Significant predictive factors for subfertility in patients with subclinical varicocele

Changes in testicular arterial hemodynamic, gonadotropin levels, and semen parameters among varicocele patients randomized to varicocelectomy or observed in Tamale, Ghana

Objective:

A randomized trial to compared testicular blood flow parameters, gonadal hormones, and semen characteristics among three groups; surgery group ( n = 127); observed group ( n = 114); and healthy controls ( n = 33).

Methods:

The blood flow parameter selected was resistive index (RI) measured using color Doppler ultrasonography. Serum total testosterone, FSH, LH were measured, and semen analysis performed at baseline and repeated 12 months of follow-up. The data was computed using GraphPad Prism (v8.0) at an alpha of 0.05.

Results:

In the observed group, increased +0.0060 in the right (R_RI) and in the left (L_RI) +0.0026 capsular arteries from baseline measurement to 12 months follow-up. Surgery group, reduced –0.079 in the right (R_RI) and −0.0731 in the left (L_RI) capsular arteries ( p < 0.0001). At 12 months, the changes for both left and right RIcap in the surgery group did not reach the values of the controls. In the surgery group, L_RIcap ( r = −0.63; p < 0.0001) and R_RIcap ( r = −0.49; p = 0.004) correlated with total testosterone, FSH ( r = 0.57; p = 0.001 for left; r = 0.52; p = 0.002 for right), and LH ( r = 0.61; p = 0.0002 for left; r = 0.41; p = 0.020 for right). Furthermore, L_RIcap correlated with changes in sperm count ( r = −0.46; p = 0.008) and sperm concentration ( r = −0.35; p = 0.011) in the surgery group.

Conclusion:

Microsurgical sub-inguinal varicocelectomy improves blood supply to the testicular tissues evidenced by reduced resistive index in the surgery group. Resistive index in the left capsular artery can be used to evaluate the success of surgery because it correlates with total testosterone, FSH, LH, and semen quality.

Role of total motile sperm count in the evaluation of young men with bilateral subclinical varicocele and asthenospermia

INTRODUCTION

In comparison to its clinical analogue, the subclinical varicocele represents a questionable entity and specific guidelines for the optimal management are lacking. In our previous study of patients with subclinical varicocele, we showed that bilateral condition is associated with risk of dyspermia. In the present study, we evaluated the risk of deterioration of semen quality in men with bilateral disease and impaired motility according to WHO criteria.

MATERIALS AND METHODS

Men with bilateral subclinical varicocele, not desiring fatherhood at the time of presentation, were included in study. During initial evaluation, the number of Total Motile Sperm Count (TMSC) was calculated and the patients' age, total testicular volume (TTV), maximum venous size and mean resistive index (RI) of the intratesticular arteries were recorded. We classified the participants in five classes according to the TMSC reading: class A-: TMSC < 5 x 106, class A: TMSC between 5-10 x 106, class B: TMSC between 10-15 x 106, class C: TMSC between 15-20 x 106, and class D: TMSC > 20 x 106 per ejaculate. The participants were seen after 6 months for a repeat spermiogram and physical examination. If clinical varicocele was diagnosed or a new abnormality in the spermiogram was noted, the participants were excluded from the study. The remaining patients were allocated to two groups according to the repeat TMSC reading: patients sub-classified into a lower class (group 1), and patients remaining at the same class (group 2). A comparative analysis was performed between two groups.

RESULTS

Nineteen men were included. Nine patients were subclassified (group 1). Three patients moved to A- class (< 5 x 106). Ten patients remained in the same class having no deterioration (group 2). Comparing the two groups, no statistically significant difference was recognized for age, TTV, maximum venous size on both sides, and mean RI (p > 0.05). However, the initial reading for TMSC was 14.57 x 106 in group 1, and 22.84 x 106 in group 2, respectively. This difference was statistically significant (p < 0.05). Additionally, in a paired analysis there was a significant difference in TMSC after 6 months (p < 0.05), too. Summary Conclusions: Young men with bilateral varicocele and asthenospermia seem to be at risk of deterioration in their semen quality after a follow-up of 6 months. The measurement of TMSC can unmask patients at risk, whereas men with the lowest readings seem to be at highest risk for deterioration. The possibility of a worsening sperm quality should be considered in the appropriate clinical context.

1H NMR-based metabonomics for infertility diagnosis in men with varicocele

PURPOSE

"Omics" techniques have been used to understand and to identify biomarkers of male infertility. We report on the first metabonomics models created to diagnose varicocele and infertility among men with varicocele.

METHODS

We recruited 35 infertile men with varicocele (VI group), 21 fertile men with varicocele (VF group) and 24 fertile men without varicocele (C group). All men underwent standard semen analysis, scrotal duplex ultrasonography, and sexual hormone level measurement. Hydrogen-1 nuclear magnetic resonance (1H NMR) spectra of seminal plasma were used to create metabonomics models to discriminate between men with and without varicocele, and between fertile and infertile men with varicocele.

RESULTS

Using the statistical formalisms partial least square discriminants analysis and genetic algorithm-based linear discriminant analysis (GA-LDA), we created two models that discriminated the three groups from each other with accuracy of 92.17%. We also created metabonomics models using orthogonal partial least square discriminants analysis and GA-LDA that discriminated VF group from VI group, with an accuracy of 94.64% and 100% respectively. We identified 19 metabolites that were important in group segregation: caprate, 2-hydroxy-3-methylvalerate, leucine, valine, 3-hydroxybutyrate, lactate, alanine, 4-aminobutyrate, isoleucine, citrate, methanol, glucose, glycosides, glycerol-3-phosphocoline, n-acetyltyrosine, glutamine, tyrosine, arginine, and uridine.

CONCLUSIONS

1HNMR-based metabonomics of seminal plasma can be used to create metabonomics models to discriminate between men with varicocele from those without varicocele, and between fertile men with varicocele from those infertile with varicocele. Furthermore, the most important metabolites for group segregation are involved in the oxidative stress caused by varicocele.

Bilateral disease and intratesticular haemodynamics as markers of dyspermia in patients with subclinical varicocele: A prospective study

Objective: To study scrotal ultrasonographic characteristics in patients with subclinical varicocele (SV) and investigate their relationship with semen parameters.

Patients and methods: In all, 56 men with SV were recruited and divided into two groups, according to their semen characteristics. Group A, comprised 34 men with normal semen analysis; and Group B, comprised 22 men who carried at least one abnormality, regarding sperm concentration, motility and morphology. Between the two groups we compared: age; body mass index (BMI); semen pH and semen volume; total testicular volume (TTV); maximal vein diameter (MVD) and degree of reflux; mean values of peak-systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) of the intratesticular arteries; whether bilateral SV; and serum testosterone and follicle-stimulating hormone (FSH) levels.

Results: Asthenospermia was present in all patients in Group B; 10 patients had asthenospermia only, six patients were astheno-oligospermic and six patients had astheno-oligo-teratospermia. Age, BMI, semen pH and volume, TTV, MVD and degree of reflux did not differ significantly between the two groups (P > 0.05). However, EDV, PSV and RI were significantly different (P < 0.05). Bilateral SV was significantly more frequent in patients in Group B (P < 0.05). Finally, FSH was elevated in Group B (P < 0.05), whereas testosterone was normal in both groups, albeit significantly lower in men with abnormal semen analyses (P < 0.05).

Conclusion: Classic ultrasonographic characteristics in men with SV, such as venous size or degree of reflux, were insufficient to distinguish patients with abnormal semen analysis. However, bilateral disease and intratesticular haemodynamics differed significantly in patients with SV and abnormal semen analysis.

Abbreviations: BMI: body mass index; CDU: colour Doppler ultrasonography; EDV: end-diastolic velocity; MVD: maximal vein diameter; PSV: peak-systolic velocity; RI: resistive index; SV: subclinical varicocele; TTV: total testicular volume; US: ultrasonography

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.

Cut-off values of the Johnsen score and Copenhagen index as histopathological prognostic factors for postoperative semen quality in selected infertile patients undergoing microsurgical correction of bilateral subclinical varicocele

Background

It remains challenging to determine which individuals are likely to benefit from microsurgical correction of subclinical varicocele, as basic semen parameters often do not improve postoperatively. We aimed to develop an easily accessible tool for prognostic stratification of infertile men indicated for microsurgical correction of bilateral subclinical varicocele characterized by prolonged and clear venous reflux and no other cause for infertility.

Methods

We retrospectively analyzed the testicular biopsy, seminal analysis, and ultrasound evaluation records of 20 men managed between 2006 and 2014. Subclinical varicocele was diagnosed through bilateral testicular palpation and auscultation of venous reflux using a Doppler stethoscope, with confirmation on color Doppler sonography. We conducted receiver operating characteristic curve analysis to identify the optimal combinations of cut-offs for the Johnsen score, Copenhagen index, and testicular volume defining histological patterns with positive prognostic value for improved postoperatively reproductive capacity.

Results

Positive prognostic value was noted for the following combinations of parameters: (I) Johnsen score >8.2 in the left testicle and right testicular volume >12.8 mL predicted improved sperm concentration; (II) Johnsen score >8.2 and Copenhagen index digit II <2.5 bilaterally predicted improved total sperm motility; (III) Johnsen score >9.1 and Copenhagen index digit III <1.5 bilaterally predicted improved progressive sperm motility; (IV) Johnsen score >7.9 and right testicular volume >13.6 mL predicted improved sperm morphology.

Conclusions

Johnsen score and Copenhagen index as histopathological prognostic factors can be easily obtained upon evaluation of testicular biopsy specimens and can be simple and reliable tool to establish a more realistic prognosis for reproductive capacity in men who undergo microsurgical correction of subclinical varicocele with no other detectable cause for infertility.

Evaluation of hemorrhoidal disease and lower extremity venous insufficiency in primary adult varicocele: A prospective controlled study

Background

The study investigated the association between varicocele, lower extremity venous insufficiency and hemorrhoidal disease.

Methods

The study included 62 patients with varicocele and 60 voluntary subjects with no varicocele. Patients who were diagnosed as having varicocele on physical examination and Doppler ultrasonography were included in the study group. Examination of lower extremity venous insufficiency was performed by physical examination and Doppler ultrasonography. Examination of hemorrhoidal disease was performed by a general surgery specialist.

Results

The patients with varicocele had a statistically significant ( p < 0.05) higher rates of venous insufficiency of the lower extremities and had a borderline significant difference of higher hemorrhoidal disease rates ( p = 0.05). Therewithal incidences of hemorrhoidal disease and lower extremity venous insufficiency were significantly higher in body mass index > 25 and age > 30 years of varicocele patients.

Conclusion

There is a statistically significant relation between varicocele, lower extremity venous insufficiency, and hemorrhoidal disease. In particular, varicocele patients who are aged over 30 years and overweight are at higher risk.

Comparison of clinical outcome of bilateral and unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: A meta-analysis of randomised controlled trials

Varicocele is the most common cause of male infertility. Varicoceles are classified into two types: clinical and subclinical varicoceles. Some researchers reported right subclinical varicoceles are often accompanied with left clinical varicoceles. However, the treatment is controversial. Our aim was to compare the clinical outcome of unilateral varicocelectomy (UV) and bilateral varicocelectomy (BV) in infertile males with left clinical and right subclinical varicocele. A total of four randomised controlled trials (RCT) were enrolled in this study, including 637 cases with left clinical and right subclinical varicocele (318 cases in the BV group and 319 cases in the UV group). The fixed effects model combined difference in progressive sperm motility between the two groups was 6.42% (95% CI: 5.09, 7.75). The random effects model combined difference in normal sperm morphology between the two groups was 2.04% (95% CI: 0.60, 3.48). The odds ratio shown by the fixed effects model in spontaneous pregnancy rate was 1.73 (95% CI: 1.24, 2.43). No statistically significant difference between the two groups was found in sperm concentration and sperm motility. Thus, BV may be superior to UV for infertile male patients with left clinical and right subclinical varicocele. However, more properly conducted RCTs are still needed.