Bilateral testicular biopsy in men with varicocele

Significant reduction in left testicular volume shown by ultrasonography in infertile patients with left-side grade 2-3 varicocele as compared to less than grade 2: An evidence for indication of varicocelectomy

PURPOSE

Testicular volume (TV) is known to be one of the main parameters for testicular function (TF). This study was conducted to re-evaluate the indications of a varicocelectomy based on a survey of preoperative TV results in left-side varicocele patients considered to reflect the detrimental effects of a varicocele on TF.

METHODS

TV results of infertile patients determined using ultrasonography by a single expert physician were retrospectively evaluated.

RESULTS

Of 590 examined patients, 424 had no varicocele findings (Group A), while 148 had a left-side varicocele (Group B). Group B was subdivided based on varicocele grade into Group B0 (subclinical), B1 (grade 1), B2 (grade 2), and B3 (grade 3). Comparisons of left-side TV showed no significant differences for grade among Group A, B0, and B1, whereas that for Group B2 and B3 was significantly lower as compared with Group A (p < 0.01, 0.02, respectively). The median TV of Group B I (composed of Groups B0 and B1) was 9.8 cm3, while that of Group B II (Groups B2 and B3) was significantly lower at 8.4 cm3 (p < 0.05). In contrast, a comparison of right TV values identified no significant differences among the groups (p = 0.918).

CONCLUSION

A varicocelectomy should be performed for patients with a grade 2 and 3 varicocele for ameliorating testicular function.

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.

The Effect of Human Chorionic Gonadotropin Therapy on Semen Parameters and Pregnancy Rate after Varicocelectomy

Introduction

To study the stimulating effect of human chorionic gonadotropin (hCG) on spermatogenesis in patients with varicocele and infertility undergoing varicocelectomy.

Materials and Methods

In the study, 188 infertile patients with varicocele were included. Open inguinal varicocelectomy was performed. They were randomized into 2 groups and hCG (91 patients) was administered intramuscularly by dosage of 5,000 international units every week for 3 months. A semen analysis was obtained at 6 months, post-operatively and cases were followed for 2 years for pregnancy report.

Results

Semen analysis of the patients shows a significant improvement in all parameters 6 months after varicocelectomy without any superiority between the 2 groups. During the follow-up, 56 couples (61.5%) in hCG treated and 22 couples (22.7%) in the group treated only by varicocelectomy achieved pregnancy. Patients treated with varicocelectomy plus hCG therapy had a significant superior pregnancy rate compared to the other group (P=0.0001).

Conclusion

Administration of hCG in this group of infertile patients might be helpful in order to enhance pregnancy rate. However some more conclusive studies are needed to be able to recommend such therapy for infertile men due to varicocele.

Spermatogenesis in humans and its affecting factors

Spermatogenesis is an extraordinary complex process. The differentiation of spermatogonia into spermatozoa requires the participation of several cell types, hormones, paracrine factors, genes and epigenetic regulators. Recent researches in animals and humans have furthered our understanding of the male gamete differentiation, and led to clinical tools for the better management of male infertility. There is still much to be learned about this intricate process. In this review, the critical steps of human spermatogenesis are discussed together with its main affecting factors.

IS VARICOCELE A PROGNOSTIC FACTOR FOR DETERMINING SPERM RETRIEVAL RATE BEFORE TESTICULAR SPERM EXTRACTION?

66 nonobstructive azoospermic mean with normal genetic analysis composed of 32 (48%) patients with and 34 (52%) patients without varicocele were evaluated for the rate of sperm extraction five months after the varicocelectomy. Sperm retrieval was successful in 22 of 32 patients (68%) who had been operated because of varicocele and in 13 of 34 patients (38.2%) who had no varicocele (OR = 3.55) (CI: 1.15-11.27) (p = 0.025). Overall, sperm extraction was successful in 35 of 66 patients (53%). Repair of varicocele in non-obstructive azoospermic patients may return spermatogenesis to normal in spermatogenic focuses. So, the present of varicocele and its treatment might be considered as a prognostic factor for sperm retrieval in these patients.

The safety of ultrasonically guided testis aspiration biopsies and efficacy of use to predict varicocelectomy outcome

BACKGROUND

We hypothesized that infertile men with varicoceles have molecular/genetic defects that interact with varicoceles to induce infertility. Studies directly on testis tissue appeared to be a way to link histology, markers for molecular/genetic defects and spermatogenesis, but testis biopsies may induce morbidity. In this report, we present safety and efficacy data on ultrasonically guided, single stick, percutaneous aspiration.

METHODS

Biopsies were performed on 115 infertile men with varicoceles and five men with obstructive azoospermia. Morbidity was examined by pre- and post-biopsy ultrasound, efficacy by ability of two markers to predict >50% increase in sperm density post-operatively. All patients had three pre- and three post-operative semen analyses.

RESULTS

78.3% of patients had no ultrasonic testicular defects immediately post-biopsy. By 2 months, 100% had no defects. Biopsy markers [testicular cadmium (<0.453 ng/mg tissue) and an intact calcium channel mRNA sequence] predicted >50% increase in sperm density with 82.9 and 90.5% accuracy, respectively.

CONCLUSIONS

Ultrasonically controlled, percutaneous aspiration testis biopsies are safe. Specimens so acquired can assist study of molecular/genetic markers associated with spermatogenesis in infertile men with varicoceles. Tissue cadmium level, calcium channel sequence and other markers may predict outcome of varicocele surgery.

Histological evaluation of multiple testicular biopsies helping assisted reproduction

Because of the fall in population in Europe, the evaluation of causes of male infertility is becoming more and more important. Testicular biopsy is a useful method of examination in the area of assisted reproduction. Testicular biopsies of 85 infertile males were evaluated histologically. According to the sperm count, 31 patients had azoospermia, 22 oligo-astheno-teratozoospermia (OATS), 29 oligozoospermia, and 3 astheno-teratozoospermia. The biopsies were carried out by atraumatic microsurgery. Samples were taken from the upper inner and lower outer quadrant of both sides. Bouin-fixed, paraffin-embedded blocks were cut and HE slides examined. Samples taken from azoospermic patients showed atrophy, maturation arrest, normal histology or Sertoli cell-only syndrome. Oligozoospermic patients presented maturation arrest, hypospermatogenesis or normal histology. In the OATS group maturation arrest hypospermatogenesis and atrophy were found. The spermatogram groups showed significant correlation with the homogeneity of the spermatogenesis. The sperm count alone is not sufficient in assessing spermatogenesis. Four samples give more adequate information than just one, because spermatogenesis is not homogeneous in the testis. After evaluating diagnostic biopsies, tissue for TESE can be taken from the most appropriate location in the testis.

The adolescent varicocele: treatment and outcome

At present, it is reasonable to counsel all patients, as well as family members of patients, who have a palpable varicocele about the long-term risks for impaired fertility. Currently, no one can predict with absolute certainty if any adolescent with a varicocele will be at risk for future infertility. Based on existing data, however, it is not reasonable simply to ignore the potential for such a problem until infertility becomes an issue because by that time the chance for reversibility may be lost. It is important to present a balanced discussion because the majority of men with a varicocele will be fertile, and no one is suggesting that all men with a varicocele undergo surgical treatment. Current recommendations for repair are based on the findings of impaired testicular growth and/or spermatogenesis. With early evaluation and selective treatment, however, we should be able to reduce the potential for future fertility problems significantly in adolescents with a varicocele.

Adolescent varicocele

The evaluation and management of adolescents with varicoceles continue to evolve. Current recommendations for repair are based on the findings of impaired testicular growth or spermatogenesis; however, with early evaluation and selective treatment, clinicians should be able to reduce the potential for future fertility problems significantly in adolescents with varicoceles.

Human chorionic gonadotropin adjuvant therapy for patients with Leydig cell dysfunction after varicocelectomy

The authors treated 135 men who underwent varicocelectomy, but had sustained Leydig cell dysfunction disclosed by LHRH test with human chorionic gonadotropin (hCG). hCG was administered for 10 weeks: 50,000 units were given in 10 divided doses intramuscularly. Semen analysis and measurement of serum hormone level were obtained 8 weeks after the completion of treatment, and every 3 months after that. All patients were followed up for 2 years to confirm pregnancy. Fifty-five percent of patients achieved pregnancy and they showed significant increase in sperm density, percentage of sperm motility, normal form sperm, and serum testosterone level. It is recommended that hCG be administered to patients who undergo varicocelectomy but have persistent subtle Leydig cell dysfunction disclosed by LHRH test to stimulate the intratesticular testosterone production.

Notulae seminologicae. 4. Mathematical evaluation of submicroscopical alterations in spermatozoa of sterile men with varicocele

In this paper the mathematical formula recently proposed by Baccetti & Mirolli in this journal is used for the quantitative electron microscopical evaluation of six submicroscopical defects frequently present in the spermatozoa ejaculated by patients affected by various degrees of varicocele. All these characteristics are independent from each other and are in some way related to imperfect sperm maturation. They concern the shape and position of the acrosome, the status of the chromatin, of the mitochondria, of the axoneme, the individuality of the cell. The incidence in the sperm population of these submicroscopical characters is clearly related to the degree of the affection as estimated by usual clinical parameters. This demonstrates that the electron microscopical sperm analysis evaluated by the present formula is a very sensitive tool in revealing fine prognostical parameters.

A quantitative approach to the classification of hypospermatogenesis in testicular biopsies for infertility

Absolute counts of germ cells were performed in 110 testicular biopsy specimens from 59 patients with either idiopathic infertility or varicocele and in a series of five autopsy specimens from age-matched controls. The tubular diameter, thickness of the tubular wall, and density of Leydig cells were measured. The following patterns were identified by germ-cell counts in the biopsy specimens: normal cell population, mild decrease in germ cells with normal ratio of cell types, advanced hypospermatogenesis with abnormal ratio of cell types, and Sertoli cell only. This sequence of progressive hypospermatogenesis was remarkably similar in both series. A separate category of maturation arrest was not recognized. Cell counts also correlated between right- and left-sided samples from the same patient in both series of biopsies. Reduction of tubular diameter, thickening of the tubular wall, and increase in Leydig cell density were often seen in severe stages of germ-cell impairment, although with an irregular distribution.

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.

Quantitative evaluation of Leydig cells in testicular biopsies of men with varicocele

A quantitative analysis of Leydig cells was performed in 23 testicular biopsies of men with left varicocele and sperm count ranging from zero to 95,000 sperm/mm3. The oligozoospermic patients had more Leydig cells and higher FSH and LH serum levels than the patient group with more than 10,000 sperm/mm3. The Leydig cell density appeared tightly correlated (p less than 0.01) with the serum level of LH. In oligozoospermic subjects, an altered Leydig cell function could trigger an increased LH secretion; this seems likely to be responsible for the stimulation of interstitial cells resulting in an exaggerated recruitment of mature Leydig cells from their precursors. The comparative analysis of left and right testes failed to show differences in Leydig cell density and spermatogenesis in normozoospermic and oligozoospermic patients. This suggests that the two testes are equally involved by a possible, although unknown, detrimental effect of left side varicocele.

Varicocele and puberty--the critical factor?

In some boys varicocele develops before puberty, when the testis is immature and vulnerable. Based on testicular size, evidence suggests that the time of development of a varicocele in relation to puberty may be the critical factor in the subsequent development of infertility. The recognition and treatment of an early-developing varicocele may help to reduce the infertility associated with this condition.

Testis morphometry in varicocele

This study was conducted to evaluate morphometrically the microscopic components of the testis in cases of varicocele, the leading cause of male infertility, with the aim to identify consistent differences from controls. In our specimens of patients with varicocele, the vascular and interstitial fractions, as well as the Leydig cell count, were significantly increased. Our data support the notion that the interstitium is the testicular compartment most consistently affected and that the damage to the tubules is erratic and probably late.

Varicocele: reversal of the testicular blood flow and temperature effects by varicocele repair

An experimental left varicocele was created in the adult rat by partial ligation of the left renal vein. A varicocele repair was performed by high ligation of the internal spermatic vein. Testicular blood flow and temperature changes were measured in control and sham animals, animals 30 days after establishment of varicocele and animals 30 days after varicocele repair. There was a statistically significant (p less than or equal to 0.01) bilateral elevation of testicular blood flow and temperature in the varicocele group compared to control and sham groups. Varicocele repair returned these blood flow and temperature values to normal. Average testicular blood flow for control, varicocele, sham varicocele and varicocele repair animals were 29.6 +/- 1, 39.8 +/- 2, 30.7 +/- 1 and 29.8 +/- 1 ml. per min. per 100 gm. tissue, respectively. Testicular temperatures averaged 34.4 +/- 0.1, 35.3 +/- 0.2, 34.4 +/- 0.1 and 34.5 +/- 0.1 degrees C, respectively. It is possible that the elevation in blood flow is associated with the elevation of intratesticular temperature, which is known to impair spermatogenesis. The data support a relationship between the varicocele and potential testicular damage.

Testicular biopsy in azoospermia and severe oligozoospermia

The continued experience of testicular biopsy application in 861 cases of azoospermia and 152 cases of severe oligospermia is reported adding to the previously published cases of 1075 patients with azoospermia. The most common finding in the whole series was that of normal testis denoting obstruction (48%), while among cases of functional azoospermia, Sertoli cell only and spermatogenic arrest were the most frequent (66%).

Andrologic aspects of varicocele

The changes in the spermatogram subsequent to surgery for varicocele because of infertility were examined, consideration being given to the various sperm parameters. Improvement of one parameter or more was demonstrable in 30 out of 40 surgical cases. The parameters indicative of motility showed the most marked improvement. The andrologic significance of early diagnosis is emphasized.

Spermatic vein ligation in varicocele: prognosis and associated male and female infertility factors

The fertility outcome of 129 spermatic vein ligations with good postoperative anatomic results is analyzed. For each couple, specific attention was also directed to other infertility factors. The study analyzes four groups: group I, 55 patients with varicocele only; group II, 16 patients with varicocele and prostatovesiculitis; group III, 16 patients with varicocele and a severe degree of testicular failure; and group IV, 42 patients with a varicocele only and associated female infertility factors. In each group, the pregnancy rate within 6 to 24 months after the operation was recorded. The control subjects were 36 patients with varicocele only who had declined or postponed intervention for 6 months. The best results were obtained in group I. Sperm motility improved following ligation and was associated with a greater percentage of pregnancies within a shorter period: 51% and 62% within 6 and 12 months, respectively, as compared with the control group (14% within 6 months). The prostatic disease required additional treatment for a longer period, but results similar to those of group I were eventually obtained (50% pregnancy rate). With testicular failure or female infertility factors, the prognosis worsened (31% overall pregnancy rate).

Pituitary gonadal function in infertile men with varicocele

Infertile men with varicocele or idiopathic infertility were compared with a control group. Spermocytograms were taken and the following radioimmunological plasma analyses carried out: testosterone, FSH and LH before and after 50 micrograms LRH, Prolactin (PRL) before and after 200 micrograms TRH; in addition, 8 patients with varicoceles and 3 controls received LRH intravenously (0.4 microgram/min.) for 4 hours. The binding of [125I] human chorionic gonadotrophin (hCG) to testicular tissue obtained by biopsy from 10 infertile men was also investigated. Of the parameters studied, no differences were found between the unilateral or bilateral varicoceles. In the two groups of infertile men, sperm motility and percentage normal forms were similar and significantly lower than in controls. As compared to the controls, in the groups of infertile men, basal LH and testosterone levels were no different but basal FSH levels was increased, basal PRL was higher (p less than 0.05) in the varicocele group. Responses of the LH, FSH and PRL to LRH and TRH stimulations were generally higher in infertile men than in controls. As compared to the idiopathic infertile men, testosterone levels and responses of plasma FSH to LRH injection were lower in varicocele group. Moreover, in infertile men with varicocele, age was correlated negatively with sperm motility and testosterone level and it was correlated positively with LH response to LRH injection. For each patient, testicular tissue was able to specifically bind [125I]hCG, but in some cases of varicoceles, hCG binding capacity was different in the two testes and seemed higher than that observed in men with obstructive azoospermia. These results suggest: 1) dysfunction in both spermatogenesis and Leydig cells with a compensatory hyperfunction of the pituitary gland in infertile men with varicocele; 2) worsening in Leydig cells and tubular lesions with longer duration of varicocele; and 3) absence of any gross abnormality in hCG binding to its specific receptors in the testis of men with varicocele. These data suggest varicoceles may play a causal role in infertility.

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.

Testicular function in varicocele

Testicular testosterone concentration serum testosterone, LH and FSH, sperm count and testicular histology were evaluated in 17 patients with varicocele. Testicular testosterone was either normal or high (mean 906 +/- 723 ng/g of tissue), and serum testosterone was within the normal range in most patients. Serum LH was elevated in half of the patients. The degree of testicular damage observed was extremely variable and correlated with sperm analysis. Testicular testosterone tended to be higher in patients with severe microscopic lesions of the testis. It is concluded that even though Leydig cell function is partially altered, this deficiency is compensated by LH stimulation and therefore, failure of spermatogenesis is not secondary to low testosterone levels.

Improvement of semen and pregnancy rate after ligation and division of the internal spermatic vein: fact or fiction?

Male partners with left-sided varicoceles of 96 infertile couples were studied. Fifty-one patients were submitted to ligation of the testicular veins and 45 individuals were randomised as controls. During an observation period of 53 months (range 36 to 74 months) we found no statiscally significant improvement in the semen crude variables, the morphology or the progressive motility in the series of men submitted to surgery. The pregnancy rate was lower in those who had an excision of varicocelle.