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

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Can preoperative gonadotropin and testosterone levels predict the success of varicocelectomy?

We examined the effects of preoperative hormonal values on varicocelectomy success. A total of 136 patients who underwent varicocelectomy for infertility in our clinic were analysed retrospectively. Improvement in semen quality was defined as >50% increase in post-operative total motile sperm count (TMSC) in those with preoperative TMSC >5 million and at least 100% increase in those with <5 million. The patients were divided into two groups as benefiting from the treatment (Group A) and no benefits (Group B). The best cut-off value for follicle-stimulating hormone (FSH) and the luteinising hormone/testosterone ratio (LTR) that can predict varicocelectomy success were 7.01 and 0.016 with an area under the curve of 0.844 and 0.856 respectively. The highest sensitivities and specificities of FSH and LTR were 0.845 and 0.788 and 0.821 and 0.846 respectively. Binary logistic regression analysis showed FSH (odds ratio [OR]: 3.7; p < .001) and LTR (OR: 5.2; p < .001) as independent predictive factors in predicting varicocelectomy success. Our study demonstrated that low FSH (7.01 IU/L) and LTR (<.016) can be a useful preoperative predictive tool to help identify men who benefit most from varicocelectomy in infertile patients with varicocele.

The clinical usefulness of a novel grading system for varicocoeles using duplex Doppler ultrasound examination based on postsurgical modifications of seminal parameters

BACKGROUND

The existing classifications of varicocoeles have poor predictive value regarding the effects of surgery on sperm count.

OBJECTIVE

To develop a new grading system for varicocoeles, useful as an indication for surgery.

MATERIALS AND METHODS

This is a three-center prospective study which examined 173 men having clinically detectable left varicocoeles and oligo ± astheno ± terato-spermia. The patients underwent medical history collection, objective examination, duplex Doppler ultrasound scrotal examination, hormonal profiles, two semen analyses before surgery, and two semen analyses after surgery. Sperm concentration, motility, and morphology (standard semen parameters) were evaluated 6 months after surgery in function of the following preoperative variables: patient age, follicle-stimulating hormone, clinical grade of varicocoele, right and left testicular volume, extension of venous reflux, and semen parameters. The venous reflux was graded in two centers using duplex Doppler ultrasound: reflux visible only with Valsalva and continuous reflux. Spearman's rank semiquantitative analysis was used. All patients had their varicocoeles corrected according to the Colpi technique.

RESULTS

The variables capable of determining an improvement in semen parameters after varicocoele correction were in order of decreasing importance: venous reflux extent assessed by scrotal duplex Doppler ultrasound examination, varicocoele clinical grade, basal semen parameters, and follicle-stimulating hormone. Male age did not influence postoperative semen quality. Only patients with continuous reflux had their standard semen parameters improved after surgery.

DISCUSSION

Venous reflux extent is the most critical variable capable of predicting semen improvement after varicocoelectomy.

CONCLUSIONS

A correct duplex Doppler assessment of venous reflux is mandatory for predicting postoperative improvement of the sperm count.

Effects of varicocelectomy on serum testosterone

Varicocele is most often surgically repaired due to male infertility, however, has recently been linked to low serum testosterone. This paper serves to review the current literature regarding varicocele and its subsequent repair on serum testosterone. Twenty-eight human studies were identified with fifteen showing improved serum testosterone after repair. The majority of the studies that demonstrated improvement had preoperative testosterone levels that were low or below normal. Additionally, multiple well-designed studies with control groups not undergoing surgical repair demonstrated significant difference between groups. This improvement was less observed in studies with normal preoperative serum testosterone. A majority of these patients studied were presenting for infertility. It remains to be determined if these findings can be reproduced in men without infertility. The findings suggest that microsurgical varicocele repair can improve serum testosterone in men with low levels preoperatively in appropriately counseled men. It remains to be seen whether varicocele repair can help prevent the development of low testosterone in the future or which patients are at risk of developing low testosterone due to varicocele.

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.