The role of microsurgical varicocelectomy in treating male infertility

A comparison of loupe-assisted and non-loupe-assisted subinguinal varicocelectomy

Introduction

Varicocele is a treatable aetiology of male infertility. Magnification with surgical loupe has been associated with improved outcome and reduced morbidity than the conventional technique without magnification.

Objective

To compare the outcomes of two techniques of subinguinal varicocelectomy, with a surgical loupe and without.

Patients and Methods

This was a prospective randomised hospital-based study. Forty-six patients were randomised to two arms - Group A: loupe-assisted subinguinal varicocelectomy (LASV) and Group B: open subinguinal varicocelectomy without Loupe (OSV). They all had their semen and hormonal parameters compared preoperatively and at 3 and 6 months postoperatively. Post-operative complications were also assessed. P < 0.05 was considered statistically significant.

Results

The mean age was 38.28 ± 4.55 years with a range of 27-46 years. The mean age in Group A was 37.35 ± 4.68 and 39.22 ± 4.33 years in Group B. There was an improvement in motility, sperm count and concentration in both the groups at 3 and 6 months (P < 0.05). However, there was no difference in these parameters on comparison of the two groups at 3 and 6 months (P > 0.05). Follicle-stimulating hormone decline was significant in the OSV group at 3 and 6 months, P = 0.010 and 0.021, respectively. There was no difference in other hormonal parameters both at 3 and 6 months (P > 0.05). The pregnancy rate in each arm of study was 4.3%. All complications occurred in Group B.

Conclusion

Both techniques resulted in improvement in seminal fluid parameters. All complications occurred in the arm that had subinguinal varicocelectomy without loupe. Loupe-assisted subinguinal varicocelectomy is safe and effective.

Intraoperative hydrodissection and Doppler ultrasound during magnified varicocelectomy: A comparative study

METHODS

We performed a non-randomized comparative trial that recruited infertile men with varicocele who were scheduled to undergo MSV. Eligible patients were allocated by the investigators in a 1:1 ratio to receive intraoperative Doppler (group I) or intraoperative Doppler plus hydrodissection (group II).

RESULTS

Sixty men were included in each group. The two study groups showed a comparable number of ligated veins on the right (4.22 ±1.57 versus 4.42 ± 1.65; p = 0.49) and left side (6.77 ± 2.14 versus 6.98 ± 2.29; p = 0.59). On the contrary, group II showed a significantly higher number of preserved arteries on the right (2.42 ± 0.56 versus 1.47 ±0.5 in group I) and left side (2.6 ± 0.53 versus 1.63 ± 0.55 in group I), with p-value < 0.001. The sperm motility was significantly higher in group II than in group I (21.25 ± 13.73 versus 13.85 ± 12.25, respectively; p = 0.002). In both groups, the sperm motility increased significantly at the end of follow-up compared to the preoperative period. The postoperative sperm mortality remained significantly higher in group II than in group I (p = 0.008).

CONCLUSIONS

Intraoperative Doppler plus hydrodissection (D+IH-MSV) has advantages in preserving more arteries and enhancing the motility of sperms. Based on these findings, we strongly recommend D+IH-MSV when treating infertile men with varicocele.

Impact of testicular delivery and vasal vein ligation on clinical outcomes in men undergoing microsurgical varicocelectomy

PURPOSE

To assess the impact of microsurgical varicocelectomy technique on clinical outcomes.

METHODS

Men diagnosed with varicocele between 2017 and 2020 were reviewed. We included men who underwent microsurgical varicocelectomy by two high-volume surgeons who differed in surgical technique: Method (1) testicular delivery with gubernacular vein ligation, and ligation of vasal veins > 2.5 mm; Method (2) no delivery and ligation of dilated vasal veins in cases of recurrence. Post-operative changes for semen parameters, DNA fragmentation, and serum testosterone were evaluated for each technique and compared.

RESULTS

313 patients were included; 162 with Method 1 and 151 with Method 2. The cohorts were of similar age (median 35 years, interquartile range (IQR) 28-43; 34, IQR 28-39, respectively), and BMI (25 kg/m², IQR 23-27; 25, IQR 23-28, respectively). For Method 1, 84 (51.9%) had bilateral surgery, and 78 (48.1%) had unilateral surgery. For Method 2, 63 (41.7%) had bilateral surgery, and 88 (58.3%) unilateral surgery. In patients with sperm concentration > 5 M/mL, both techniques resulted in an improvement (p < 0.01), but there was no difference between the methods (p = 0.18). Both methods were associated with an improvement in total motile count (p < 0.05) and the amount of DNA fragmentation (p < 0.05), although no differences were apparent between the techniques (p = 0.09, p = 0.81, respectively). Finally, testosterone levels improved with Method 1, but the post-operative difference was not different than Method 2 (p = 0.06).

CONCLUSION

Delivery of the testis and ligation of dilated vasal veins compared to not performing those steps do not impact semen parameters, but are associated with improvement in testosterone levels.

The yield of microscopic varicocelectomy in men with severe oligospermia

Introduction:

Varicocele is detected in 35%–50% of men with primary infertility and up to 81% with secondary infertility. Various studies have shown that varicocele is related to testicular hypotrophy and impaired spermatogenesis. The effect of varicocelectomy in mild-to-moderate male factor infertility has been well reported. However, only a few studies addressed the impact of varicocelectomy in severe oligospermia.

Methods:

We included 45 patients with severe oligospermia (<5 million/mL) who underwent microsurgical varicocelectomy between May 2014 and November 2017. Results of semen analysis taken at 6 months after varicocelectomy were compared and patients were divided into responders and nonresponders. Chi-square was used to compare the preoperative and postoperative sperm count, motility, and volume.

Results:

After 6 months only one patient was found to be a responder with a pre- to post-operative motility of 45%–74% and a sperm concentration of 1 million/mL to 28.1 million/mL. There was a significant improvement in the mean sperm concentration after varicocelectomy which improved from 1.31 million/mL to 5.32 million/mL. However, a significant decrease in sperm motility was noted which decreased from 35.62% to 28.64% postoperatively. Postoperative semen volume increased from 2.56 mL to 3.19 mL, but this difference was not found to be statistically significant (P > 0.05). Four patients (8.9%) were found to have azoospermia after a 6-month follow-up. In these four patients who turned azoospermic had count <50,000 sperm/mL, two of them had a history of cryptospermia before varicocelectomy. Ejaculate sperm returned in two of these four patients in long-term follow-up (>6 months).

Conclusion:

The magnitude of improvement after microsurgical varicocelectomy for severely oligospermic patients is less profound than reported in mild male factor infertility.

Surgical or radiological treatment for varicoceles in subfertile men

BACKGROUND

Varicoceles are associated with male subfertility; however, the mechanisms by which varicoceles affect fertility have yet to be satisfactorily explained. Several treatment options exist, including surgical or radiological treatment, however the safest and most efficient treatment remains unclear.  OBJECTIVES: To evaluate the effectiveness and safety of surgical and radiological treatment of varicoceles on live birth rate, adverse events, pregnancy rate, varicocele recurrence, and quality of life amongst couples where the adult male has a varicocele, and the female partner of childbearing age has no fertility problems.

SEARCH METHODS

We searched the following databases on 4 April 2020: the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) if they were relevant to the clinical question posed and compared different forms of surgical ligation, different forms of radiological treatments, surgical treatment compared to radiological treatment, or one of these aforementioned treatment forms compared to non-surgical methods, delayed treatment, or no treatment. We extracted data if the studies reported on live birth, adverse events, pregnancy, varicocele recurrence, and quality of life.

DATA COLLECTION AND ANALYSIS

Screening of abstracts and full-text publications, alongside data extraction and 'Risk of bias' assessment, were done dually using the Covidence software. When we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses; otherwise, we reported results narratively. We used the I² statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We dually rated the risk of bias of studies using the Cochrane 'Risk of bias' tool, and the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 1897 citations after de-duplicating the search results. We excluded 1773 during title and abstract screening. From the 113 new full texts assessed in addition to the 10 studies (11 references) included in the previous version of this review, we included 38 new studies, resulting in a total of 48 studies (59 references) in the review providing data for 5384 participants. Two studies (three references) are ongoing studies and two studies are awaiting classification. Treatment versus non-surgical, non-radiological, delayed, or no treatment Two studies comparing surgical or radiological treatment versus no treatment reported on live birth with differing directions of effect. As a result, we are uncertain whether surgical or radiological treatment improves live birth rates when compared to no treatment (risk ratio (RR) 2.27, 95% confidence interval (CI) 0.19 to 26.93; 2 RCTs, N = 204; I² = 74%, very low-certainty evidence). Treatment may improve pregnancy rates compared to delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, N = 1193; I² = 65%, low-certainty evidence). This suggests that couples with no or delayed treatment have a 21% chance of pregnancy, whilst the pregnancy rate after surgical or radiological treatment is between 22% and 48%. We identified no evidence on adverse events, varicocele recurrence, or quality of life for this comparison. Surgical versus radiological treatment We are uncertain about the effect of surgical versus radiological treatment on live birth and on the following adverse events: hydrocele formation, pain, epididymitis, haematoma, and suture granuloma. We are uncertain about the effect of surgical versus radiological treatment on pregnancy rate (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, N = 456, low-certainty evidence) and varicocele recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs, N = 380, low-certainty evidence). We identified no evidence on quality of life for this comparison. Surgery versus other surgical treatment We identified 19 studies comparing microscopic subinguinal surgical treatment to any other surgical treatment. Microscopic subinguinal surgical treatment probably improves pregnancy rates slightly compared to other surgical treatments (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, N = 1473, moderate-certainty evidence). This suggests that couples with microscopic subinguinal surgical treatment have a 10% to 14% chance of pregnancy after treatment, whilst the pregnancy rate in couples after other surgical treatments is 10%. This procedure also probably reduces the risk of varicocele recurrence (RR 0.48, 95% CI 0.29, 0.79; 14 RCTs, N = 1565, moderate-certainty evidence). This suggests that 0.4% to 1.1% of men undergoing microscopic subinguinal surgical treatment experience recurrent varicocele, whilst 1.4% of men undergoing other surgical treatments do. Results for the following adverse events were inconclusive: hydrocele formation, haematoma, abdominal distension, testicular atrophy, wound infection, scrotal pain, and oedema. We identified no evidence on live birth or quality of life for this comparison. Nine studies compared open inguinal surgical treatment to retroperitoneal surgical treatment. Due to small sample sizes and methodological limitations, we identified neither treatment type as superior or inferior to the other regarding adverse events, pregnancy rates, or varicocele recurrence. We identified no evidence on live birth or quality of life for this comparison. Radiological versus other radiological treatment One study compared two types of radiological treatment (sclerotherapy versus embolisation) and reported 13% varicocele recurrence in both groups. Due to the broad confidence interval, no valid conclusion could be drawn (RR 1.00, 95% CI 0.16 to 6.20; 1 RCT, N = 30, very low-certainty evidence). We identified no evidence on live birth, adverse events, pregnancy, or quality of life for this comparison.

AUTHORS' CONCLUSIONS

Based on the limited evidence, it remains uncertain whether any treatment (surgical or radiological) compared to no treatment in subfertile men may be of benefit on live birth rates; however, treatment may improve the chances for pregnancy. The evidence was also insufficient to determine whether surgical treatment was superior to radiological treatment. However, microscopic subinguinal surgical treatment probably improves pregnancy rates and reduces the risk of varicocele recurrence compared to other surgical treatments. High-quality, head-to-head comparative RCTs focusing on live birth rate and also assessing adverse events and quality of life are warranted.

Seminal SIRT1-oxidative stress relationship in infertile oligoasthenoteratozoospermic men with varicocele after its surgical repair

This work assessed seminal SIRT1-oxidative stress (OS) relationship in infertile oligoasthenoteratozoospermic (OAT) men after varicocele repair. Overall, thirty OAT men with varicocele were investigated. Inclusion criteria were infertile males (males who were unable to initiate a pregnancy within 1 year of regular unprotected intercourse), confirmed OAT and normal female factor. These cases were subjected to history taking, clinical checkup and semen analysis. In their semen, seminal SIRT1, malondialdehyde (MDA) and glutathione peroxidase (GPx) levels were assessed. These men were subjected to varicocele surgical repair and were followed up for 3 months. Post-operatively, the mean seminal SIRT1, GPx levels showed significant increases and the mean MDA level showed significant decrease compared to the pre-operative levels linked to improved sperm parameters. The mean seminal SIRT1, GPx, MDA levels showed more significant improvement in grade III varicocele cases compared to grade II cases after surgical repair. Seminal SIRT1 levels showed significant positive correlations with sperm concentration, sperm motility, sperm normal morphology, seminal GPx levels and a significant negative correlation with seminal MDA levels. It could be concluded that seminal SIRT1 is significantly decreased in infertile OAT men with varicocele after its surgical repair linked to improved sperm parameters as well as seminal OS.

Microsurgical varicocele ligation: surgical methodology and associated outcomes

The impact of clinical varicoceles on semen parameters and male infertility has long been established. In the era of assisted reproduction, clinical discussion has questioned the role of varicocelectomy, offering the potential to bypass, rather than treat, varicocele-associated male infertility. However, current literature supports improved semen parameters and reproductive outcomes following repair. This article presents the stepwise operative approaches to microsurgical varicocelectomy and discusses the recent publications on outcomes.

Effects of Varicocele Treatment on Sperm Conventional Parameters: Surgical Varicocelectomy Versus Sclerotherapy

INTRODUCTION

Varicocele is often associated with impaired sperm parameters. Different procedures have been developed for varicocele treatment. The aim of this study was to evaluate the effects of varicocele treatment on conventional sperm parameters.

MATERIALS AND METHODS

We compared two different techniques of intervention: surgical varicocelectomy and sclerotherapy. We also evaluated the number of varicocele recurrences and the pregnancy rate. We included 102 patients (mean age 29.8 ± 0.8 years) with ultrasound diagnosis of varicocele. We excluded patients whose ultrasound evaluation and/or sperm parameters were not known before and after varicocele correction. We divided the patients (excluding 8 with azoospermia) into two subgroups: surgical varicocelectomy (n = 44) and sclerotherapy (n = 50). For each patient, we compared conventional sperm parameters before and after varicocele correction.

RESULTS

After varicocele correction, we found a significant improvement in sperm concentration, total count and total motility. Considering the two subgroups, baseline sperm parameters did not differ significantly. Sperm concentration and total count increased significantly after varicocele correction by varicocelectomy. Varicocele correction by sclerotherapy resulted in a significant increase in sperm concentration, progressive and total motility. We found varicocele recurrence in 32% of patients who underwent varicocelectomy and in 19.7% of patients undergoing sclerotherapy. The pregnancy rate was higher after sclerotherapy (28%) than after surgical varicocelectomy (13%).

CONCLUSION

Varicocele treatment must be recommended when other causes of infertility have been treated. Our results suggest the use of sclerotherapy for varicocele repair.

LEVEL OF EVIDENCE

2 b.

Microscopic subinguinal varicocelectomy in 100 consecutive cases: Spermatic cord vascular anatomy, recurrence and hydrocele outcome analysis

Objective

To evaluate the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases with regard to varicocele recurrence and hydrocele formation.

Patients and methods

In all, 100 varicocele cases including 74 left-sided and 26 bilateral, comprising 126 spermatic cord units with clinically palpable varicoceles underwent microscopic subinguinal varicocelectomy. Detailed description of vascular anatomy of the spermatic cords was reported. The number of spermatic, cremasteric, and inguinal veins was recorded. A record of testicular arteries and lymphatics was noted. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, as well as scrotal Doppler ultrasonography, to detect varicocele recurrence and hydrocele formation. The mean (range) postoperative evaluation period was 6 (3–12) months.

Results

The mean number of spermatic veins was 14 on both sides. The mean number of spermatic arteries on both sides was 1.3. For lymphatics, the mean number was around three on both sides. The gubernacular veins were noted in 75% of the cases on the left side (mean number of 1.2) and in 85% on the right-side, (mean number of 1). The mean number of cremasteric veins on the left and right sides was 1.4 and 1.2, respectively. Finally, inguinal floor vessels were noted in 9% on the left-side and were not seen in the right-side cases. The incidence of varicocele recurrence was 2% and for hydrocele that was not clinically significant was 0.07%.

Conclusion

Microscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.