Predictors of improved seminal characteristics by varicocele repair

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.

Determination of the time for improvement in semen parameters after varicocelectomy

This retrospective study aimed to determine the time for improvement in semen parameters after varicocelectomy. A total of 175 patients over 18 years of age, who underwent microscopic inguinal varicocelectomy in a tertiary centre between 2005 and 2016 and had post-operative follow-up data of at least 12 months, were included in the study. Serial semen analyses in the pre-operative period and at the post-operative third, sixth, ninth and 12th months were retrospectively documented. With respect to their pre-operative total motile sperm counts, the patients were classified into three subgroups as <5 million, 5-9 million and >9 million. In the overall cohort and the group with a total motile sperm count of >9 million, the semen parameters continued to improve up to the post-operative 12th month. No further significant improvement was observed after the post-operative third and sixth months for the patients with pre-operative total motile sperm counts of <5 million and 5-9 million respectively. For the candidates of varicocelectomy, the decision of treatment strategies, such as assisted reproductive technologies and waiting for spontaneous pregnancy can be based on the prediction of the time for improvement in semen parameters.

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.

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.

Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men

PURPOSE

A continuous spermatic venous reflux (SVR) at colour Doppler ultrasound (CDU) is an evidence for varicocele, a frequent correlate for male subfertility. We explored whether SVR after left varicocele repair is predictive for changes in semen quality in subfertile men.

METHODS

Blood hormones (FSH, LH, and total testosterone) and scrotal CDU were obtained in subfertile patients with left grade II or grade III varicocele on physical evaluation and a poor sperm quality. Semen analysis and CDU were re-evaluated 6 months after a retrograde internal spermatic vein scleroembolisation.

RESULTS

The retrospective study included 100 men with a baseline SVR >3 cm/s; 60 men showed a disappearance (group 1) and 40 men (group 2) showed a reduced SVR after varicocele repair. Total motile sperm count (TMC) was markedly increased after treatment (p < 0.0001; F = 35.79) and the increase was more relevant in group 1 compared to group 2 (p = 0.04; F = 4.20). TMC and left SVR values after varicocele repair were negatively correlated (R = -0.218; p = 0.035). Multivariate analysis showed that adjusted SVR after repair negatively predicted TMC change (TMC after repair minus baseline TMC) (ß = -2.56; p = 0.022). Disappearance of a continuous left SVR at CDU after varicocele repair was associated to a better improvement of semen parameters in subfertile men.

CONCLUSION

Recording of a continuous left spermatic vein reflux is an objective method to assess a successful varicocele repair aimed to improve sperm parameters in subfertile men.

The impact of coexisting sperm DNA fragmentation and seminal oxidative stress on the outcome of varicocelectomy in infertile patients: A prospective controlled study

OBJECTIVES

To study the relationship between sperm DNA fragmentation (SDF) and reactive oxygen species (ROS) levels in infertile patients with varicocele, and to examine the beneficial effect of varicocelectomy and elucidate predictors of improvement after repair.

PATIENTS SUBJECTS AND METHODS

We prospectively studied 60 patients with varicocele and abnormal semen variables who attended the outpatient clinic complaining of infertility for ≥12 months. In all, 25 patients (41.7%) had bilateral varicoceles and 35 (58.3%) had left varicoceles. The DNA fragmentation index (DFI%, percentage of sperm with denatured nuclei), ROS and total non-enzymatic antioxidant capacity (TAC) were measured. Inguinal varicocelectomy was performed in all patients. At 3-6 months postoperatively, all measurements were repeated. A control group, comprised of 20 normozoospermic fertile men, was included. Regression analysis was used to examine predictors of improvement.

RESULTS

The mean (SD) DFI% in the 60 infertile patients with varicocele was 29.9 (8.3) and 7.56 (2.84)% in the controls; ROS levels were 4.49 (0.9) in patients and 2.62 (0.8) photons/min in controls; and the TAC was 0.97 (0.4) in patients and 1.5 (0.5) mM in controls; with highly significant differences between the patients and controls. The DFI% showed a positive correlation with ROS levels, whilst the total motile sperm count (TMSC) had a significant negative correlation with DFI%, ROS levels and grade of varicocele, whilst there was significant positive correlation with TAC. The grade of varicocele and duration of infertility were related to the presence of higher levels of ROS and increased of DFI%. Postoperatively, improvement (measured as a >50% increase in TMSC) occurred in 40 of 55 (73%) patients available at follow-up, with a significant reduction in the mean (SD) DFI% from 29.49 (8.58) to 18.78 (7.23)%, ROS levels from 4.49 (0.88) to 3.27 (1.3) photons/min (both P < 0.001), and a significant increase in the mean (SD) TAC from 1.01 (0.44) to 2.05 (0.51) mM (P < 0.001). Responders had a shorter infertility duration and lower preoperative DFI% and ROS levels. Regression analysis showed that DFI% is a predictor of improvement after varicocelectomy.

CONCLUSION

SDF was shown to have a negative impact on improvement after varicocelectomy. Hence, DFI% could be recommended as a prognostic test in infertile patients with varicocele to help decision-making as regards the necessity and the anticipated outcome of varicocelectomy in patients with infertility.

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.

Can We Predict the Outcome of Varicocelectomy Based on the Duration of Venous Reflux?

OBJECTIVE

To investigate the outcome of varicocelectomy based on the duration of venous reflux (DVR) of the pampiniform plexus veins.

MATERIALS AND METHODS

In total, 138 patients with clinically palpable varicoceles were evaluated for DVR with color Doppler ultrasonography from May 2009 to August 2014. The DVR was defined as the DVR of a varicocele in the supine position during the Valsalva maneuver. Patients with bilateral, recurrent, or subclinical varicoceles; hormonal imbalances involving follicle-stimulating hormone, luteinizing hormone, or total testosterone; azoospermia; and intraoperative or postoperative complications were excluded. Of the 138 patients, 76 met the inclusion criteria. All patients were treated with subinguinal microscopic varicocelectomy. Restoration of all three semen parameters (concentration, motility, and morphology) to normal values 6 months postoperatively was considered to indicate treatment success. The patients were divided into those with a DVR of <4.5 seconds (Group 1) and ≥4.5 seconds (Group 2).

RESULTS

The mean age of the patients was 29.39 (±6.03) years. No statistically significant relationship was found between the success rate and varicocele grade. The cutoff DVR value was calculated as 4.5 seconds using a receiver operating characteristics curve according to patients who underwent successful treatment. The success rates of Groups 1 and 2 were 40.0% and 88.2%, respectively (P = .0001).

CONCLUSION

The results of this analysis indicate that a DVR of ≥4.5 seconds predicts better outcomes of varicocelectomy.

Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study

INTRODUCTION

We aim to predict results of varicocelectomy on sperm density and progressive motility using preoperative clinical, laboratory and radiological data and to propose cut-off values for significant parameters.

METHODS

This prospective study was carried out between July 2011 and June 2014. We included 123 patients in our study. They were diagnosed with primary infertility with varicocele, were scheduled for varicocelectomy, and completed their follow-up. We excluded patients with azoospermia, total necrospermia, recurrent varicocele, and pituitary hormonal abnormalities. Varicocele was diagnosed and graded by physical examination and colour Doppler ultrasound. Semen analyses were completed preoperatively and 6 months postoperatively. Microscopic subinguinal varicocelectomy was done in all cases. Patient demographics, pre- and postoperative clinical data (varicocele grade and semen parameters) were statistically analyzed.

RESULTS

The mean ± standard deviation of age, body mass index, and subfertility duration was 28.3 ± 7.4 years, 29.1 ± 2.7 kg/m(2), and 21.9 ± 7.1 months, respectively. About 53% of our patients (n = 66) had bilateral varicocele, and unilateral disease was found in the other 57 (46.3%) cases. Varicocele grade I was diagnosed in 42 (34.1%) patients, while the other 81 (65.9%) patients had grade II or III. Higher grades of varicocele, preoperative total testosterone level, sperm density, and progressive motility had a statistically significant impact on the outcome of varicocelectomy in univariate testing. Multivariate logistic analysis revealed that grade of preoperative varicocele (95% confidence interval [CI] 5.6-6.3, p = 0.007) and sperm density (95% CI 2.7-1.6, p = 0.0035), and progressive motility (95% CI 1.1-2.3, p = 0.0123) are independent predictors of semen parameters improvement after varicocelectomy.

CONCLUSION

The grade of the varicocele, sperm density, and progressive motility are major predictors of outcome in varicocelectomy. Cut-off values of >8 million/mL and >18% for sperm density and progressive motility, respectively, in men with varicocele grade II or III, indicate a successful outcome.

The influence of antisperm antibodies, intratesticular haemodynamics and the surgical approach to varicocelectomy on seminal variables

Objective

To evaluate the effect of antisperm antibodies (ASAs), hormonal levels, intratesticular haemodynamics and the surgical approach on the outcomes of varicocelectomy in infertile men, as assessed by seminal variables.

Patients and methods

In a prospective case-series study, 82 infertile men with varicocele (35 left and 47 bilateral) were evaluated. The preoperative assessment included a physical examination, semen analysis, assessment of ASAs in seminal plasma, hormonal levels (follicle-stimulating hormone (FSH), luteinising hormone and testosterone), and scrotal colour Doppler ultrasonography (CDUS) to measure the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and pulsatility index. Patients were scheduled for varicocelectomy, with high ligation (Palomo) used in 40 patients (18, 45%, with left and 22, 55%, with bilateral varicocele), or an inguinal approach (Ivanissivich) with loupe magnification used in 42 (17, 40%, with left and 25, 60%, with bilateral varicocele). The men were reassessed at ⩾3 months after surgery and according to the improvement in seminal variables (expressed as a ⩾50% increase in total motile sperm count, TMSC), patients were further categorised into ‘improved’ or ‘unimproved’. Binary logistic regression analysis was used to investigate the predictors of improvement.

Results

Before surgery the ASAs were positive in 17 men (21%). There was no significant difference between the right and left sides in intratesticular haemodynamics. The TMSC was improved in 52 (63%) patients who had a significant improvement in the haemodynamic variables. Intratesticular haemodynamics, serum FSH and testosterone levels differed significantly between the improved and unimproved patients. Positivity for ASAs, the surgical approach and laterality of the varicocele were not significantly different, although the ASA-positive cases were characterised by a significant decrease in motility. Logistic regression analysis showed that the EDV, PSV, FSH, testosterone level and bilateral testicular volume (BTV) were significant predictors of improvement.

Conclusion

Positivity for ASAs is not a predictor of the outcome after varicocelectomy but affects only the motile fraction in positive cases, despite the improvement in other seminal variables and testicular haemodynamics, and regardless of the surgical approach. The EDV, PSV, FSH, testosterone and BTV were significant predictors of a successful outcome.

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

In the literature, there is no good agreement with variables to predict seminal outcome after varicocelectomy. The purpose of this study was to evaluate the FSH percentage change (Δ% FSH) as a predictor of the seminal outcome after varicocelectomy together with other known predictors. We evaluated 118 patients who underwent varicocelectomy. We assessed factors that could be predictors of the improvement of semen characteristics: LH, FSH, total and free testosterone before operation, testis volume, age, testicular pain, body mass index (BMI), Δ% FSH, varicocele Doppler ultrasound grade using regression analysis. Mean sperm concentration increased from 27 ± 12 to 52 ± 15 million per ml post-operatively (P < 0.003), mean sperm motility increased from 31 ± 12 to 40 ± 13 million per ml following the operation (P < 0.02), also mean FSH value changed from 10.2 ± 8.3 to 6.7 ± 7.2 UI/L (P < 0.01). In unvaried regression analysis, Δ% FSH, BMI and age were predictors of the improvement of semen characteristics. In multiple regression analysis, only Δ% FSH and age were predictors. Negative correlation with age and positive correlation with Δ% FSH were observed. Our findings suggest that Δ% FSH (before and after varicocelectomy) and age are significant factors predicting the improvement of semen characteristics.

Predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele

To examine the predictive factors of successful redo varicocelectomy in infertile patients with recurrent varicocele, we made a retrospective study. Twenty-one patients who had improved quality of spermatozoon 6 months after RV were designated as group 1, those with no improvement as group 2 (17 subjects) and those who received close surveillance as group 3 (10 patients) were recruited. The predictive factors included were time to recurrent varicocele; semen quality; testicular volume; number of ligated veins; body mass index; serum levels of follicle-stimulating hormone (FSH), luteinising hormone and testosterone; scrotal temperature; and peak retrograde flow (PRF) and maximal vein diameter (MVD) by colour Doppler ultrasound. The quality of spermatozoon improved significantly 6 months after RV in group 1 patients (21, 55.3%), and no improvement in group 2 and 3 patients. Patients in group 1 also had significantly lower FSH and PRF, longer time to recurrent varicocele, higher number of ligated veins and larger testicular volume than the group 2 (17, 44.7%) and group 3 patients. The significant predictive factors of successful RV were lower FSH and PRF; longer time to recurrent varicocele; and larger testicular volume preoperatively and a higher number of ligated veins during redo varicocelectomy.

Current issues in varicocele management: a review

The most common cause of male infertility is varicocele, and varicocele is the most common correctable cause of male factor infertility. In this article we reviewed the concept of varicocele in terms of its diagnosis, method of treatment, indications for treatment, treatment outcomes, and prognostic factors. Physical examination is an essential diagnostic tool in the evaluation of a patient with a varicocele. However, as it depends on subjective findings, standardization of the physical examination method is needed. Various methods for treatment of varicocele exist, including open surgical, laparoscopic, microscopic surgical, and radiologic treatment such as embolization. Among these treatment approaches, microscopic inguinal or subinguinal varicocelectomy has superior outcomes, with a low complication rate. The influence of the treatment of varicocele on fertility is still a controversial issue and a difficult question to address, because there are limitations to performing a randomized control study, and previous studies had a heterogeneity of subjects and high dropout rate. However, there is robust evidence that varicocelectomy improves semen parameters as a surrogate marker of the potential for fertility. To date, general indications for treatment of varicocele are limited in patients with proven infertility, clinical palpable varicocele, and abnormal semen characteristics. Recently, it was shown that some symptoms other than infertility could be an indication for varicocelectomy because these symptoms are frequently related to deterioration of semen parameters. Varicocele in the adolescent presents a more difficult decision regarding whether to treat. A testicular size discrepancy of more than 20% is helpful for treatment decisions. Various prognostic factors were noted in several studies without, however, a consistent consensus.

Factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment

OBJECTIVE

To assess the factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment.

METHODS

A total of 76 men with left painful varicocele and normal semen quality were recruited for the present prospective study. The patients who showed complete or partial resolution of pain 6 months after varicocelectomy were designated as responders, and those who did not have improvement were designated as nonresponders. The predictive factors examined included the number of ligated veins, preoperative pain score, duration of pain, body mass index, scrotal temperature, the distance from the renal hilum to the scrotum, the serum concentration of follicle-stimulating hormone, luteinizing hormone, and testosterone, grade of varicocele, peak retrograde flow, and maximal vein diameter on color Doppler ultrasound scans.

RESULTS

Of the 76 patients, 55 (72.4%) were responders and 21 (27.6%) were nonresponders, with a mean age of 31.8 and 32.4 years, respectively. The responders had a significantly greater number of ligated veins, preoperative pain score, and longer duration of pain than the nonresponders. No significant differences were found in body mass index, scrotal temperature, distance from the renal hilum to the scrotum, peak retrograde flow, follicle-stimulating hormone, luteinizing hormone, testosterone, and maximal vein diameter between the responders and nonresponders.

CONCLUSION

The findings of the present study suggest that the factors predicting symptomatic relief by varicocelectomy in patients with normospermia and painful varicocele nonresponsive to conservative treatment are a greater number of ligated veins (>7), greater preoperative pain score (>6), and longer duration of pain (>9 months).

Testicular volume and semen parameters in patients aged 12 to 17 years with idiopathic varicocele

PURPOSE

Varicocele is potentially a progressive condition that may affect fertility. The authors have encouraged sperm banking for their postpubertal patients with varicocele and aim to evaluate the sperm parameters in this cohort of patients.

METHODS

With institutional ethical approval, sperm variables (volume, concentration, and forward motility) of patients with postpubertal varicocele who opted for sperm banking were prospectively recorded. The following parameters were also acquired: (a) ultrasound measurement of testicular volume, (b) clinical grade, and (c) venous Doppler. Patients were divided into 2 groups: symmetrical testis (group A) and asymmetrical testis (group B). Testicular asymmetry was defined as greater than 20% difference in testicular volume compared with contralateral testis. Sperm parameters were compared between groups A and B using Mann-Whitney U test and P < .05.

RESULTS

Fifteen patients were included: 10 in group A and 5 in group B. Median semen concentration in group B was significantly lower than group A (3 vs 26 million/mL; P = .04). One hundred percent of group B failed World Health Organisation adult criteria for normal spermiograms compared with 50% of group A.

CONCLUSIONS

Sperm concentration and quality was lower in patients with asymmetrical testis. Testicular dysfunction may be present before the onset of testicular hypotrophy. When testicular hypotrophy is present, testicular dysfunction is very likely.

Testicular volume discrepancy is associated with decreased semen quality in infertile Japanese males with varicoceles

Purpose

We retrospectively reviewed infertile Japanese males for testicular volume discrepancies (D) and semen parameters to evaluate whether left grade II-III varicoceles (V) cause testicular damage.

Methods

Seventy-seven patients who had idiopathic male infertility and 88 who had V without other causes of infertility were examined. We excluded cases of azoospermia. Testicular volume was measured using a punched-out orchidometer. D was defined as a size difference of at least 3 ml. The frequency of D was compared between the patients with and without V. The semen parameters were reviewed in association with D and V.

Results

The mean left and right testicular volumes were 19.4 and 20.1 ml, respectively (p < 0.001). D with a smaller left testis was more common in V+ cases than in V- cases (26.1 vs. 13.0%, p = 0.0351). The sperm count and motility were also significantly lower (p = 0.0213 and p = 0.0217, respectively) in the D+ patients with a smaller left testicular volume.

Conclusions

In the patients with V, D was more common than in those without V. The semen parameters were worse if D was present in the patients with V. These results indicated that V could induce testicular atrophy and negatively affect semen quality. Therefore, the ipsilateral reduced testicular volume is considered to be a sign of persisting testicular damage by V.

Risk factors for progressive deterioration of semen quality in patients with varicocele

OBJECTIVE

To assess the risk factors for progressive deterioration of semen quality (PDSQ) in adult patients with varicocele.

METHODS

A total of 32 men with left varicocele and impaired semen quality (group 1) and 30 age-matched patients with left varicocele and normal semen quality (group 2) were recruited for the present study. All the subjects received conservative treatment, and the parameters for evaluation every 12 months included semen quality, peak retrograde flow (PRF) and spontaneous venous reflux by color Doppler ultrasonography, body mass index, serum concentration of follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, testicular volume and discrepancy, grade of varicocele, and scrotal temperature.

RESULTS

The mean follow-up time was 63.2 months (range 60-66). The patients in group 1 had a significantly greater PRF, lower testicular volume, greater testicular volume discrepancy, lower testosterone level, higher scrotal temperature, and greater follicle-stimulating hormone level than those in group 2 at first. The semen quality deteriorated in 28 subjects (87.5%) in group 1, but in only 6 patients (20%) in group 2 during follow-up. Furthermore, the 6 subjects with PDSQ in group 2 had greater PRF and scrotal temperature than those without.

CONCLUSION

The rate of PDSQ was significantly greater in the varicocele patients with an initially abnormal semen quality than in those with initially normal semen quality (87.5% vs 20%). Furthermore, the varicocele patients with initially normal semen quality who had greater PRF and scrotal temperature might have a greater risk of PDSQ.

Varicocele repair: does it still have a role in infertility treatment?

PURPOSE OF REVIEW

To review the role of varicocele repair in the treatment of male infertility.

RECENT FINDINGS

Since the advent of technologies bypassing boundaries of natural selection, this question may seem outdated. Over the past 20 years, fertility has decreased, and testicular damage (cryptorchidism, tumors) has increased. Thus the exploration of the infertile male is still unavoidable. However, what should be done and assigned to the discovery of a varicocele?The issue raised is whether varicocele found during the review of the infertile couple should be treated or 'ignored'.This study will update significant findings with regards to the pathophysiology of varicocele-induced infertility, such as oxidative stress and role of varicocele in bilaterality of testicular damage. Benefits of varicocele repair in semen analysis and simplifications of assisted reproductive techniques are reported. But reviews of randomized clinical trials have raised doubts about the benefit of varicocele treatment in infertile men.

SUMMARY

We conclude that varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility. Deleterious cofactors, like obesity or smoking, could also be reduced for the benefit of general health and fertility.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

Differences in biochemical markers and body mass index between patients with and without varicocele

BACKGROUND

Varicocele is characterized by abnormal tortuosity and dilatation of the veins of the pampiniform plexus within the spermatic cord and is one of the causes of male infertility. This study aimed to evaluate the differences in biochemical markers and body mass index (BMI) between patients with and without varicocele.

METHODS

Between January 2004 and June 2009, 102 patients with varicocele (Group A) were evaluated. Ninety-five age-matched male patients who did not have varicocele were selected as controls (Group B). Varicocele was diagnosed by physical examination and confirmed by Doppler ultrasonography. The range of ages was between 18 and 50 years old. BMI, testosterone, serum alkaline phosphatase, calcium, lactic dehydrogenase, inorganic phosphate, gammaglutamine transpeptidase, uric acid, albumin, iron, cholesterol, triglyceride, alanine aminotransferase, and aspartate aminotrans-ferase levels were measured for all the subjects.

RESULTS

The mean age was 35.4 years in group A and 36.5 years in group B. Of the 102 patients in group A, 20 were grade 1 varicocele, 55 were grade 2 and 27 were grade 3. The BMI (mean +/- SD) of patients with varicocele (22.8 +/- 3.2) was significantly lower than that of patients without varicocele (24.9 +/- 4.1). Patients with varicocele had significantly lower serum levels of cholesterol than patients without varicocele (176.5 +/- 31.1 vs. 187.7 +/- 42.1 mg/dL). There were no significant differences for the other biochemical markers between the groups. Patients with grade 3 varicocele had a lower BMI than patients with grades 1 and 2 varicocele, but this was not significant. No significant differences were found for the other biochemical markers among the patients with grade 1, 2 or 3 varicocele.

CONCLUSION

Patients with varicocele had significantly lower serum levels of cholesterol than those without varicocele. In addition, the prevalence of varicocele was higher in patients with a lower BMI. Our findings suggest that patients with a greater BMI may have advantages in relieving the nutcracker phenomenon, which causes significant varicoceles.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.