Varicocele sclerotherapy improves serum inhibin B levels and seminal parameters

Predictive parameters of the efficacy of varicocele repair: a review

ABSTARCT

Varicocele has a prevalence of 15% in the population and represents a primary cause of infertility in 40% of cases and a secondary cause in approximately 80% of cases. It is considered the major correctable cause of male infertility. Despite its high prevalence in the infertile population, a large number of patients with varicocele do not experience reproductive difficulties. For this reason, it is still highly debated which parameters could be used to predict which patients with varicocele will be most likely to benefit from its repair. The main international and European guidelines state that treatment should only be considered in infertile patients with abnormal sperm quality. However, these guidelines do not help physicians to identify which of these patients may benefit from the treatment. Therefore, this narrative review collects the evidence in the literature on the usefulness of some factors as predictors of improvement, highlighting how some of them may be effective in an initial selection of patients to be treated, while others are promising but further studies are needed. Finally, a brief consideration on the possible role of artificial intelligence is proposed.

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.

Effects of Varicocele Surgical Repair on Serum Hormone and Inhibin B Levels for Patients With Varicocele: A Systematic Review and Meta-Analysis

Varicocele surgical repair can improve the function of the testis for patients with varicocele. We carried out a systematic review and meta-analysis to assess the effects of varicocele surgical repair on serum hormones and inhibin B levels in patients with varicocele. A literature search was performed in August 2022, and no language or geographic region restrictions were applied. The search included the following databases: PubMed, Embase, and Medline. A literature review was performed to identify all published clinical trials assessing serum hormone and inhibin B levels before and after varicocele surgical repair. The reference lists of retrieved studies were also investigated. A systematic review and meta-analysis were conducted. Eight articles were selected from 162 articles, including 452 patients. The combined analysis showed that after surgical treatment, mean serum testosterone, inhibin B, and sperm concentration levels increased compared with preoperative levels (p < .05). After surgical treatment, mean serum follicle-stimulating hormon (FSH), and Luteinizing hormone (LH) levels decreased compared with preoperative levels (p < .05). This meta-analysis demonstrates that varicocele surgical repair can improve testicular function, increase serum testosterone, and inhibin B levels and decrease serum FSH and LH levels in patients with varicocele. This might be related to the improvement of infertility. A large-scale multicenter randomized controlled study is needed for further confirmation.

Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis

PURPOSE

Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls.

MATERIALS AND METHODS

A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies).

RESULTS

A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; p<0.001; I²=97.6%), total sperm count (SMD 1.894; 95% CI 0.566 to 3.222; p<0.05; I²=97.8%), progressive sperm motility (SMD 3.301; 95% CI 2.164 to 4.437; p<0.01; I²=98.5%), total sperm motility (SMD 0.887; 95% CI 0.036 to 1.738; p=0.04; I²=97.3%) and normal sperm morphology (SMD 1.673; 95% CI 0.876 to 2.470; p<0.05; I²=98.5%). All the outcomes showed a high inter-study heterogeneity, but the sensitivity analysis showed that no study was sensitive enough to change these results. Publication bias was present only in the analysis of the sperm concentration and progressive motility. No significant difference was found for the semen volume (SMD 0.313; 95% CI -0.242 to 0.868; I²=89.7%).

CONCLUSIONS

This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies' practice recommendations favoring VR to improve conventional semen parameters in infertile men.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Indications and outcomes of varicocele repair

Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.

Treating varicocele in 2018: current knowledge and treatment options

PURPOSE

Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein. The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In this review, the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in pediatric/adolescent subjects.

METHODS

We conducted a Medline and a PubMed search from 1965 to 2018 to identify publications related to varicocele clinical aspects, treatment procedures and treatment outcomes. Keywords used for the search were: "varicocele", "varicocelectomy", "sclerotherapy", "male infertility", "subfertility", and "semen abnormalities".

RESULTS

Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach.

CONCLUSIONS

Varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies.

Safety and effectiveness of the different types of embolic materials for the treatment of testicular varicoceles: a systematic review

OBJECTIVE

The purpose of this study is to assess the current evidence regarding the safety and effectiveness of the various embolic materials used in varicoceles embolization.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases were searched for clinical studies that investigated the clinical outcomes of embolization treatment for the management of testicular varicoceles. Study methodological quality was analyzed.

RESULTS

23 retrospective and 7 prospective clinical studies were identified with a total of 3505 patients. Technical success rates appear to be above 90% for all embolic materials without any significant differences. In terms of recurrence rates, glue (N = 251) appeared to have the lowest and sclerosants alone (N = 728) the highest recurrence rates which were 4.2% (11-3.08%, SD: 5.9) and 11.03% (18.8-5.15%, SD: 6.06) within an average follow up (f/u) of 16.13 and 25.48 months respectively. Coils alone (N = 898) had an average recurrence rate of 9.1% (17.8-1.4%; SD: 5.79) and a mean f/u of 39.3 months. After an average of 12 months of f/u, the addition of sclerosants (N = 1628) as an adjunct to coils did not improve recurrence rates (8.44%, 16.5-5.1%; SD: 3.4). No differences were reported regarding the safety profile of the various embolic materials.

CONCLUSION

Despite the heterogeneity of the included studies, preliminary evidence supports the safe and effective use of the various embolic materials currently used for the management of varicoceles. At 1 year, glue appears to be the most effective in preventing recurrence with coils being the second most effective. The addition of sclerosants to the coil embolization did not appear to have an impact on recurrence rates. Further research is required to elucidate the cost-effectiveness of these approaches. Advances in knowledge: Varicocele embolization appears to be a safe and effective technique regardless of the embolic agent. Addition of a sclerosant agent to coil embolization does not appear to improve outcomes.

Varicoceles: prevalence and pathogenesis in adult men

Varicocele, or dilation of the pampiniform venous plexus, affects up to 15% of men. However, few of these men encounter problems with fertility. This discrepancy between men with varicocele and the number of adversely affected men has led to abundant research to identify the mechanisms for formation of varicocele as well as the pathologic mechanisms by which varicoceles affect fertility potential. In this review, we discuss the prevalence of varicocele in adults, the anatomic features of varicocele, the leading theories as to how varicocele can negatively affect fertility potential, and finally, the current literature on the impact of varicocele on testosterone production.

Microsurgical Subinguinal Varicocele Repair of Grade II-III Lesions Associated with Improvements of Testosterone Levels

INTRODUCTION

The results of reports on the association between varicocele repair and testosterone levels were conflicting. The aim of the present study is, therefore, to investigate the impact of varicocele repair on testosterone levels.

MATERIALS AND METHODS

The study is based on 20 men who experienced microsurgical subinguinal varicoceles repair because of chronic dull scrotal pain. All hormonal profiles available in the clinical records were reviewed. Follow-up evaluation was done at 1 and 12 months after surgery. Men were classified into groups based on the preoperative testosterone levels: euogonadal (serum levels of testosterone > 12 nmol/l), hypogonadal men (serum levels of testosterone ≤ 12 nmol/l).

RESULTS

Microsurgical subinguinal varicocele repair was associated with a significant improvements of testosterone levels at 1 and 12 months after surgery as compared to the preoperative levels (13 nmol/l vs. 18 nmol/l, p = 0.03; 13 nmol/l vs. 15 nmol/l, p = 0.01). The same trend was seen in men who were classified as being hypogonadal (7.0 nmol/l vs. 15 nmol/l, p = 0.01; 7.0 nmol/l vs. 10 nmol/l, p = 0.02). No significant improvements in testosterone levels were observed in euogonadal men (p > 0.05).

CONCLUSION

Microsurgical subinguinal varicocele repair was associated with a significant improvements of testosterone levels in men with grade II-III lesions and low preoperative testosterone values.

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.

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.

Varicocele - a case for early intervention

Testicular varicocele, which is defined as the dilation of the veins draining the testicle, has long been associated with a detrimental effect on testicular function. Despite a lack of high-quality, prospective data, recent evidence has shed light on potential links between varicocele and male infertility and serum testosterone levels. Similarly, varicocele repair has increasingly been shown to have a beneficial impact on pregnancy rates, semen parameters, and on improving serum testosterone in adult men. Numerous studies have assessed the optimal technique for varicocele repair and the bulk of the evidence has shown the microsurgical inguinal/subinguinal approach to have the highest success rates, the lowest overall complication rates, and the lowest recurrence rates. The management of varicocele in adolescents remains a clinical conundrum, but contemporary evidence suggests early deleterious effects of varicocele on testicular function in some patients. Well-designed prospective trials are critical to delineate the true impact and role of varicocele repair on male infertility and hypogonadism in adult and adolescent men.

Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up

Introduction

To study the impact on adult’s fertility of serum inhibin B levels in adolescent patients with idiopathic varicocele after minimally invasive surgical correction and to compare fluctuation of pituitary-testis hormonal values and testicular volumes.

Materials and Methods

A case-control study was carried out on a group adolescent patients (n=60) affected by idiopathic left varicocele (group V) and compared with control adolescents (n=40) in the Paediatric Surgery Section of Siena (from June 1993 till September 2013). Inhibin B levels and testicular volume before (T0) and after at 6 and 12 months from surgery (T1 and T2) were evaluated.

Results

A positive correlation between testicular growth at T1 and T2 (P<0.001) was found. Linear regression analysis showed a positive correlation between inhibin B levels and testicular volume (expressed as the sum of the right and left values) (P<0.0001).

Conclusions

Inhibin B levels are a valid marker for studying the effects of varicocele on the testicular function and confirm the necessity of early surgical correction for preventing the trophic testicular damage and male infertility.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques

OBJECTIVES

We report our experience with polidocanol foam sclerotherapy with no additional coils, evaluating clinical success, patients' satisfaction, and complications.

METHODS

We conducted a retrospective study of 141 patients with 146 varicoceles (mean age: 29.3 years; range: 13 - 60 years) who underwent foam sclerotherapy with polidocanol 2% (range: 2 - 12 ml) in an outpatient setting between January 2007 and December 2013. For the follow-up, telephone interviews with the patients were conducted (mean follow-up time: 46.4 months, standard deviation: 20.17 months).

RESULTS

The technical success rate was 91.8%. There was a 55.8% response rate to the telephone interviews. Follow-up revealed a clinical success rate of 83.9% and a persistence or relapse rate of 16.1%. Of the patients, 81.9% were absolutely satisfied with the outcome. In 94.9% of cases, pain or discomfort resolution was reported, and in 97% of cases, aesthetic issues were no longer a problem. Of partners, 63.2% achieved pregnancy, and in 50% of patients with preprocedural testicular atrophy, catch-up growth was observed. One patient with pampiniform plexus phlebitis received inpatient treatment with no long-term damage recorded.

CONCLUSIONS

Polidocanol foam varicocele sclerotherapy is a safe and effective procedure, with a high rate of patients' satisfaction, clinical and technical success, and considerable catch-up growth and pregnancy achievement.

KEY POINTS

• Varicocele treatment using polidocanol foam sclerotherapy is a safe and effective procedure. • It is easily feasible in an outpatient setting. • The clinical and technical success rates are high. • It shows a high rate of patients' satisfaction and symptom resolution. • Postinterventional catch-up growth and pregnancy achievement are considerable.

[The varicocele: the proper therapy for the proper patient]

Varicocele is present in 15% to 20% of the general population, but in approximately 35% to 40% of males presenting for an evaluation of their infertility. Indeed it is well known that varicocele can cause testicular damage and infertility. No evidence indicates a varicocele treatment in infertile men who have normal semen analysis or in men with subclinical varicocele. In this situation, varicocelectomy cannot be recommended. Varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility, but we need further randomized studies to confirm that this subgroup of infertile couples will benefit from treatment. There is no doubt about the standard indications of varicocelectomy, but recent literature seems to go towards new indications of varicocele repair. The aim of this review is to give a look at the literature to analyze the proper indications to varicocelectomy for the proper patient.

Varicocele: How this condition and its management affects men's health

Varicocele is a relatively common condition that can impact men’s health in various ways. Unfortunately, its prevalence and the availability of various different methods of repairing it might lead to unnecessary treatment. An understanding of the various ways that this condition can impact men’s health is necessary in order to manage it appropriately. At present, there is substantial evidence to support varicocele repair in men who present with infertility, abnormal semen parameters, clinical varicocele and a female partner with normal fertility (or one with a potentially correctable abnormality). Varicocele repair appears to improve seminal fluid quality and might improve pregnancy rates. It might also have a role in managing men with non-obstructive azoospermia. Varicocele can also be a cause of scrotal pain that is usually of a dull character. Varicocele repair is an effective method of managing this type of pain, especially once proper measures have been taken to exclude other possible causes of orchalgia. Conservative measures are generally not effective in managing varicocele-related scrotal pain. There is growing evidence to suggest that varicocele repair might have a role in improving the serum testosterone level in men with hypogonadism, especially in the subfertile population. Well-designed prospective studies are needed to support the utilization of varicocele repair in managing these patients, as well as in preventing testicular dysfunction on a prophylactic basis.

Beneficial effects of varicocele embolization on semen parameters

BACKGROUND

The value of varicocele repair and the latter's impact on semen parameters are still subject to debate.

METHODS

We analyse changes over time in initially abnormal sperm parameters and serum concentrations of testosterone, FSH and inhibin B after embolization treatment of males with high-grade varicocele. From 2007 to 2012, we recruited 47 male infertile patients with clinically visible left varicocele in the resting patient and at least one abnormal semen parameter. Sperm parameters and serum levels of total testosterone, FSH and inhibin B were measured prior to retrograde embolization (M0) and then 3 (M3) and 6 (M6) months afterwards.

RESULTS

At M0, the median sperm concentration was 5.78 [0.84-37.70] × 10(6)/ejaculate. The mean ± SD sperm progressive motility, vitality and percentage of normal sperm were respectively, 21.83 ± 16.48%, 61.88 ± 15.98% and 12.88 ± 7.15%. The corresponding values at M3 were significantly higher (38.75 [3.96-95] × 10(6)/ejaculate, 29.32 ± 14.21%, 69.14 ± 14.86% and 19.03 ± 11.02%, respectively). The mean percentage of spermatozoa with a thin head was significantly lower at M6 (6.35 ± 5.29%) than at M0 (14.03 ± 13.09%). The mean serum testosterone, FSH and inhibin B levels did not change significantly over time.

CONCLUSIONS

Embolization treatment in men with clinically visible left varicocele, abnormal sperm parameters and documented infertility is associated with a significant improvement in semen parameters including sperm head morphology.

The varicocele

Varicoceles are an abnormal dilation of the pampiniform plexus of veins within the scrotum. Varicoceles are highly prevalent and can result in a myriad of deleterious effects on male reproduction. Numerous therapeutic options are available for correcting varicoceles, including surgical varicocelectomy and radiographic venous embolization. Varicocele correction is a more cost-effective therapeutic modality than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples. In summary, varicoceles contribute significantly to male reproductive pathology, and varicocele correction is an important option for both clinicians and patients to consider in this era of assisted reproductive techniques.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis

OBJECTIVES

To determine the effect of surgical varicocele repair in improving testicular Leydig cell function as shown by increased testosterone production.

METHODS

Eligible studies were searched in Medline and the Pubmed database, and cross-referenced as of 31 May 2011 using the terms "varicocele,""testosterone" and "surgery." The database search, quality assessment and data extraction were independently carried out by two reviewers. Only studies including patients with testosterone evaluation before and after surgery were considered for the analysis. A systematic review and meta-analysis was carried out for continues variables using random effect models.

RESULTS

Out of 125 studies, a total of nine were selected, including 814 patients. The combined analysis showed that mean serum testosterone levels after surgical treatment increased by 97.48 ng/dL (95% confidence interval 43.73-151.22, P=0.0004) compared with preoperative levels.

CONCLUSIONS

Surgical treatment of varicocele significantly increases testosterone production and improves testicular Leydig cell function.

Serum inhibin B levels before and after varicocelectomy in early adolescence

BACKGROUND

Whereas no clear relationship has been observed between varicocelectomy and serum inhibin B levels in men, in adolescents comparison between inhibin B levels before and after varicocelectomy is lacking.

AIM

To evaluate the effect of varicocele surgical treatment on inhibin B levels in adolescents at the beginning of puberty compared to a group of healthy adolescents.

SUBJECTS AND METHODS

We studied 28 adolescents in Tanner 2 pubertal stage with a grade III left-sided varicocele (patients) compared to 13 age and pubertal stage-matched healthy adolescents (controls). All patients underwent blood tests to determine serum inhibin B levels before and 6 months after varicocelectomy by Palomo procedure. For comparison we investigated inhibin B levels in controls and repeated this test 6 months later. Testicular ultrasound was performed for patients only.

RESULTS

Baseline inhibin B concentrations of patients and controls were 109.90 ± 40.26 and 109.33 ± 38.34 pg/ml, respectively. No significant changes were observed in patients' inhibin B concentrations after varicocelectomy (116.00 ± 42.65 pg/ml), or in controls during the 6 months' follow-up (99.12 ± 30.09 pg/ml). Doppler examination after treatment shows a complete resolution of varicocele in all the patients without alterations in testicular parenchyma.

CONCLUSIONS

Varicocelectomy performed on adolescents at T2 pubertal stage might be useful to avoid alteration in inhibin B production and consequently in testicular function. Further studies are necessary to confirm the prognostic value of inhibin B levels and the benefit of early varicocelectomy in preserving the fertility of these adolescents.

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.8±3.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI).