The role of internal spermatic vein plasma catecholamine determinations in subfertile men with varicoceles

The Evolving Landscape of Male Varicocele Pathophysiology in the Era of Multi-Omics: A Narrative Review of the Current Literature

Male-factor infertility is implicated in over half of the millions of cases of infertility worldwide, and varicoceles are the most common correctable cause of male-factor infertility. The pathophysiologic mechanism for varicoceles is complex and next-generation technologies offer promising insights into the molecular underpinnings of this condition. In this narrative review, we highlight historical and contemporary paradigms associated with varicoceles, with an emphasis on the biological underpinnings of this disease. Specifically, we review the literature describing the underlying causes of varicoceles, discuss the molecular and cellular mechanisms causing pathological changes in some (but not all) men, and highlight key articles regarding the next-generation analyses (e.g., transcriptome, epigenome, proteome, and microbiome) being applied to better understand the condition and its treatment. These data demonstrate an ongoing evolution of the knowledge of varicoceles and the potential for improved personalized care in the future for men with this condition.

Expression of vascular endothelial growth factor and its receptors in infertile men with varicocele

OBJECTIVES

An enlargement of the spermatic vein is known as a varicocele. Research studies suggest that immune system mediators such as vascular endothelial growth factor (VEGF) and its receptors including VEGFR1, VEGFR2, and VEGFR3 can play a role in angiogenesis and inhibition of endothelial cell apoptosis and correspondingly suppress spermatogenesis. Thus, the purpose of this study was to measure the expression of VEGF and its receptors in infertile men with varicocele.

MATERIALS & METHODS

To meet the research objectives, a total number of 30 infertile male patients affected with varicocele (Grade 3) and 30 healthy fertile male subjects without any varicocele or urogenital tract disorder were enrolled in the study. The varicose and normal veins were obtained from the patients along with the blood flowing in these spermatic veins during surgery. Also, peripheral blood samples were collected from the mentioned patients and healthy subjects. The serum levels of VEGF were also measured via enzyme-linked immunosorbent assay (ELISA) and subsequently mRNA level of VEGFR1, VEGFR2, VEGFR3, B Cell Lymphoma-Associated X (Bax), and B-cell lymphoma 2 (Bcl2) genes were measured using the real-time polymerase chain reaction (RT-PCR) technique.

RESULTS

The findings of this study revealed that VEGFR2 gene expression in varicose veins was significantly increased compared with normal veins in varicocele patients (P < 0.001) and Bax/Bcl2 ratio reduced in varicose veins when compared to normal veins of the patients (P < 0.05). Our findings also showed a significant rise in the serum levels of VEGF in the peripheral blood and varicose vein bloodstream compared with those in healthy subjects (P < 0.0001). Moreover, a significant difference was observed in the serum levels of VEGF in the peripheral blood and varicose vein blood of patients suffering from varicocele (P < 0.001).

CONCLUSION

According to the results of this study, VEGF/VEGFR2 axis might act in the survival of endothelial cells of varicocele vein through inhibition of apoptosis and stimulation of angiogenesis. Additionally, increased VEGF in the testis can probably play a role in suppressing spermatogenesis and varicocele-based infertility.

Significant alterations of 6-keto prostaglandin F1a and NO levels in spermatic vein plexus patients with varicocele

To investigate the level variation of correlative factors between the spermatic vein plexus and peripheral blood in patients with varicocele, a total of 22 patients diagnosed with varicocele were enrolled in the study. All patients were performed a testicular artery-sparing microsurgical varicocelectomy. During the operation, a blood sample from the left spermatic vein plexus and a peripheral blood sample were collected. A radioimmunoassay was used to determine the 6-keto prostaglandin F1a (6-keto-PGF1a ). A colorimetric method was performed to determine the NO. The enzyme immunoassay method was used to determine the creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT. The mean age of all patients was 29.3 ± 7.8 years. Compared with the level of 6-keto-PGF1a and NO in the peripheral blood, 6-keto-PGF1a and NO were significantly increased in left spermatic vein plexus (347.3 (230.8-415.1) versus 99.7 (80.4-119.9) pg/ml and 192.3 ± 178.5 versus 107.1 ± 73.6 μmol/L, p < .05). There were no differences in the level of creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT between the peripheral blood and left spermatic vein plexus (p > .05). The 6-keto-PGF1a and NO concentrations in left spermatic vein plexus were significantly higher than that in peripheral blood patients with varicocele.

Epidemiology of varicocele

Varicocele is a common problem in reproductive medicine practice. A varicocele is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, especially regarding its effect on male infertility. We have conducted a systematic review of studies evaluating the epidemiology of varicocele in the general population and in men presenting with infertility. In this article, we have identified some of the factors that can influence the epidemiological aspects of varicoceles. We also recognize that varicocele epidemiology remains incompletely understood, and there is a need for well-designed, large-scale studies to fully define the epidemiological aspects of this condition.

Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species (ROS) and the resultant oxidative stress (OS) in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient.

Glutathione-S-transferase-oxidative stress relationship in the internal spermatic vein blood of infertile men with varicocele

This study aimed to assess glutathione-S-transferase (GST) enzyme- oxidative stress (OS) relationship in the internal spermatic vein (ISV) of infertile men associated with varicocele (Vx). Ninety five infertile oligoasthenoteratozoospemic (OAT) men associated with Vx were subjected to history taking, clinical examination and semen analysis. During inguinal varicocelectomy, GST, malondialdehyde (MDA) and glutathione peroxidase (GPx) were estimated in the blood samples drawn from ISV and median cubital veins. The mean levels of GST, GPx were significantly decreased and the mean level of GPx was significantly increased in the ISV compared with the peripheral blood. The mean level of GST and GPx in the ISV was significantly decreased, and the mean level of MDA was significantly increased in Vx grade III compared with Vx grade II cases. There was nonsignificant difference in the mean level of GST in the ISV in unilateral Vx cases compared with bilateral Vx cases. There was significant positive correlation of GST with sperm count, sperm motility, GPx and significant negative correlation with sperm abnormal forms, MDA. It is concluded that ISV of infertile men associated with Vx has decreased levels of GST compared with peripheral venous circulation that is correlated with both OS and Vx grade.

Increased testicular 8-hydroxy-2'-deoxyguanosine in patients with varicocele

OBJECTIVES

To assess immunohistochemically 8-hydroxy-2'-deoxyguanosine (8-OHdG, a sensitive biological marker of oxidative damage and stress) in testicular tissue from patients with varicocele, to determine whether 8-OHdG is related to spermatogenesis, as oxidative stress in testicular DNA is associated with poor semen quality and reduced fertility.

PATIENTS, SUBJECTS AND METHODS

Testicular tissue samples were collected from the testes of 36 patients with varicocele and five normal volunteers. The mean (sd) age of the patients was 35.3 (5.4) years. The prevalence of immunostained germ cells among all the germ cells in >20 seminiferous tubules was calculated.

RESULTS

The mean (sd) sperm concentration and Johnsen's score in the varicocele group was lower than in the normal group, at 27.6 (11.8) vs 80.4 (21.7) million/mL (P < 0.001) and 7.6 (1.1) vs 9.0 (0.7), respectively (P < 0.05). In all patients, 8-OHdG was mainly expressed in the spermatogonia and spermatocytes in the seminiferous tubule. Immunostained germ cells correlated negatively with sperm concentration (r = -0.48, P = 0.01) and Johnsen's score (r = -0.46, P = 0.02), but not with follicle-stimulating hormone, luteinizing hormone or testosterone level. Immunostained germ cells were significantly more prevalent in the varicocele group, at 53.6 (5.7)%, than that in the normal group, at 14.3 (2.3)% (P < 0.001). The prevalence of immunostained germ cells and clinical grades were positively related; the ratio recorded for varicocele grades I, II and III was 38.0 (10.0)%, 41.0 (9.1)%, and 57.0 (9.3)%, respectively (grade I vs grade III, P < 0.05).

CONCLUSIONS

Increased 8-OHdG expression in the testis was associated with deficient spermatogenesis in infertile men with varicocele.

Varicocele and retrograde adrenal metabolites flow. An experimental study on rats

BACKGROUND

Idiopathic varicocele is one of the causes of potentially correctable male subfertility. The mechanisms causing spermatogenesis impairment have yet to be clarified. The aim of this study is to analyze the effects of renal and adrenal metabolite reflux on testicular exocrine function in a rat experimental model.

MATERIALS AND METHODS

In the study, 45 male Lewis Stock adult rats, each weighing 300 g, were used. The rats were subdivided into three groups of 15 rats. In group A (control group) testicular volume and basal follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels were measured at the beginning of the study and after 9 months. In group B, varicocele was induced by means of rings introduced in the left renal vein in order to cause a renospermatic reflux. In group C, similarly to group B, varicocele was induced after removal of left adrenal gland. The effects of varicocele on testicular function were then analyzed 3, 6 and 9 months after surgery. After 9 months, all rats underwent testicular biopsy.

RESULTS

Both groups B and C showed a reduction in testicular volume, an increase in FSH and a decrease in testosterone levels. These levels were higher in group B. Testicular histological assessment showed important structural abnormalities in group B rats.

CONCLUSIONS

These data support the hypothesis that renal and adrenal metabolites enhance varicocele-induced testicular damage. This theory is supported both by hormonal impairment and testicular histological analysis.

Color Doppler ultrasound investigation of varicocele

Varicocele, whose association with male infertility has been clearly documented in the literature, is a common finding in adolescents and adult men, being diagnosed in 20-40% of infertile patients. A correct and early diagnosis of this affliction is of great importance because, in most cases, a timely correction, usually performed using percutaneous sclerotherapy, leads to an improvement in semen quality. Currently, physical examination in a warm room is the mainstay of diagnosis, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele. Colour Doppler ultrasound (CDU) is a new, reliable and non-invasive diagnostic method for the evaluation of varicocele testes which allows the detection of even subclinical varicocele thanks to its capacity for measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic veins. At present, there is a lack of completely standardised diagnostic criteria, but when this problem is solved, clinical examination and CDU will certainly become the "gold standard" in the investigation of varicocele.

Increased nitric oxide is accompanied by lipid oxidation in adolescent varicocele

Summary One of the mechanisms of injury in varicocele has been proposed to be elevated nitric oxide (NO). We aimed to determine the association between the elevation of NO and lipid oxidation in varicocele compared with peripheral venous levels of these two substances as it has not been studied before. The study group consisted of 13 adolescents with left idiopathic varicocele of grades II-III. Blood specimens were obtained from dilated spermatic and peripheral veins simultaneously. Peripheral samples were also collected from 13 healthy children as controls. Nitrite/nitrate levels (NO(x)) and levels of malonedialdehyde (MDA) were determined using Griess reaction and thiobarbituric acid test, respectively. Results were compared with Kruskal-Wallis and Mann-Whitney tests. Peripheral NO(x) and MDA were the same in the study and control groups (p = 0.069 and p = 0.27, respectively). Spermatic vein NO(x) and MDA levels were elevated significantly compared with the peripheral levels in the study group (p = 0.005 and p = 0.048, respectively). Increased NO(x) levels with lipid oxidation occur locally in adolescent varicocele, implying that these events could be reversed by early treatment.

Effect of varicocele on testicular artery blood flow in men--color Doppler investigation

OBJECTIVE

Varicocele can be defined as an abnormal tortuosity and dilatation of the veins of the pampiniform plexus. Contradictory results have been obtained from experimental animal models and a few clinical human studies on testicular arterial blood flow in varicocele. The purpose of this study was to determine the changes in testicular arterial blood flow parameters in patients with varicocele.

MATERIAL AND METHODS

A total of 62 patients with a clinical diagnosis of left varicocele and a scrotal vein with a diameter of > or = 3 mm on color Doppler ultrasonography were included in the study. A total of 44 fertile normal male volunteers served as controls.

RESULTS

Median testicular arterial blood flow and median flow rate in milliliters per minute per 100 g of testicular tissue were found to be significantly decreased in the patient group compared to the control group: blood flow, 1.42 and 2.00 ml/min; flow rate, 9.63 and 12.35 ml/min/100 g, respectively (p < 0.05). Positive correlations were found between sperm concentration and left testicular artery blood flow (p < 0.05) and between left testicular volume and testicular artery blood flow (p < 0.05).

CONCLUSIONS

Testicular arterial blood flow was found to be significantly decreased in men with varicocele. This may be a reflection of the impaired microcirculation. Following decreased testicular arterial blood flow, impaired spermatogenesis may result from defective energy metabolism in the microcirculatory bed.

Varicocele: current concepts in pathophysiology, diagnosis, and treatment

Although significant advances have been made in the understanding of varicoceles, a clear pathophysiologic mechanism remains elusive. Most likely, a varicocele is the result of a multifactorial process. Appreciation of the complex venous drainage of the testis remains a key to maximizing the chances for treatment success. Likewise, the advent of microsurgical repair has minimized complications. Fortunately, times have improved since the early nineteenth century, when the French surgeon Delpech (1772-1832) was killed by a disgruntled patient on whom he had performed a varicocele repair.

The role of adrenomedullin in varicocele and impotence

OBJECTIVE

To assess the levels of adrenomedullin (a vasodilatory peptide) in penile blood before and after injection with papaverine in impotent men, and in the internal spermatic vein in infertile patients with varicocele, comparing the results with levels in the brachial vein in the same patients.

PATIENTS AND METHODS

Intracavernosal levels of adrenomedullin were determined in 14 impotent men (with no vascular pathology, as assessed by colour Doppler ultrasonography) before and after papaverine-induced penile erection. The effect of needle puncture alone was assessed in eight control patients. The level of adrenomedullin was also measured in the internal spermatic vein and brachial vein in 14 infertile men with varicocele.

RESULTS

The mean (SD) intracavernosal adrenomedullin levels in the 14 impotent men were significantly different between the flaccid and papaverine-induced erectile state, at 93.5 (33.0) and 135.8 (34.9) pmol/mL, respectively, (P < 0.05). Needle puncture alone had no effect on adrenomedullin levels. In men with varicocele, the adrenomedullin level of 139.0 (34.3) pmol/mL within the internal spermatic vein was significantly higher than that in the brachial vein, at 103.9 (37.6) pmol/mL (P < 0.05).

CONCLUSION

Injection with papaverine increases adrenomedullin release into penile blood; this release may be responsible for the increase in penile blood flow and penile erection. Higher levels of adrenomedullin within the internal spermatic vein of patients with varicocele may result from the retrograde flow of venous blood from the left adrenal gland and kidney. Further studies are needed to determine the role of adrenomedullin in male infertility and impotence.

The effect of varicoceles on testicular blood flow in man

OBJECTIVES

To assess the effect of varicoceles on testicular blood flow in man.

METHODS

Testicular blood flow was measured in 248 consecutive men attending an infertility clinic and 34 fertile volunteers using color duplex ultrasonography.

RESULTS

The testicular blood flow of men with either clinical and/or subclinical varicoceles was not significantly different from controls without varicoceles.

CONCLUSIONS

Varicoceles do not significantly alter testicular blood flow in man.

Anatomy of the spermatic venous plexus (pampiniform plexus) in men with and without varicocele: intraoperative venographic study

Venous anatomy of the testis was reexamined by retrograde spermatic venography during surgery in 17 men with and in 11 without a varicocele. The route of venous drainage of the testis was the internal spermatic vein and the external pudendal vein. The cremasteric and vasal veins were smaller collaterals. There was no cross communication between the right and left spermatic venous systems in the scrotal, retropubic or pelvic areas. In men with a varicocele the spermatic venous plexus was formed of numerous venous sinuses and large dilated veins.

Blood/seminal serotonin levels in infertile men with varicocele

Seminal and blood serotonin levels were measured in 37 men with varicocele and in 33 men without palpable varicocele. Elevated levels of blood serotonin and lower levels of seminal serotonin were found in oligozoospermic men with varicocele as compared with men having varicocele but normal seminal quality. No differences in seminal serotonin levels were observed in oligozoospermic men without varicocele. Elevated levels of blood serotonin and lower levels of seminal serotonin in semen in men with varicocele were associated with low sperm count, low sperm motility, low fructose levels, and high citric acid levels. It would appear that serotonin may play a role as an infertility determinant in subjects with varicocele.

Effects of experimental varicocele require neither adrenal contribution nor venous reflux

Experimental left varicocele (ELV) is known to induce bilateral changes in the rat testis that, where comparisons are possible, are similar to the changes induced by unilateral varicocele in the human. In the present study, we have determined whether or not left adrenal products are important to the changes induced by ELV and whether or not reflux of left renal vein content occurs in the ELV rat. In the first study, testicular blood flow and temperature were studied in control animals and those with ELV, left adrenalectomy (LAX), or ELV + LAX. Control left and right testicular blood flow (33.6 +/- 0.8 and 33.6 +/- 1.5 ml./min./100 gm. tissue respectively) was significantly elevated by ELV (to 39.9 +/- 0.9 and 41.2 +/- 2.7 ml./min./100 gm. tissue, respectively) and the difference between abdominal and testicular temperatures (delta T) was significantly reduced. Control delta T's for right and left testes were 3.2 +/- 0.2C and 3.2 +/- 0.2C, respectively, and right and left delta T's for ELV animals were 2.0 +/- 0.3 degrees C and 2.0 +/- 0.3C, respectively. These blood flow and temperature changes also occurred when ELV animals were subjected to simultaneous LAX. Additionally, when 85Sr-labelled microspheres were infused into the left renal vein, they did not appear in either left or right testes of ELV animals. We conclude that there is no evidence for reflux down the spermatic vein in ELV in rats and adrenal products do not reach the testis via this route after being secreted into the renal vein. We raise the suggestion that the same may be true in the human.

Factors predicting the outcome of varicocele repair for subfertility: the value of the luteinizing hormone-releasing hormone test

The mechanism by which varicocele caused infertility is not yet clear. Endocrine factors have been suggested to explain impaired spermatogenesis in patients with varicocele. We conducted a prospective study on testosterone and gonadotropin levels and their response to the luteinizing hormone-releasing hormone test to determine the possible role of a hormonal defect in subfertility. Luteinizing hormone-releasing hormone tests were performed on 11 subfertile men with varicocele preoperatively and 3 months postoperatively. The differences in the luteinizing hormone response were statistically significant. The maximal luteinizing hormone levels also were significantly lower in patients whose spermiogram changed postoperatively. No significant changes were noted in testosterone and other gonadotropin levels postoperatively. A prognostic correlation between the change in response of luteinizing hormone to luteinizing hormone-releasing hormone (preoperatively and postoperatively) and improvement in fertility (pregnancy success) was found. We suggest that the luteinizing hormone-releasing hormone test should be considered to estimate the hormonal derangement and also the prognosis of an operation in subfertile men with varicocele.

The role of impairment of adrenal mineraloglucocorticoid function in the development of infertility in varicocele patients

The study was aimed at the understanding of pathophysiological mechanisms of the impairment of spermatogenesis in varicocele patients. The crucial role of tension increase in the venous plexus of the spermatic cord in spermatogenesis damage in the testis on the varicocele side and absence of any effect of haemodynamic abnormalities on spermatogenesis in the complementary testis has been determined. Retrograde blood flow through the central vein of the left adrenal gland in varicocele has been evidenced by X-ray examination. The role of this phenomenon in the changes of functional activity of the adrenal gland is discussed. Results of the study of functional status of adrenal glands revealed their tendency to provide hyperactivity in synthesis of mineraloglucocorticoids. Correlation between cortisol level in peripheral blood and percentage of abnormal sperm in ejaculate was shown. This fact supported the idea about the existence of a causal interrelationship between abnormalities in the functional status of adrenal glands and development of infertility in varicocele patients.

Biochemical changes in testicular varicocele

The precise mechanism of the hypospermatogenesis associated with varicocele has remained uncertain, although there have been a number of speculations on the etiology of the associated infertility. The altered spermatogenesis has been attributed to the reflux of toxic metabolites from either adrenal or renal origin, disturbed hormone status, spermatic venous hypertension, testicular hypoxia secondary to stasis, and abnormal temperature regulation. However, the biochemical changes of the testicular tissue with varicocele have been only partially explored. This overview includes the available information on the biochemical change in the testes associated with varicocele as well as the introduction of basic biochemical aspects on the testes, which may give new insights into the possible pathophysiological mechanism of male infertility.

The causes of male infertility in 504 consecutive Nigerian patients

The causes of infertility in 504 men were studied prospectively. The major causes were varicocele (28.8%), infection (20.8%), bilateral testicular failure (15%), idiopathic oligospermia (6.6%), multifactorial (5.6%), cryptorchidism (4%), sexual problems (3.8%) and surgical injury (1.6%). Unilateral testicular torsion and sickle cell disease though of less frequent occurrence were of particular interest because their roles are only now beginning to be realized. Gonadotrophin deficiency was an insignificant cause of subfertility. In spite of the high incidence of infection and past history of urethritis Neisseria gonorrheae was surprisingly not isolated from any patient. Compared with Caucasian studies, the high incidence of infection, and the low incidence of gonadotrophin deficiency are major points of difference.

Effects of varicocele after unilateral orchiectomy and sympathectomy

An experimental varicocele was created in the adult rat by partial ligation of the left renal vein. There was a significant bilateral elevation of both testicular blood flow and temperature in the varicocele animals (p less than 0.01). Mean testicular blood flow for control and varicocele animals was 29.6 +/- 1.0 and 39.8 +/- 2.0 ml./min./100 gm. tissue, while mean testicular temperature was 34.4 +/- 0.1 and 35.3 +/- 0.2C, respectively. A left orchiectomy was combined with a left varicocele to determine if the left testis is essential for the right testicular response to a varicocele. Elevation of right testicular blood flow was not altered by left orchiectomy (p less than 0.05); however, right testicular temperature was no longer significantly increased. Mean right testicular blood flow and temperature for this group was 39.0 +/- 1.5 ml./min./100 gm. tissue and 34.2 +/- 0.15C, respectively. A left sympathectomy was combined with a left varicocele to ascertain if the right testicular response to the left varicocele was mediated through a neural pathway. A significant bilateral increase in testicular blood flow was noted with a left sympathectomy alone, and thereby masked the ability to evaluate the right testicular response to the simultaneous left sympathectomy and varicocele. Elevation of right testicular blood flow in response to the left varicocele is independent of the presence of a left testis and any immune response it may stimulate. The role of the sympathetic nervous system as a mediator of the bilateral varicocele effect remains undetermined.

Further studies on testicular lipids and glycogen in human patients with unilateral varicocele

In the present study the lipid and glycogen content of human testis in patients with unilateral varicocele is presented. Eight cases were taken for the present study. Testicular biopsy specimens taken from these patients were analyzed and the normal testis acted as control groups. There was marked increase in total lipids, ester cholesterol and glycerides in the testis of varicocele patients. The abnormal increase observed in estercholesterol may be due to non-utilization of cholesterol esters for androgen biosynthesis. The glycogen level was reduced significantly in the affected testis. Thus, varicocele seem to alter the availability of substrates of energy required for normal functioning of germinal and non-germinal cells which results in defective spermatogenesis and steroidogenesis.

Physiopathologic aspects of Leydig cell function in varicocele patients

Leydig cell function was studied in 108 varicocele (V) patients with a mean age of 30.9 years, and a control group (C) of 46 men with a mean age of 30 years. Plasma gonadotropin levels were determined before and after GNRH stimulation. Testosterone (T), 17-OH-progesterone (17-OH-P), dihydrotestosterone (DHT) and estradiol (E2) were also assayed. Mean plasma T levels were significantly decreased in varicocele patients (V = 416 +/- 12.9, n = 106; C = 487 +/- 19.9, n = 40; P less than 0.01), while the basal 17-OH-P/T ratio was significantly increased (V = 0.38 +/- 0.02, n = 56; C = 0.28 +/- 0.02, n = 40; 0.02 greater than P greater than 0.01) and remained higher after hCG stimulation (P less than 0.01). No significant differences in mean sex steroid levels were observed when comparing varicocele patients with normal sperm counts (VN) and those who had oligozoospermia (VO). There was a significant negative linear correlation between age and 17-OH-P (n = 56; r = -0.47; P less than 0.01) and T values (n = 106; r = 0.27; P less than 0.01) in varicocele patients, which contrasted with the absence of any significant correlation with age in the controls. These data suggest that the duration of idiopathic varicocele influences testicular hormone secretion.

The microsurgical drainage of the varicocele

A new technique for surgical treatment of primary and recurrent varicocele is proposed. The technique consists of direct anastomosis of two or three dilated veins of the pampiniform plexus with the great saphenous vein. A connection between a high venous pressure region and a lower pressure region is established. Twenty-five patients were operated on, 7 with recurrent varicocele and 18 with primary varicocele. The immediate and long-term results (6 year follow-up) have always been good.

Testicular arterial perfusion in varicocele: the role of rapid sequence scintigraphy with technetium in varicocele evaluation

Rapid sequence scintigraphy was used to study testicular arterial perfusion and venous stasis in 53 patients with varicocele-associated infertility, 17 with idiopathic testicular failure and 9 treated for varicocele. Arterial blood supply to the diseased testicle was decreased in 63 per cent of the patients with subclinical or low grade varicocele compared to 18 per cent with idiopathic testicular failure. In the majority of cases the disturbance of perfusion disappeared immediately after interruption of retrograde blood flow in the internal spermatic vein by transcatheter embolization, whereas persistently impaired perfusion was found in a few cases with no improvement of semen quality after treatment. Venous stasis was found in only 18 per cent of the patients with low grade varicocele compared to 88 per cent with large varicoceles. It is suggested that impaired arterial blood supply rather than venous stasis is the pathogenic factor in epididymo-testicular dysfunction associated with low grade varicocele.

Testosterone and dihydrotestosterone seminal plasma levels in varicocele patients

Testosterone (T) and Dihydrotestosterone (DHT) were measured in seminal plasma levels of forty-four varicocele patients and in seventeen normal men. T values were not significantly different from controls, while DHT values were significantly lower in varicocele patients. When we grouped the patients according to the sperm count, we observed a decrease of DHT similar to that reported by other authors in oligozoospermic patients. However in the patients with normal sperm count, where the motility was the only parameter significantly lower, DHT in the ejaculate showed again a marked decrease. In contrast to that observed in the normal subjects, in the latter group, with normal sperm count, we observed a negative correlation between the age of the patients and DHT in the ejaculate. This suggests that the duration of varicocele per se could affect DHT seminal plasma levels.

FSH, LH, E2, progesterone, and testosterone in peripheral blood, spermatic vein, and semen of subfertile men with varicocele

Peripheral blood (PB), spermatic vein (Sp. V.), and semen samples were collected from 31 subfertile men with varicocele. Levels of FSH, LH, estradiol, progesterone, and testosterone were determined in the three biological fluid compartments using RIA. Remarkable increases in both testosterone and estradiol in the spermatic vein samples, as compared to either peripheral blood or semen, were evident. Correlation coefficient indicated significant positive correlation between PB FSH and each of PB LH, Sp. V. FSH, and Sp. V. LH. Significant positive correlation existed between PB LH and each of Sp. V. FSH, LH, and testosterone. Significant positive correlations were found between PB testosterone and each of Sp. V. testosterone and semen testosterone, as well as between PB estradiol and each of Sp. V. FSH and progesterone. Significant positive correlations between Sp. V. FSH and Sp. V. testicular progesterone was significantly correlated with seminal estradiol.

Morphological findings in varicocele: an ultrastructural study of 30 bilateral testicular biopsies

A systematic study of a series of thirty bilateral biopsies of testes was performed using electron microscopy. Observations showed how frequently there were bilateral changes within the Sertoli cells. These included a sometimes extensive vacuolization of the endoplasmic reticulum which may cause germ cells to exfoliate. Bilateral vascular lesions including modifications of the capillary endothelium which becomes thick and rich in pinocytotic vesicles and arteriolar spasms with an increase in number of microfilaments in the endothelial cells were constantly observed.

The recurrent varicocele--a poorly recognized problem

A varicocele is most likely the result of an incompetent vein with retrograde flow of blood into the scrotum. Surgical ligation of this incompetent system is the present-day procedure of choice. In our series of 225 varicocelectomies, there have been three definite recurrences, due to either recollateralization or failure to ligate all branches of this venous plexus.

The effect of varicocelectomy on sperm count, motility, and conception rate

One hundred and eighty-seven male partners of involuntarily infertile couples were evaluated and found to have dilatation of the left spermatic vein. One hundred and forty-nine underwent varicocelectomy and achieved a statistically significantly improved conception rate as compared with the nonoperated group. Although 70.5% of men whose wives subsequently conceived had improved semen count and motility postoperatively, no parameter distinguished these men from other patients with similar improvement who remained infertile.

The varicocele: new experimental and clinical data

Numerous reports have shown that serotonin (5-HT) has a detrimental effect on spermatogenesis and androgen synthesis. Serotonin has two mechanisms of action on the testicle: (1) vasoconstrictive changes possibly causing premature sloughing of spermatozoa, and (2) alteration of androgen metabolism. The data in our animals with the experimental varicocele clearly mimic the human situation. All seminal parameters except volume are decreased after the varicocele is created. In many infertile patients with a varicocele, serotonin may be the inciting factor which results in subfertile semen. This is corroborated by the presence of elevated serotonin levels in spermatic vein plasma of most patients with a varicocele who undergo surgery. More data, comparing the relationship between spermatic vein and peripheral blood serotonin levels in patients with and without a varicocele, are needed. This investigation is being pursued in patients undergoing inguinal surgery for other lesions.

A possible mechanism for the detrimental effect of varicocele on testicular function in man

Seminiferous epithelium histology, Leydig cell density, and in vitro testosterone synthesis were quantitated in bilateral testicular biopsies from men with varying degrees of unilateral or bilateral varicoceles. Results were correlated with plasma levels of gonadotropins (follicle-stimulating hormone [FSH], luteinizing hormone [LH]) and testosterone (T), as well as with semen quality. In patients with bilateral varicoceles, spermatogenesis, Leydig cell density, plasma T levels, and in vitro T synthesis were significantly lower than in patients with unilateral varicoceles. Varicoceles appeared to affect maximally the latest stages of spermatogenesis. A negative correlation between FSH and LH levels and spermatogenesis was observed; however, a dissociation between the two gonadotropins occurred when spermatogenesis declined. Plasma T levels were within the normal range in all patients. The T:LH ratio was significantly correlated with spermatogenesis and sperm motility. Leydig cell density was abnormally low in oligospermic patients, and it was significantly correlated with in vitro T synthesis, spermatogenesis, sperm motility, and semen volume. Sperm count and motility were significantly correlated in this group of patients, suggesting a common pathophysiology for the effect of varicocele on spermatogenesis and sperm motility. This common pathophysiology appears to be disturbed Leydig cell function resulting in decreased testicular androgen production, in turn causing inadequate spermatogenesis and epididymal function.

Varicocele and male fertility

Over the past 25 years the association of varicocele with male subfertility has been repeatedly demonstrated and the beneficial effect of varicocele ligation in infertile men with oligoasthenospermia has been documented. Since the precise mechanisms by which a varicocele affects spermatogenesis are still unclear, the proper approach to the management of "asymptomatic" varicoceles is controversial.

Bilateral testicular biopsy in men with varicocele

Fifty-two infertile men with varicoceles were subjected to bilateral testicular biopsy to detect the effect of the varicocele on each testis. The results indicate that varicocele can result in infertility primarily through sloughing of immature cells or through arrest of spermatogenesis at the spermatid or primary spermatocyte stage. The effect is bilateral but is more marked on the varicocele side. However, the presence of a varicocele could not explain the infertility of seven men with normal biopsies and of four men with a normal biopsy on the varicocele side and arrest on the other side.