Indications and outcomes of varicocele repair

Varicocele repair in improving spermatozoa, follicle-stimulating hormone, and luteinizing hormone parameters in infertile males with azoospermia: a systematic review and meta-analysis

ABSTRACT

Patients with azoospermia show a prevalence of varicocele of 10.9% and a 14.8% contribution to male infertility. Patients with azoospermia are thought to produce high-quality semen following varicocele treatment. Advising varicocelectomy prior to sperm retrieval in a reproductive program is still debated. This study reviewed the impact of varicocele repair on male infertility using several factors. A literature search was conducted using Scopus, PubMed, Embase, the Wiley Online Library, and Cochrane databases. Sperm concentration, sperm progression, overall sperm motility, sperm morphology, and follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were also compared. Outcomes were compared between those who received treatment for varicocele and those who did not. The data from the pooled analysis were presented as standardized mean difference (SMD) along with a 95% confidence interval (CI). Heterogeneity was evaluated using I2. Additionally, we conducted analyses for publication bias, sensitivity, and subgroup analysis as appropriate. Nine studies were included after screening relevant literature. Statistical analysis revealed a significant improvement in sperm concentration (SMD: 1.81, 95% CI: 0.84-2.77, P < 0.001), progressive sperm motility (SMD: 4.28, 95% CI: 2.34-6.22, P < 0.001), and sperm morphology (SMD: 3.59, 95% CI: 2.27-4.92, P < 0.001). Total sperm motility showed no significant difference following varicocele repair (SMD: 0.81, 95% CI: -0.61-2.22, P = 0.26). No significant differences were seen in serum FSH (SMD: 0.01, 95% CI: -0.16-0.19, P = 0.87) and LH (SMD: 0.19, 95% CI: -0.01-0.40, P = 0.07) levels as well. This study supports varicocele repair in infertile men with clinical varicocele, as reflected by the improvement in sperm parameters after varicocelectomy compared with no treatment. There were no significant improvements in serum FSH and LH levels.

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

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

Predictive factors for successful testicular biopsy

INTRODUCTION

Infertility, the inability to conceive, constitutes a major problem in modern societies. It affects 10 to 15 percent of couples in the United States. Evaluation of infertile men is usually complex and often demands a testicular biopsy.

MATERIALS AND METHODS

We reviewed all azoospermic men submitted to testicular biopsy, in our center, during infertility investigation between January 2015 and December 2021.

RESULTS

A total of 117 patients with a mean age of 36.5 was considered. Biopsy was positive, as defined by the presence of viable spermatozoids by microscopy, in 48.7% of patients (n = 57). Patients were divided in two separate groups based on positive (PB) or negative biopsy (NB) and compared. PB-group had normal serum total testosterone levels and higher than NB-group (3.7 ng/mL vs. 2.85 ng/mL, p = 0.021), and normal serum FSH levels and lower than NB-group (6.0 mIU/mL vs. 16.0 mIU/mL, p < 0.001). The groups were similar concerning serum LH levels (3.9 mIU/mL vs. 6.3 mIU/mL, p = 0.343.

CONCLUSIONS

Predicting outcomes of testicular biopsy is a difficult task. Our study found that men with normal testicular volume, normal levels of testosterone and FSH and those with type 1 diabetes mellitus had a higher probability of positive testicular biopsy.

Safety and efficacy of acupuncture for varicocele-induced male infertility: a systematic review protocol

INTRODUCTION

Varicocele (VC) is a common clinical disease in andrology. Among a number of ways for VC treatment, surgery is the most common one, but the measurable benefit of surgical repair was slight. A growing exploration of complementary therapies has been conducted in clinical research on acupuncture for VC, but there is no relevant systematic review and meta-analysis to assess the efficacy and safety of acupuncture for VC.

METHODS AND ANALYSIS

All relevant publications published from database inception through August 2022 will be searched in three English-language databases (Embase, CENTRAL, MEDLINE) and four Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, Chinese Biomedical Literature Database and Wanfang Data). Randomised controlled trials in English and Chinese concerned with acupuncture for patients with VC will be included. The input clinical data will be processed by the Review Manager software (RevMan). The literature will be appraised with the Cochrane Collaboration risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation system (GRADE system) will be used to evaluate the quality of evidence.

ETHICS AND DISSEMINATION

This study is a secondary study based on clinical studies so it does not relate to any individual patient information or infringe the rights of participants. Hence no ethical approval is required. The results will be reported in peer-reviewed journals or disseminated at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022316005.

Nomogram for predicting spontaneous pregnancy after microscopic varicocelectomy in infertile men with normal hormone

INTRODUCTION

The current challenge for the treatment of varicocele is identifying patients who could benefit the most from surgery. We aimed to develop and validate a nomogram for predicting spontaneous pregnancy following microscopic varicocelectomy in infertile men, based on a large cohort.

METHODS

Two hundred eighty-two consecutive patients who underwent microscopic varicocelectomy from January 2018 to December 2020 were enrolled as participants in the study. Xiang Hua center (206 patients) as a development cohort. Hu Nan center (76 patients) as a validation cohort. Patient clinicopathologic data were recorded. Multivariate logistic regression was used to build a predictive model with regression coefficients. Then, backward stepwise selection was applied, and the likelihood ratio test with Akaike's information criterion was used as the stopping rule. The performance of this predictive model was assessed for discrimination, calibration, and clinical usefulness.

RESULTS

Predictors of this model included the age of female partners, diameter of veins, initial and increased total progressively motile sperm count. The model demonstrated good discrimination with an AUROC of 0.925 (p < 0.001) and calibration (Unreliability test, p = 0.522) in the validation cohort. Furthermore, the model was clinically useful, according to decision curve analysis.

CONCLUSIONS

Our findings indicated that younger female partners, larger diameter of veins, higher initial and increased total progressively motile sperm count were significant predictors of spontaneous pregnancy in infertile men, post microscopic varicocelectomy. This nomogram may assist in individual decision-making on the treatment strategy of varicocele preoperatively and improve the treatment outcome.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.

Diagnosis of bacteriospermia and its impact on spermogram parameters in adolescents with varicocele

Infectious etiology is the cause of about 15% of cases of male infertility. And if sexually transmitted infections are easily diagnosed, the role of asymptomatic bacteriospermia in the formation of infertility in men, and especially in adolescents against the background of the existing pathology of the reproductive sphere (varicocele), remains insufficiently studied. A microbiological study in the ejaculate of adolescents revealed the following types of bacteria: Escherichia coli, Enterococcus faecalis, Corynebacterium glucuronolyticum, Corynebacterium minitissimum, Streptococcus anginosus, Staphylococcus epidermidis, Staphylococcus haemolyticus. Bacteria in the ejaculate were also detected during semen analysis and electron microscopic examination of spermatozoa. With abundant growth of microorganisms in a monoculture or an association of two microorganisms present in a moderate amount, in all cases, violations of sperm motility, an increase in the viscosity of the ejaculate, the presence of leukocytes in the seminal fluid were detected, and damage to the chromatin, acrosome and mitochondria was recorded at the ultrastructural level, which may indicate active infection. When bacterial flora was detected in a small and moderate amount (<10 CFU/ml), no pathological changes in the ejaculate were observed. The microflora of the ejaculate of the examined adolescents is represented by gram-positive microflora. Simultaneous study of the ejaculate sample by bacteriological seeding, the performance of spermogram and EMIS allowed to increase the detection of bacteriospermia. Opportunistic pathogens with abundant growth or their various combinations can serve as a factor in the development of pathospermia. It is possible to distinguish an active infection from commensal microflora or sample contamination not only by the presence of bacteria in the ejaculate and their quantitative accounting, but also by the degree of damage to the function of spermatozoa and pathological changes in the parameters of the ejaculate, by combining diagnostic methods. Most often, in the presence of bacteria in the ejaculate, asthenozoospermia is diagnosed.

Oxidative Stress and Varicocele-Associated Male Infertility

Despite being regarded as one of the most common causes of male subfertility, the pathophysiology of varicocele remains largely unknown. Recently, oxidative stress (OS) is proposed to be the mediator in how varicocele may negatively impact fertility. The imbalance of reactive oxygen species (ROS) and seminal antioxidants results in damage to sperm DNA and lipid membrane. There is evidence demonstrating higher OS level in men with varicocele which is also positively correlated with clinical grading of varicocele. Moreover, a number of studies have revealed the negative correlation between OS and conventional semen parameters. Furthermore, various interventions have shown their potential in alleviating OS in men with varicocele-associated infertility. Although direct evidence on improving pregnancy rate is not available at the moment, varicocelectomy has demonstrated promising results in relieving OS. Oral antioxidants represent another option with a favourable safety profile. The supplement can be used alone or as adjunct to varicocelectomy. However, most of the studies are hampered by heterogenous dose regime and high-level evidence is lacking.

Verbascoside attenuates experimental varicocele-induced damage to testes and sperm levels through up-regulation of the hypothalamus-pituitary-gonadal (HPG) axis

CONTEXT

Verbascoside (VB), which is found in many medicinal plant families, exhibits biological activities in various diseases. However, its effects on varicocele (VCL)-induced damage remain unknown.

OBJECTIVE

To investigate the effects and mechanism of VB on experimental rats with varicocele (VCL)-induced damage.

MATERIALS AND METHODS

Sixty sexually mature male Sprague-Dawley (SD) rats were divided into six groups (n = 10): control, control-sham, VCL-vehicle (normal saline), and VCL + VB groups (50, 100, and 200 mg/kg/day, intraperitoneally). After 4 weeks of VB treatment, all animals were sacrificed, and the body and testicular weight, sperm quality parameters, histopathology, antioxidant status, and hormone levels were tested. The levels of gonadotropin-releasing hormone (GnRH) and gonadotropin-inhibitory hormone in the hypothalamus were detected by western blot.

RESULTS

Compared with the VCL-vehicle group (41.14%), administration of VB significantly increased the sperm viability (59.29, 65.45, 84.93%). VB groups showed higher Johnson's score (3.57 ± 0.15, 4.71 ± 0.26, 7.93 ± 0.37) than VCL-vehicle group (2.72 ± 0.24). Antioxidant status and hormone levels alterations were also observed. Meanwhile, the mean number of apoptotic tubules (8.15 ± 0.96, 6.61 ± 1.05, 2.17 ± 0.08) and apoptotic index showed a marked decrease. Compared with the VCL-vehicle group (0.21 ± 0.09), the VB groups (0.36 ± 0.07, 0.42 ± 0.06, 0.88 ± 0.10) showed considerable increases in GnRH.

DISCUSSION AND CONCLUSIONS

VB has protective effects on reproductive organs and VB may be therapeutically useful in the treatment of varicocele through up-regulation of the HPG axis.

Clinical effectiveness of microsurgical subinguinal varicocelectomy with enhanced recovery after surgery for varicocele

Background

Varicocele (VC) is one of the most common causes of infertility in men, and microscopic varicocelectomy is currently the major surgical procedure for VC. We assessed the clinical effectiveness of microsurgical subinguinal varicocelectomy (MSV) with enhanced recovery after surgery (ERAS) in the treatment of VC in terms of semen quality improvement rate, pregnancy rate, pain relief rate, recurrence rate, and complication rate after MSV and explored the indications for VC surgery.

Methods

In total, 216 patients undergoing MSV in our center between June 2019 and July 2020 were enrolled in this study. All patients received the surgery under local anesthesia and were admitted and discharged within 24 hours. All patients were followed up for more than 6 months, and the rates of semen quality improvement, pregnancy, pain relief, recurrence, and postoperative complications were recorded. We can evaluate the pain degree of patients through the numerical rating scale (NRS). (I) 0 points for painless; (II) 1-3: mild pain; (III) 4-6: moderate pain; (IV) 7-10 points are severe pain. 0 is the most slightly, indicating comfort, and 10 is the most painful and unbearable.

Results

The sperm concentration, total sperm count, progressive motility rate, sperm viability, and morphology were significantly improved after the surgery (all P values <0.05). The rate of semen quality improvement was 88.2%, and the semen indicators returned to normal in 26.6% of the patients. Among the patients who were followed up for 1 year, the natural conception rate reached 27.1% and was accompanied by a 95.5% pain relief rate, a 0.5% VC recurrence rate, and a 2.3% postoperative complication rate.We obtained data through laboratory examination of semen DNA fragments index (DFI). Compared with preoperative and postoperative DFI, postoperative DFI was improved, and the pregnancy outcome was improved.

Conclusions

MSV under local anesthesia increases the rates of semen quality improvement, pregnancy, and pain relief while lowering the rates of recurrence and postoperative complications. MSV may also help to improve the pregnancy outcomes in patients with VC accompanied by sperm DNA fragmentation or nonobstructive azoospermia, but this should be verified by further investigation.

Surgical procedures for male infertility: an update

PURPOSE OF REVIEW

The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes.

RECENT FINDINGS

Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures.

SUMMARY

Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

Varicocele indicated scrotoplasty with varicocelectomy: A case report

A 72 -year- old male patient presented to the clinic complaining of mild dragging scrotal pain and hanging scrotum interfering with his daily activity. Clinical examination revealed grade three left varicocele, enlarged hanging scrotum for more than 15 cm from the scrotal neck. The scrotum was explored and left varicocelectomy was done then scrotoplasty. Fifteen months post-operatively patient has an excellent outcome.

NLRP3 Inflammasome: A New Pharmacological Target for Reducing Testicular Damage Associated with Varicocele

Many bioactive natural compounds are being increasingly used for therapeutics and nutraceutical applications to counteract male infertility, particularly varicocele. The roles of selenium and Polydeoxyribonucleotide (PDRN) were investigated in an experimental model of varicocele, with particular regard to the role of NLRP3 inflammasome. Male rats underwent sham operation and were daily administered with vehicle, seleno-L-methionine (Se), PDRN, and with the association Se-PDRN. Another group of rats were operated for varicocele. After twenty-eight days, sham and varicocele rats were sacrificed and both testes were weighted and analyzed. All the other rats were challenged for one month with the same compounds. In varicocele animals, lower testosterone levels, testes weight, NLRP3 inflammasome, IL-1β and caspase-1 increased gene expression were demonstrated. TUNEL assay showed an increased number of apoptotic cells. Structural and ultrastructural damage to testes was also shown. PDRN alone significantly improved all considered parameters more than Se. The Se-PDRN association significantly improved all morphological parameters, significantly increased testosterone levels, and reduced NLRP3 inflammasome, caspase-1 and IL-1β expression and TUNEL-positive cell numbers. Our results suggest that NLRP3 inflammasome can be considered an interesting target in varicocele and that Se-PDRN may be a new medical approach in support to surgery.

Male infertility

It is estimated that infertility affects 8-12% of couples globally, with a male factor being a primary or contributing cause in approximately 50% of couples. Causes of male subfertility vary highly, but can be related to congenital, acquired, or idiopathic factors that impair spermatogenesis. Many health conditions can affect male fertility, which underscores the need for a thorough evaluation of patients to identify treatable or reversible lifestyle factors or medical conditions. Although semen analysis remains the cornerstone for evaluating male infertility, advanced diagnostic tests to investigate sperm quality and function have been developed to improve diagnosis and management. The use of assisted reproductive techniques has also substantially improved the ability of couples with infertility to have biological children. This Seminar aims to provide a comprehensive overview of the assessment and management of men with infertility, along with current controversies and future endeavours.

Microscopic subinguinal varicocelectomy for testicular pain: a retrospective study on outcomes and predictors of pain relief

Background

Approximately 2–10% of patients with varicocele complain of pain. Varicocelectomy for testicular pain is a surgical choice when conservative therapy fails to relieve the pain. Different variables have been reported as prognostic factors for pain relief following varicocele ligation. Moreover, the success rate of varicocelectomy for testicular pain has varied among studies. This retrospective study aimed to investigate the predictors and success rate of microscopic subinguinal varicocelectomy performed for the treatment of painful varicocele.

Results

Among the 132 patients, 83.3% reported pain relief. A significant association was identified between varicocelectomy for unilateral testicular pain and pain resolution (P < 0.0001); no other factors were predictors of pain relief.

Conclusions

Microscopic subinguinal varicocelectomy for testicular pain is an effective surgical alternative. Varicocelectomy for unilateral testicular pain may predict postoperative pain relief in appropriately selected patients.

Recent advances and controversies in diagnosing and treating male infertility

Interest in male infertility has increased, as it plays an important role in up to 50% of couples struggling with infertility, which is an estimated 48.5 million couples globally. Despite recent advances, diagnosing and treating male infertility remain a significant clinical challenge owing to complex multifactorial pathways and the diversity of treatment options. This review will assess current controversial topics on male infertility such as the use of home-based semen testing, management of subclinical varicocele, and recent advances in the field of sperm proteomics.

TUNEL assay-Standardized method for testing sperm DNA fragmentation

Sperm DNA integrity is important for normal functions such as fertilization, implantation, pregnancy and fetal development. Sperm DNA fragmentation (SDF) is more common in infertile men and may be responsible for poor reproductive function. Although there are a number of tests available to measure SDF, the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-nick end labelling TUNEL) assay using flow cytometry is becoming more popular to measure the sperm DNA fragmentation. It is a direct test that measures both single- and double- DNA strand breaks. In this review, we describe the protocol, quality control and measurement of sperm DNA fragmentation using a benchtop flow cytometer. We also briefly discuss the factors that can affect the results, challenges and clinical implications of TUNEL in assessing male infertility.

Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective

Pediatric varicocele has an overall prevalence of 15%, being more frequent as puberty begins. It can damage testicular function, interfering with Sertoli cell proliferation and hormone secretion, testicular growth and spermatogenesis. Proper management has a pivotal role for future fertility preservation. The aim of this review was to discuss the diagnosis, management and treatment of childhood and adolescent varicocele from an endocrinologic perspective, illustrating the current evidence of the European Society of Pediatric Urology (ESPU), the European Association of Urology (EAU), the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) scientific societies. According to the ASRM/ESPU/AUA practice committee, the treatment of adolescent varicocele is indicated in the case of decreased testicular volume or sperm abnormalities, while it is contraindicated in subclinical varicocele. The recent EAS/ESPU meta-analysis reports that moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration increase. No specific phenotype in terms of testicular volume cut-off or peak retrograde flow (PRF) is indicated. Based on current evidence, we suggest that conservative management may be suggested in patients with PRF < 30 cm/s, testicular asymmetry < 10% and no evidence of sperm and hormonal abnormalities. In patients with 10-20% testicular volume asymmetry or 30 < PRF ≤ 38 cm/s or sperm abnormalities, careful follow-up may ensue. In the case of absent catch-up growth or sperm recovery, varicocele repair should be suggested. Finally, treatment can be proposed at the initial consultation in painful varicocele, testicular volume asymmetry ≥ 20%, PRF > 38 cm/s, infertility and failure of testicular development.