sensitivity 79%, specificity 42%). Diameter during Valsalva had the greatest AUC for determining clinical Grades 1 versus 2 (AUC=0.57) with diameter threshold of 5.7 mm (sensitivity 71%, specificity 33%). For differentiating between Grades 2 and 3, diameter at rest had the greatest AUC of 0.65 with a threshold of 3.6 mm (sensitivity 71%, specificity 58%).

Conclusion

Our results corroborate other studies that have shown a weak correlation between US and clinical grading. The use of diameter during Valsalva was less predictive than diameter at rest and was only clinically significant in differentiating between Grade 1 and 2 varicocele. A standardized method for determining clinically relevant varicoceles on US would allow for improved patient counseling and clinical decision-making.

Differential DNA methylation pattern and sperm quality in men with varicocele

OBJECTIVE

To study the global DNA methylation pattern in spermatozoa of patients with varicocele as well as investigate their semen quality.

DESIGN

Prospective observational case-control study.

SETTING

University-affiliated hospital.

PATIENT(S)

A total of 26 men with varicocele and 26 fertile men without the disorder.

INTERVENTIONS

Analysis of semen quality and sperm DNA methylation patterns.

MAIN OUTCOME MEASURE(S)

Semen quality evaluated by semen analysis, and sperm DNA methylation patterns investigated using the Infinium MethylationEPIC BeadChip platform.

RESULT(S)

Men with varicocele displayed decreased semen quality. The sperm DNA methylation analysis showed that men with varicocele exhibit global hypomethylation in comparison with the control group. A total of 59 differentially methylated CpG sites were identified, most of them hypomethylated in the varicocele group. In regional analyses, 1,695 DNA regions were differentially methylated in men with varicocele. These regions show associations with gamete generation, meiotic and meiosis cell cycle, and semen quality based on gene ontology analysis.

CONCLUSION(S)

Gene ontology results suggest that changes in methylation may be associated with the low semen quality phenotype observed in some varicocele patients because the observed differentially methylated regions in varicocele patients are related to male reproductive pathways. Additionally, the varicocele grade may influence the magnitude of global sperm DNA methylation change. To our knowledge, this is the first report analyzing changes at a regional or CpG-specific level in men with varicocele.

Relation of nitric oxide synthase gene (NOS3) polymorphisms to varicocele risk and post-varicocelectomy seminal oxidative stress reduction

The pathophysiology of varicocele remains to be unknown. Several genetic factors have been implicated in varicocele etiopathogenesis. We studied the relationship between NOS3 c.894G>T, c.786T>C and 4b/a polymorphisms to varicocele risk and their prognostic value as regards improvement of the post-operative seminal parameters &/or seminal malonaldehyde levels. The three NOS3 polymorphisms were evaluated in 100 patients with varicocele and 100 healthy subjects by RT-PCR. Seminal plasma MDA level was measured pre-operatively and 3 months after varicocelectomy by the thiobarbituric acid method. The GT, TT, TC and bb genotypes of NOS3 polymorphism were more commonly observed in varicocele patients (30%, 9%, 28% and 70% respectively) compared to normal controls (12%, 0%, 10% and 50% respectively). The mean percentage of post-varicocelectomy seminal MDA reduction was highest with the GT genotype (p < .001). Genotypes GT+TT, TC and bb were associated with varicocele occurrence in our patients. The T (c.894G>T), C (c.786T>C) and b (NOS3 intron 4 VNTR) alleles were significantly associated with varicocele occurrence in our cohort of patients. We also report a better response regarding the reduction of seminal MDA after varicocelectomy with the GT and ba genotypes.

Clinical factors affecting semen improvement after microsurgical subinguinal varicocelectomy: which subfertile patients benefit from surgery?

Background

The exact mechanism of varicocele-related infertility is still elusive, therefore, the current challenges for its management lie in determining which patients stand to benefit most from surgical correction. The authors aimed to assess the clinical factors affecting semen improvement after left microsurgical subinguinal varicocelectomy (MSV) in relation to patient age, ultrasound varicocele grading (USVG), and presence of a right subclinical varicocele (RSV).

Methods

From 2010 to 2017 a total of 228 infertile patients underwent left MSV for clinical varicocele. Descriptive statistics were used to describe the cohort and verify the surgical benefit in terms of semen improvement, in addition, subsets of patients were selected according to clinical covariates. Logistic regression modeling was applied to evaluate the presence of RSV, operative time, age, and USVG as explanatory variables.

Results

Sperm concentration (SC), progressive sperm motility (PSM), and normal sperm morphology (NSM) increased significantly after surgery (p = 0.002; p = 0.011; p = 0.024; respectively). Mean SC improved after MSV in ⩾35 year-old patients and the grade 3 USVG group (p = 0.01; p = 0.02; respectively). Logistic regression modeling showed a that the probability of SC improvement was 76% lower in subjects presenting RSV (p = 0.011). In addition, patients with a grade 3 USVG presented a three-times greater probability of SC improvement compared with patients with a lower USVG (p = 0.035). In addition, older patients showed a greater probability of SC improvement after MSV (p = 0.041).

Conclusions

MSV is an effective varicocele-related infertility treatment that should also be offered to older patients. In addition, patients with a higher USVG benefit from surgery. In infertile men with an RSV in association with a left clinical disease, a bilateral varicocele repair should be considered.

Prognostic factors for a favorable outcome after varicocele repair in adolescents and adults

The effect of varicocele repair on male fertility remains controversial. It would be helpful to determined which men would benefit most from varicocele repair, and target repair efforts at those individuals. A detailed review of the literature on prognostic factors for varicocele repair was performed using the PubMed NLM database. We found that the best predictor of postvaricocelectomy semen parameters is the preoperative semen parameters. The greatest improvements in semen parameters were found in men with larger varicoceles. While there is controversy, higher testosterone, younger age and larger testis size, in some studies predict for improvements in semen parameters postvaricocelectomy. A nomogram has been developed to predict the postvaricocelectomy semen parameters based on the preoperative semen parameters, varicocele grade and the age of the man (www.fertilitytreatmentresults.com). Limited data consistently demonstrates the greatest improvements in DNA fragmentation rates in men with higher baseline DNA fragmentation rates. With respect to reproductive outcomes, higher baseline sperm density consistently predicts for natural pregnancy or assisted reproductive technology (ART) pregnancy rates. In addition, varicocele repair does seem to reduce the need for more invasive modalities of ART. In conclusion, we can now start to use specific parameters such as baseline semen quality, varicocele grade and patient age to predict post-repair semen quality and fertility potential following varicocelectomy.

Does the number of veins ligated during varicococele surgery influence post-operative semen and hormone results?

Varicocele is a well-established cause of male subfertility, which is directly proportional to its clinical grade. Although newer ultrasonic grading systems have taken into account the existence of pampiniform venous plexi, little is known about the clinical significance of the number of veins ligated during surgery. Very few undersized studies reported an influence which triggered the need to evaluate such association. This is a retrospective study of 378 patients who underwent left microsurgical subinguinal varicocoelectomy. Semen analyses and blood hormone studies performed pre-operatively were compared to those executed 6 months after surgery. Patients were divided into abnormal semen and normal semen groups based on their initial semen results. They were also subdivided according to the number of veins ligated intraoperatively into three groups: <5, 5-10, and >10 veins. Sperm count, total motility, and progressive motility were significantly increased in 62, 60.3, and 53.3% of patients post-operatively (p = 0.001), respectively. No significant differences in hormone levels were detected overall. Of the 378 patients, 332 had an abnormal semen analysis, while the remaining 46 patients had a normal result. Sperm count, total motility, and progressive motility significantly increased after varicocoelectomy in patients with an abnormal initial semen analysis (p = 0.001). In 48.7% of patients, 5-10 veins were ligated during surgery, whereas 28.3% had >10 and 23% had <5 ligated veins. No statistically significant differences were noted in the initial or the follow-up results among the number of vein subgroups. Varicocele ligation improves patients' fertility potential. This improvement, however, is not influenced by the number of veins ligated intraoperatively. Clinical grading maintains its superiority in the evaluation of varicocele patients.

Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study

INTRODUCTION

We aim to predict results of varicocelectomy on sperm density and progressive motility using preoperative clinical, laboratory and radiological data and to propose cut-off values for significant parameters.

METHODS

This prospective study was carried out between July 2011 and June 2014. We included 123 patients in our study. They were diagnosed with primary infertility with varicocele, were scheduled for varicocelectomy, and completed their follow-up. We excluded patients with azoospermia, total necrospermia, recurrent varicocele, and pituitary hormonal abnormalities. Varicocele was diagnosed and graded by physical examination and colour Doppler ultrasound. Semen analyses were completed preoperatively and 6 months postoperatively. Microscopic subinguinal varicocelectomy was done in all cases. Patient demographics, pre- and postoperative clinical data (varicocele grade and semen parameters) were statistically analyzed.

RESULTS

The mean ± standard deviation of age, body mass index, and subfertility duration was 28.3 ± 7.4 years, 29.1 ± 2.7 kg/m(2), and 21.9 ± 7.1 months, respectively. About 53% of our patients (n = 66) had bilateral varicocele, and unilateral disease was found in the other 57 (46.3%) cases. Varicocele grade I was diagnosed in 42 (34.1%) patients, while the other 81 (65.9%) patients had grade II or III. Higher grades of varicocele, preoperative total testosterone level, sperm density, and progressive motility had a statistically significant impact on the outcome of varicocelectomy in univariate testing. Multivariate logistic analysis revealed that grade of preoperative varicocele (95% confidence interval [CI] 5.6-6.3, p = 0.007) and sperm density (95% CI 2.7-1.6, p = 0.0035), and progressive motility (95% CI 1.1-2.3, p = 0.0123) are independent predictors of semen parameters improvement after varicocelectomy.

CONCLUSION

The grade of the varicocele, sperm density, and progressive motility are major predictors of outcome in varicocelectomy. Cut-off values of >8 million/mL and >18% for sperm density and progressive motility, respectively, in men with varicocele grade II or III, indicate a successful outcome.

Percentage change of FSH value: new variable to predict the seminal outcome after varicocelectomy

In the literature, there is no good agreement with variables to predict seminal outcome after varicocelectomy. The purpose of this study was to evaluate the FSH percentage change (Δ% FSH) as a predictor of the seminal outcome after varicocelectomy together with other known predictors. We evaluated 118 patients who underwent varicocelectomy. We assessed factors that could be predictors of the improvement of semen characteristics: LH, FSH, total and free testosterone before operation, testis volume, age, testicular pain, body mass index (BMI), Δ% FSH, varicocele Doppler ultrasound grade using regression analysis. Mean sperm concentration increased from 27 ± 12 to 52 ± 15 million per ml post-operatively (P < 0.003), mean sperm motility increased from 31 ± 12 to 40 ± 13 million per ml following the operation (P < 0.02), also mean FSH value changed from 10.2 ± 8.3 to 6.7 ± 7.2 UI/L (P < 0.01). In unvaried regression analysis, Δ% FSH, BMI and age were predictors of the improvement of semen characteristics. In multiple regression analysis, only Δ% FSH and age were predictors. Negative correlation with age and positive correlation with Δ% FSH were observed. Our findings suggest that Δ% FSH (before and after varicocelectomy) and age are significant factors predicting the improvement of semen characteristics.

Should older patients be offered varicocoele correction to improve their fertility?

We reviewed a large number of patients from 2000 to 2010 that underwent varicocoele correction using the retrograde sclerotization approach. Three hundred and seventy-six of them were included in the study, as they met the inclusion criteria. Mean age at the time of surgery was 32 years (SD: 6.5); 32% of them were 35 years and older. Patients were classified according to the clinical classification (GC) and Sarteschi's Doppler ultrasound classification (GS). The patients showed up at the clinic after an average time of 30 months of referred infertility related (SD: 28.54). Patients underwent pre-operative assessment with physical examination, sperm analysis and Doppler ultrasound, and again the same assessment at least 3 months after surgery. We evaluated the following parameters: sperm concentration (millions/mL, CONC), percentage motility (a+b, MOT) and the percentage of morphologically typical spermatozoa (MOR). Univariate and Multivariate analysis were performed. The research of Pearson's coefficients was performed to test the correlation between sperm parameters and age, SG, CG. Semen specimens were evaluated according to WHO 1999 criteria. Mean CONC varied from 34.5 to 47.0 millions/mL (+12.5; p < 0.001); MOT from 27.2 to 34.5% (+7.3%; p < 0.001); and MOR from 44.0 to 47.6% (+3.6%; p = 0.001). Univariable and multivariable analysis of variance related to age showed no significant difference of parameters improvement. Pearson's correlation coefficient for pre-operative and post-operative sperm MOT related to patients' age was respectively -0.11 (p < 0.001) and -0.18 (p = 0.04). No other significance was found. Usefulness of treating infertile patients affected by varicocoele is confirmed: varicocoele correction leads to significant sperm parameters improvement. There is no evidence of different improvement related to patients' age. The decline in sperm motility related to age of the patients seems to be only age-dependent: the usefulness of treating patients affected by varicocoele is not influenced by their age: treatment should also be offered to older patients.

Varicocelectomy is associated with increases in serum testosterone independent of clinical grade

OBJECTIVE

To determine whether the varicocele grade is related to the degree of improvement in serum testosterone levels after varicocelectomy.

MATERIALS AND METHODS

We performed a retrospective review of men with a total serum testosterone level <400 ng/dL who had undergone microsurgical subinguinal varicocelectomy for infertility and/or hypogonadism. All men had clinically palpable left varicoceles and preoperative and postoperative total serum testosterone levels available. For patients with bilateral varicoceles, the greatest grade on either side was used to stratify the patients. The men with an isolated, left-side, grade I varicocele were not offered varicocelectomy. The changes in the testosterone levels were evaluated, with the results expressed as the mean ± standard error. P ≤.05 was considered statistically significant.

RESULTS

A total of 59 patients had undergone bilateral varicocelectomy and 19 unilateral varicocelectomy. Overall, an increase in testosterone was seen in 65 of the 78 men (83%) in the present study. The mean follow-up was 7 months. The mean serum testosterone level increased from 308.4 to 417.5 ng/dL, with a mean increase of 109.1 ± 12.8 ng/dL (n = 78). The improvements in the serum testosterone levels were seen regardless of the clinical grade.

CONCLUSION

Microsurgical varicocelectomy resulted in significant increases in the serum testosterone level, independent of the varicocele grade.

Microsurgical ligation for painful varicocele: effectiveness and predictors of pain resolution

PURPOSE

We evaluated the effectiveness of microsurgical ligation for painful varicocele and predictive factors of pain resolution.

MATERIALS AND METHODS

Between January 2006 and March 2009, a total of 114 patients (mean age, 30.2 ± 8.9 years), who underwent microsurgical inguinal varicocelectomy for painful varicocele, were included and followed up for 1 year after the surgery. The quantity of preoperative and postoperative pain was assessed by means of 11-point numeric rating scale (NRS). We retrospectively analyzed the outcome of surgical ligation and predictive factors of pain resolution using patient age, height, weight, body mass index, grade and location of varicocele, duration, quantity and quality (dull, dragging, aching) of pain, and postoperative pain resolution.

RESULTS

In 104 patients (91.2%), complete or marked resolution of pain was reported at follow-up 1 year after surgery. Only 10 patients (8.8%) had recurrent or persistent pain (≥ 3 points in NRS scores). On multivariate analysis, low quantity (≤ 6 points in NRS scores) and dull or dragging natured preoperative pain were independent factors associated with surgical success rates (p=0.004; odds ratio=1.62, p=0.012; odds ratio=1.76, respectively).

CONCLUSION

Microsurgical ligation is an effective treatment of painful varicocele. The quantity and quality of preoperative pain are independent predictive factors of pain resolution after surgery.

Predictors of sperm recovery and azoospermia relapse in men with nonobstructive azoospermia after varicocele repair

PURPOSE

In this study we determined the recoverability and sustainability of motile sperm in semen of men with nonobstructive azoospermia after varicocelectomy as related to different variables.

MATERIALS AND METHODS

Men with documented infertility for more than 1 year, with nonobstructive azoospermia and clinically palpable varicoceles were included in this prospective noncontrolled study. Participants underwent simultaneous subinguinal microsurgical varicocelectomy and testicular biopsies. Preoperative as well as initial and late followup semen analyses were performed. Outcomes of sperm recovery and relapse of azoospermia were correlated with the variables of patient age, infertility duration, varicocele grade, laterality, follicle-stimulating hormone, testicular volume and testicular histology.

RESULTS

The study included 31 men with a mean ± SD age of 34.9 ± 8.7 years and mean followup of 19.3 ± 3.3 months. Hypospermatogenesis, late maturation arrest, early maturation arrest and Sertoli-cell-only were observed in 13, 6, 2 and 10 patients, respectively. Overall, sperm recovery was evident in 10 of 31 (32.3%) patients (persistent recovery 19.4%, intermittent recovery 6.5%, relapse 6.5%). Sperm were recovered in patients with hypospermatogenesis (7 of 13, 53.8%) and late maturation arrest (3 of 6, 50%). No sperm were recovered in those with early maturation arrest or Sertoli-cell-only. Among the variables only histological patterns demonstrated a significant correlation with recovery (rho = 0.504, p = 0.004). None of variables was significantly correlated with relapse. Bilateral varicocele repair demonstrated a strong yet nonsignificant negative correlation with relapse (rho = -0.612, p = 0.06).

CONCLUSIONS

Varicocelectomy could recover motile sperm in men with nonobstructive azoospermia, palpable varicoceles and hypospermatogenesis or late maturation arrest. No sperm was recovered with early maturation arrest or Sertoli-cell-only. Recovery might be persistent or intermittent, or involve relapse of azoospermia. Testicular histology was the sole parameter significantly correlated with recovery and no predictors of relapse could be identified. This prognostic role of testicular biopsy is imperative in couple counseling.

Effect of age on semen parameters in infertile men after varicocelectomy

Background

The effectiveness of varicocelectomy in restoration of fertility and improvement of semen parameters is still controversial. The purpose of this study was to determine the effect of age on semen parameters following varicocelectomy in a group of infertile men.

Methods

Improvements in sperm count, morphology, and motility were studied in 67 infertile patients 4–10 months after varicocelectomy.

Results

The mean age of the patients was 30.48 ± 7.49 years. Significant improvements in total sperm count, percentage normal morphology, and motility were noted in all age groups (P < 0.05). Patients aged <25 years demonstrated the greatest increase in sperm counts, normal morphology, and motility following varicocelectomy. There was a significant negative correlation between age and sperm count, sperm morphology, and sperm motility (P < 0.05).

Conclusion

The effect of age on improvement in sperm parameters after varicocelectomy is inconsistent with some reports in the literature, and could be attributable to the duration of infertility prior to surgery; in the long term, varicoceles are known to have deleterious effects on testis biology.

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).

Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy

PURPOSE

It is generally accepted that men with clinically palpable varicocele are at high risk for a progressive decrease in fertility and testosterone levels with time. Varicocelectomy is thought to improve testicular function or at least halt the accelerated decrease in testicular function associated with varicocele. Substantial controversy exists as to whether varicocelectomy is effective in older men, possibly due to irreversible testicular damage or limited potential for recovery from varicocele induced damage.

MATERIALS AND METHODS

We retrospectively reviewed the records of men who underwent microsurgical subinguinal varicocelectomy, as done by a single surgeon. Demographics, patient questionnaires, operative notes, charts, testosterone and semen analysis were reviewed. Patients were divided into 3 groups based on age at surgery, including less than 30, 30 to 39 and 40 years or greater.

RESULTS

A total of 272 men met study inclusion criteria. In all 3 age groups we noted similar testosterone and baseline semen analysis parameters. There were significant increases in sperm concentration and total sperm count in all age groups. When analysis was restricted to men with baseline testosterone 400 ng/dl or less, there was a mean 110, 133 and 136 ng/dl increase in 21 men who were 40 years old or older, in 30 who were 30 to 39 years old and in 21 who were younger than 30 years, respectively.

CONCLUSIONS

Microsurgical varicocelectomy resulted in significant increases in sperm concentration, total sperm count and testosterone in all age groups studied, including men in the fifth and sixth decades of life. Microsurgical varicocelectomy should be offered to older men for infertility and/or hypogonadism.

Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: a comparative study

OBJECTIVES

To determine whether it is necessary to perform bilateral varicocelectomy (BV) in infertile men with left clinical and right subclinical varicoceles by comparing the outcomes of BV with those of left varicocelectomy (LV) in these patients.

METHODS

A total of 104 infertile men with left clinical and right subclinical varicoceles were randomly divided into 2 groups: BV (n = 51) and LV (n = 53). Both BV and LV were performed using a retroperitoneal approach with ligation of the dilated internal spermatic veins. The sperm concentration, sperm motility, normal morphology, serum testosterone level, bilateral testicular volume, and spontaneous pregnancy rate were measured pre- and postoperatively. Statistical analysis was performed using analysis of variance and the chi(2) test, with significance determined by P < .05.

RESULTS

The patients in the 2 groups had comparable preoperative age, partner age, sperm concentration, sperm motility, normal morphology, left varicocele grade, serum testosterone level, and bilateral testicular volume (P > .05). Both BV and LV resulted in significant increases in sperm concentration, sperm motility, and normal morphology (P < .05). No significant changes in serum testosterone level or bilateral testicular volume were observed after varicocelectomy in the 2 groups (P > .05). No significant differences were found in the postoperative sperm concentration, sperm motility, normal morphology, bilateral testicular volume, serum testosterone level, and spontaneous pregnancy rate between the 2 groups (P > .05).

CONCLUSIONS

These findings suggest that no benefit is realized with BV compared with LV in infertile men with left clinical and right subclinical varicoceles.

Microsurgical varicocelectomy for isolated asthenospermia

PURPOSE

Varicocele represents the most common cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. We evaluated the clinical outcomes of infertile couples with varicocele and isolated asthenospermia who chose to undergo varicocelectomy as well as those who chose not to undergo the procedure.

MATERIALS AND METHODS

We performed a retrospective review of 118 consecutive infertile couples in whom the man presented with clinical varicocele and isolated asthenospermia (less than 50% motile sperm). All couples were presented with possible treatment options (observation, varicocelectomy, assisted reproductive technologies). The clinical characteristics and outcomes of 2 subgroups of men--those who elected to undergo surgery (varicocelectomy, 69) and those who did not (49)--were examined and compared.

RESULTS

Mean male and female patient age, duration of infertility and baseline total motile sperm count were not significantly different in the control and surgery groups. The mean total motile sperm count increased significantly after varicocelectomy (29.6 million preoperatively vs 39.0 million postoperatively, p <0.05). The spontaneous pregnancy rate was significantly higher in the surgery group compared to the control group (65% vs 32%, respectively, p <0.01). The combined spontaneous and intrauterine insemination pregnancy rate was also significantly higher in the surgery group compared to the control group (74% vs 36%, respectively, p <0.01). Use of in vitro fertilization/intracytoplasmic sperm injection was significantly higher in the control group compared to the surgery group (32% vs 11%, respectively, p <0.05).

CONCLUSIONS

Our data support the practice of varicocelectomy for the treatment of clinical varicocele and isolated asthenospermia.