Preoperative neutrophil-to-lymphocyte ratio as a new prognostic predictor after microsurgical subinguinal varicocelectomy

A Nomogram for Predicting Infertility Risk in Patients With Varicocele Using Inflammatory Markers

The purpose of this study was to develop a nomogram using hemogram inflammatory markers to predict the risk of infertility in patients with varicocele (VC). Patients with VC from March 2022 to June 2024 were retrospectively investigated. We divided the patients into two groups based on their fertility status. A total of 162 patients were enrolled: 81 in the infertile group and 81 in the fertile group. Statistical differences were observed between the two groups in lymphocyte, monocyte, erythrocyte, red cell distribution width (RDW), mean erythrocyte volume (MCV), mean platelet volume (MPV), platelet distribution width (PDW), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), MPV/platelet ratio (MPVPR), and systemic inflammation response index (SIRI) (p < .05). The 162 patients were divided into a modeling cohort and a validation cohort in a 7:3 ratio. A predictive nomogram was constructed based on independent influencing factors identified through univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis, calibration curve, and decision curve analysis were used to assess the model's performance. Multivariate logistic regression analysis indicated that erythrocyte count, PDW, NLR, and SIRI were independent influencing factors. The area under the curve for the nomogram predicting the risk of infertility in patients with VC was 0.869 in the validation cohort. The nomogram demonstrated good predictive performance. In this study, we developed an effective predictive nomogram for assessing the risk of infertility in VC patients using inflammatory markers. However, further external validation is crucial.

The effect of systemic inflammatory index and systemic inflammatory response index on success of varicoselectomy

BACKGROUND

Varicocele is the most common correctable cause of male infertility. The treatment of varicocele is surgery. However, which patients will benefit from the surgery is controversial. Our aims to investigate the effect of systemic immune-inflammation index (SII) and systemic inflammatory response index (SIRI) on varicocelectomy success.

METHODS

Patients who underwent varicocelectomy in our clinic between January 2016 and June 2022 were analyzed retrospectively. Varicocelectomy success was defined as >50% increase in post-operative total motile sperm count (TMSC) in those with pre- operative 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 1) and no benefits (Group 2).

RESULTS

Of the 207 patients who underwent varicocelectomy, 144 (69.6%) of them improved their semen parameters, and 63 (30.4%) did not. The optimum cut-off value of SII was 334.6, with an AUC of 0.733 (95% CI: 0.665-0.813). The best cut-off value for SIRI of 0.882, with an AUC of 0.692 (95% CI: 0.607-0.772). The highest sensitivity and specificity were 0.692 and 0.601 (p < 0.001). In the multivariate analysis, only SII (OR: 3.152, 95% CI: 1.316-7.358; p = 0.003) and SIRI (OR: 2.919, 95% CI: 1.472-5.774; p = 0.002) were independent predictive factors for varicocelectomy success.

CONCLUSIONS

Our results showed that preoperative SII and SIRI values were lower in infertile patients who underwent successful varicocelectomy. Therefore, we think that these parameters will be useful in identifying patients who will benefit before varicocelectomy.

Effect of varicocele and varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele

Varicocele is the leading cause of male infertility. It can affect sperm quantity and quality through various non-mutually exclusive pathophysiological mechanisms, mainly oxidative stress. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress and harm the sperm's DNA. Excessive sperm DNA breaks, so-called sperm DNA fragmentation, result from the oxidative stress cascade and are commonly found in the ejaculates of men with varicocele and fertility-related issues. Measuring sperm DNA fragmentation can provide valuable information on the extent of harm and might help select candidates for surgical treatment. Varicocelectomy is beneficial for alleviating oxidative stress-associated infertility and improving sperm DNA integrity. However, reproductive outcomes of infertile men with elevated sperm DNA fragmentation rates and surgically treated varicoceles remain poorly studied, and there is a need for well-designed trials to determine the impact of sperm DNA fragmentation reduction on natural and medically assisted reproduction.

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.

Insight into inflammation involvement in varicocele: A narrative review

BACKGROUND

Varicocele is one of the main causes of male infertility. Although the pathophysiology mechanism of varicocele is very well described and understood, there are some unanswered questions that remains unknown. Some studies have previously described the state of testicular inflammation and sperm in animal models, especially the mouse model, and the seminal plasma of men with varicocele, with or without changes in semen parameters.

METHODS OF STUDY

This review intended to verify the role of inflammatory mechanism in varicocele, using clinical studies as well as animal model studies on the effect of inflammation caused by varicocele on the function of testicular somatic and germ cells.

RESULTS

In-vivo studies confirmed whether anti-inflammatory molecules could treat the semen of men with varicocele and rats with varicocele. The use of different anti-inflammatory agents in mouse model studies provided a new perspective for future clinical studies to investigate the effect of concurrent treatment with surgery to improve surgical outcomes.

CONCLUSION

Similar to animal model studies, previously conducted clinical trials have demonstrated the effectiveness of anti-inflammatory therapy in varicocele patients. However, clinical trials using anti-inflammatory are needed to be conducted agents to evaluate different aspects of this therapeutical approach in varicocele patients.

Impact of body mass index on semen parameters and reproductive hormones among men undergoing microsurgical subinguinal varicocelectomy

Background

Few studies assessed the relationships between BMI and post varicocelectomy semen quality and fertility potential and they reported inconsistent findings.

Objective

To assess the association of BMI with semen parameters and reproductive hormones before and after microsurgical varicocelectomy.

Materials and Methods

Retrospective chart review in a tertiary infertility center. Of 1170 patients with clinical varicocele during the study period (8 years), 813 patients were eligible and included. Patients were grouped into: Group A (kg/m2, n = 251 patients), B (BMI 25-29.9 kg/m2, n = 289), C (BMI 30-34.9 kg/m2, n = 183) and D (kg/m2, n = 90). Clinical data, semen parameters, sperm DNA fragmentation and hormonal profile were collected before and 3 months after microsurgical varicocelectomy.

Results

Patients' mean age was 35.87 ± 8.17 years. Higher-grade varicocele was significantly more prevalent in the lower BMI groups. BMI was significantly negatively correlated with preoperative sperm concentration, total motility progressive motility and total motile sperm count. Pre-operatively, sperm concentration, total motility, progressive motility and total motile sperm count showed significant differences between BMI groups, where higher BMI (Groups C and D) exhibited the poorest semen parameters. Postoperatively, all groups showed significant improvement in sperm concentration compared with pre-operative values. However, total and progressive motility were significantly improved in Groups A, B and C, while in Group D (highest BMI), total motility improved clinically but not statistically, progressive motility did not display improvement, and total motile sperm count was significantly improved only in Groups B and C. Postoperatively, mean improvements in semen parameters across the BMI groups were not significantly different, except for morphology, which improved significantly more in the less obese patients.

Conclusion

For infertile patients with clinical varicocele undergoing micro-surgical varicocelectomy, BMI appears not to impact the improvements across most of the semen parameters and hormones. The procedure might improve the fertility potential.

Prediction of semen analysis parameters improvement after varicocelectomy using 1 H NMR-based metabonomics assays

BACKGROUND

Varicocele is the most common correctable cause of male infertility, however, predicting varicocelectomy outcomes is difficult. "Omics" techniques have been increasingly used to develop new diagnostic and prognostics tools for several male infertility causes, and could be applied to study varicocele.

OBJECTIVES

To create metabolomics models capable of segregating men who improved semen analysis (SA) parameters or achieved natural pregnancy after microsurgical varicocelectomy (MV) from those who did not, using Hydrogen-1 nuclear magnetic resonance (¹ H NMR) spectra of seminal plasma of pre-operative samples.

MATERIAL AND METHODS

We recruited 29 infertile men with palpable varicocele. ¹ H NMR spectra of seminal plasma were obtained from pre-operative samples and used to create metabonomics models. Improvement was defined as an increase in the total motile progressive sperm count (TMC) of the post-operative SA when compared to the baseline, and pregnancy was assessed during 24 months after MV.

RESULTS

Using Linear Discriminant Analysis (LDA), we created a model that discriminated the men who improved SA from those who did not with accuracy of 93.1%. Another model segregated men who achieved natural pregnancy from men who did not. We identified 7 metabolites that were important for group segregation: caprylate, isoleucine, N-acetyltyrosine, carnitine, N-acetylcarnitine, creatine and threonine.

DISCUSSION

We described the use of metabonomics model to predict with high accuracy the outcomes of MV in infertile men with varicocele. The most important metabolites for groups segregation are involved in energy metabolism and oxidative stress response, highlighting the pivotal role of these mechanisms in the pathophysiology of varicocele.

CONCLUSIONS

¹ H NMR spectroscopy of seminal plasma can be used in conjunction with multivariate statistical tools to create metabonomics models useful segregate men with varicocele based on the reproductive outcomes of MV. These models may help counseling infertile men with varicocele regarding their prognosis after surgery. This article is protected by copyright. All rights reserved.

Can preoperative inflammatory markers predict the success of varicocelectomy?

The aim of this study was to evaluate the effect of inflammation on the success of varicocelectomy by using some inflammatory markers. Adult male patients aged ≥18 years who were evaluated for infertility, had abnormal parameters in at least two preoperative semen analyses and underwent subinguinal microscopic varicocelectomy were retrospectively evaluated. The patients were divided into two groups; those showing improvement in semen parameters were determined as Group A and those without improvement as Group B and compared with each other. A total of 102 patients were included in this study. Group A contained 32 (31.4%) patients while Group B had 70 (68.6%) patients. Monocyte/lymphocyte ratio (MLR) and neutrophil/lymphocyte ratio (NLR) were found to be statistically significantly higher in Group B (p = 0.014 and p = 0.028 respectively). Although preoperative sperm concentration and total motile sperm count were higher in Group B, postoperative all semen parameters were significantly higher in Group A. The cutoff points that were determined using the Youden test were <2.02 for NLR (AUC = 0.636, CI = 0.519-0.754; p = 0.028) and <0.22 for MLR (AUC = 0.652, CI = 0.531-0.773; p = 0.014). Pre-varicocelectomy low NLR and MLR values were found to be significant parameters in predicting the success of the surgery.

Developing a novel prediction model for the impact of varicocelectomy on postoperative fertility

The objective of this study was to evaluate inflammatory markers as predictors of fertility after varicocelectomy and to develop a prediction model. This prospective cohort was conducted on patients with varicoceles who were presented to the clinic of Imam Reza hospital of Tehran during 2019-2020. Semen analysis, complete blood count (CBC), and scrotal ultrasonography was requested. Patients with abnormalities of semen analysis were chosen as candidates for varicocelectomy. 6 months after the operation, semen analysis was repeated. Hematologic and semen analysis parameters were recorded at baseline and follow-up visits. Treatment success was defined as 50% increase in total motile sperm count (TMSC) in cases with preoperative TMSC> 5 million/cc or 100% increase in TMSC in cases with preoperative TMSC< 5 million/cc. Patients were then categorized into two groups based on treatment success and statistical analysis was performed on these two groups. 124 infertile patients with varicocele were evaluated in our study. 52 patients (41.93%) showed improvements in semen analysis after varicocelectomy. After univariate and multivariate analysis three parameters were used in our predictive model as body mass index (BMI)>23.70 kg/m2 (4 scores), neutrophil-lymphocyte ratio (NLR) >1.80 (3 scores), and TMSC<14.69 million (2 scores). A cut-off value of 5 was associated with an 87.5% sensitivity and an 84.6% specificity for the prediction of failure of varicocelectomy. Varicocelectomy can improve semen analysis parameters in almost all infertile men with varicocele. Using BMI, NLR, and baseline TMSC as the suggested scoring system can predict the success of varicocelectomy for improving fertility and determine the appropriate infertile candidates for surgery.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment: critical assessment and systematization

In this review, we tried to systematize all the evidence (from PubMed [MEDLINE], Scopus, Cochrane Library, EBSCO, Embase, and Google Scholar) from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment. Regarding the outcomes of varicocele repair, we considered semen improvement and pregnancy and analyzed them separately. Based on the 2011 Oxford CEBM Levels of Evidence, we assigned a score to each trial that studied the role of the predictor. We systematized the studied predictors based on the total points, which were, in turn, calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant, into three levels of significance: predictors of high, moderate, and low clinical significance. Preoperative total motile sperm count (TMSC) coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy. In addition, for semen improvement alone, scrotal Doppler ultrasound (DUS) parameters, sperm DNA fragmentation index (DFI), and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Combination of early Interleukin-6 and -18 levels predicts postoperative nosocomial infection

BACKGROUND

The inflammatory response plays a critical role in postoperative nosocomial infections, which are the most common postoperative complications causing adverse events and poor postoperative outcomes. This study aimed to explore the ability of early inflammation-related factor levels to predict the occurrence of nosocomial infections after abdominal surgery.

METHODS

The study included 146 patients with open abdominal surgery (a nosocomial infection group (NI group, n=42) and a no-nosocomial infection group (NNI group, n=104)). After 1:1 matching, the patients were divided into a matching nosocomial infection group (M-NI group, n=25) and a matching no-nosocomial infection group (M-NNI group, n=25). Serum levels of interleukin (IL)-6, IL-8, IL-10, IL-12, IL-18, macrophage migration inhibitory factor (MIF), and monocyte chemotactic protein (MCP-1) were tested at three time points (pre-operation, 0-hour post-operation (POD1) and 24-hour post-operation (POD2)). The area under the receiver operating characteristic curve (AUC-ROC) was used to test the predictive abilities.

RESULTS

There were significant differences in the levels of IL-6, IL-12, and IL-18 between the M-NI and M-NNI groups (p < 0.05), but not in the levels of other inflammatory factors. MIF, IL-8, and MCP-1 levels were higher in the M-NI group than in the M-NNI group at POD2 (p < 0.05). In the ROC analysis, the AUC for prediction of nosocomial infection using a combination of IL-6 and IL-18 at POD1 was 0.9616, while the AUCs for IL-6 alone and IL-12 alone were 0.8584 and 0.8256, respectively.

CONCLUSIONS

The combination of the levels of inflammatory factors, IL-6 and IL-18, at the 0-hour postoperative time point, significantly improved the predictive ability to the development of postoperative infection during perioperative period. Our study suggests the importance of monitoring postoperative inflammatory markers.

Prediction of reproductive function recovery after microsurgical varicocelectomy in men from infertile couples: Clinical and laboratory predictors

The objective was to reveal predictors for fertility recovery after varicocelectomy in subfertile men. This retrospective study recruited 93 men with clinical varicocele and pathozoospermia who underwent microsurgical varicocelectomy. Stepwise discriminant analysis was performed to identify predictors of spontaneous pregnancy (SP) after surgery. 'Clinically significant improvement' (CSI) following varicocelectomy was defined as an increase in total progressively motile sperm count (TPMSC) by at least 12.5 million (calculated from WHO-2010 reference values). 52% of patients showed CSI, and 28% reported SP after surgery. Patients who reported SP (group II), compared to that remained infertile (group I), were younger (27.3 ± 2.9 versus 30.2 ± 4.2 years; p < .01), had less infertility period (24.1 ± 14.0 versus 44.4 ± 32.9 months; p < .05) and had initially higher TPMSC (median (25% -75%) = 34 (11-67) versus 9.5 (0-33) mln; p < .05). The stepwise discriminant analysis showed that male age (coefficient value = -0.157), total sperm motility (0.024) and postoperative increase in TPMSC (0.010) were the significant predictors of SP. The predictive ability, sensitivity and specificity of the discriminant function were 84%, 87%, 76% respectively. This algorithm can be recommended after varicocelectomy in decision-making on natural conception or the ART protocols usage.

What is the role of pre-operative blood parameters in forecasting varicocelectomy success?

BACKGROUND

We aimed to examine the effects of pre-operative blood values on varicocelectomy success.

MATERIALS AND METHODS

A total of 130 patients who underwent varicocelectomy in our clinic were retrospectively analyzed. Operation success was defined as the return of all semen parameters (concentration, progressive motility, and morphology) to normal values 6 months after surgery. The patients were separated as two groups as benefiting from the treatment (Group A) and not (Group B).

RESULTS

The best cut-off value for the neutrophil/lymphocyte ratio (NLR), which can predict varicocelectomy success, was assigned to be 2.27, with AUC of 0.859 (%95 CI 0.795-0.922). The highest sensitivity and specificity were 0.857 and 0.731 (p < 0.001). The best cut-off value for the mean platelet volüme (MPV) value, which can predict varicocelectomy success, was assigned to be 9.45, with AUC of 0.729 (%95 CI 0.639-0.819). The highest sensitivity and specificity were 0.655 and 0.635 (p < 0.001). Binary logistic regression analysis showed NLR ratio (odds ratio (OR): 11.2, p < 0.001) and MPV (OR: 2.65, p = 0.002) parameters as independent predictive factors in predicting varicocelectomy success.

DISCUSSION AND CONCLUSION

Our study showed that low NLR ratio (≤2.27) and high MPV (≥9.45) ratio levels may be a useful pre-operative predictive tool in identifying men who benefit most from varicocelectomy in infertile patients with varicocoele.

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.