The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives

A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome

Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.

Testicular and scrotal abnormalities in pediatric and adult patients

Testicular and scrotal abnormalities can occur in children, adolescents, and adults. The lesions, often accompanied by pain and swelling/enlargement of the scrotum, can cause anxiety in patients and their parents. Regardless of age, proper diagnosis is based on adequate anamnesis and physical examination. Color Doppler ultrasound is the first-line test in the differential process of testicular and scrotal diseases. Testicular and scrotal lesions require differentiation for benign and malignant processes as well as therapeutic management, including urgent surgical intervention. The aim of this paper is to present the most common causes of testicular and scrotal abnormalities in pediatric and adult patients and to outline the symptoms and diagnostic and therapeutic management.

Male infertility

Clinical infertility is the inability of a couple to conceive after 12 months of trying. Male factors are estimated to contribute to 30-50% of cases of infertility. Infertility or reduced fertility can result from testicular dysfunction, endocrinopathies, lifestyle factors (such as tobacco and obesity), congenital anatomical factors, gonadotoxic exposures and ageing, among others. The evaluation of male infertility includes detailed history taking, focused physical examination and selective laboratory testing, including semen analysis. Treatments include lifestyle optimization, empirical or targeted medical therapy as well as surgical therapies that lead to measurable improvement in fertility. Although male infertility is recognized as a disease with effects on quality of life for both members of the infertile couple, fewer data exist on specific quantification and impact compared with other health-related conditions.

The learning curve of bilateral laparoscopic varicocelectomy: a prospective study

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

Ergothioneine attenuates varicocele-induced testicular damage by upregulating HSP90AA1 in rats

This study investigates the therapeutic effect and the underlying mechanisms of ergothioneine (EGT) on the testicular damage caused by varicocele (VC) in vivo, in vitro, and in silico. This preclinical study combines a series of biological experiments and network pharmacology analyses. A total of 18 Sprague Dawley (SD) male rats were randomly and averagely divided into three groups: the sham-operated, VC model, and VC model with EGT treatment (VC + EGT) groups. The left renal vein of the VC model and the VC + EGT groups were half-ligated for 4 weeks. Meanwhile, the VC + EGT group was intragastrically administrated with EGT (10 mg/kg). GC1 and GC2 cells were exposed to H₂ O₂ with or without EGT treatment to re-verify the conclusion. The structure disorder of seminiferous tubules ameliorated the apoptosis decrease in the VC rats receiving EGT. EGT can also increase the sperm quality of the VC model rats (p < 0.05). The exposure to H₂ O₂ decreased proliferation and increased apoptosis of GC1 and GC2 cells, which was revisable by adding EGT to the plates (p < 0.05). The network pharmacology and molecular docking were conducted to explore the potential targets of EGT in VC, and HSP90AA1 was identified as the pivotal gene, which was validated by western blot, immunohistochemistry, and RT-qPCR both in vivo and in vitro (p < 0.05). Overall, EGT attenuates the testicular injury in the VC model both in vivo and in vitro by potentially potentiating the expression of HSP90AA1.

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.

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.

Evaluation of free light chains of immunoglobulins in normal and pathological seminal fluids: Preliminary data

Immunoglobulins free light chains (FLCs) are assayable in several biological fluids. Currently, there are no reports on FLCs in seminal plasma. The aims of our study were to investigate the presence and detectability of FLCs in seminal plasma and to evaluate the usefulness of this assay in the diagnostic approach to infertile patients. We enrolled 61 patients aged 18-50 years. Semen analysis was performed. They were divided into four groups: controls-normozoospermic, 10 patients, mean ± SEM age 35 ± 1.5 years; varicoceles (VAR), 18 patients aged 24.3 ± 0.96 years; inflammatory (INF) seminal fluids, 24 patients, aged 38.8 ± 2.2 years; and varicoceles and inflammatory (VAR/INF) seminal fluids, 9 patients, aged 29.5 ± 0.71 years. A trend towards higher λ FLCs levels was evidenced in the INF and VAR/INF groups. κ FLCs were higher in normozoospermic patients with lower levels in VAR, both isolated and associated with inflammatory parameters. This differential pattern of the two types of FLCs reached statistical significance when comparing κ/λ ratio, with significant lower levels in VAR vs controls. This is the first report of FLCs assay in seminal plasma. We can hypothesize that λ FLCs are increased in inflammatory processes, whether κ FLCs seem to be influenced by other molecular mechanisms related to varicocele.

lncRNA and mRNA sequencing of the left testis in experimental varicocele rats treated with Morinda officinalis polysaccharide

Varicocele is a common disease of the male reproductive system. Morinda (M.) officinalis is a Chinese herbal medicine, whose main bioactive component M. officinalis polysaccharide (MOP) is believed to have a therapeutic effect on varicocele; however, the underlying molecular mechanisms of this effect are poorly understood. In the present study, 24 rats were randomly divided into three groups: i) Control group; ii) experimental varicocele group; and iii) 300 mg/kg MOP administration group. Analysis of mRNA and long non-coding RNA (lncRNA) expression in rat left testicular tissue was performed. The results suggested that a total of 144 mRNAs and 63 lncRNAs, 63 mRNAs and 148 lncRNAs, and 173 mRNAs and 54 lncRNAs were differentially expressed between the varicocele non-treatment and control groups, the varicocele treatment and varicocele non-treatment groups, and the varicocele treatment and control groups, respectively. Following validation by reverse transcription-quantitative PCR, the Yip1 domain family member 7 (YIPF7) gene was identified as a key mediator of varicocele pathogenesis and repair effect of MOP. Additionally, genes such as purinergic receptor P2X 4 (P2RX4), transmembrane protein 225B (TMEM255B) and Wnt family member 9B (WNT9B) were confirmed to be differentially expressed between the varicocele non-treatment and control groups. We hypothesize that TMEM255B could be a potential novel diagnostic biomarker for varicocele; WNT9B and P2RX4 likely play notable roles in the pathophysiology of the disease through the Wnt signaling pathway and regulation of transmembrane ion channels, respectively. In summary, the present study delineated the molecular mechanisms underlying varicocele pathogenesis and the therapeutic effect of MOP, identified a potential novel diagnostic marker and therapeutic target for varicocele, and provided feasible directions for further studies in the future.

Evaluation of testicular spermatogenic function by ultrasound elastography in patients with varicocele-associated infertility

OBJECTIVE

To investigate the application of ultrasound elastography and color Doppler ultrasound in the evaluation of testicular spermatogenic function in patients with varicocele (VC) associated infertility.

METHODS

A total of 196 patients with VC-associated infertility treated in our hospital from January 2018 to January 2020 were included as the research subjects (VC group), and were classified into VC I group (66 cases), VC II group (60 cases), and VC III group (70 cases) according to the diameter of spermatic vein and the degree of reflux under ultrasound. 50 age-matched healthy subjects were included as the control group. Color ultrasound, ultrasound elastography and semen examination were performed on all patients.

RESULTS

Compared with control group, a lower left testicular volume in VC group and a lower right testicular volume in VC III group were observed, and the left testicular volume was inversely proportional to VC grade (all P<0.05). Statistically significant differences in sperm viability, sperm density, peak systolic velocity (PSV), and MEAN values were determined among the 4 groups by one-way ANOVA, and between two groups by the independent-samples t test (all P<0.05). Pearson correlation analysis revealed that sperm viability and sperm density had no correlation with PSV, resistive index (RI) and pulsatility index (PI) of the left testicular artery in VC group, but were negatively correlated with the MEAN values of the testis.

CONCLUSION

Ultrasound elastography can predict the semen quality in patients with VC-associated infertility.

CLINICAL TRIAL REGISTRATION

This study was registered with the registration No. ChiCTR2010189 (URL: http://www.chictr.org.cn/showproj.aspx?proj=2018XE057-3).

Disruption of anchoring junctions in the testes of experimental varicocele rats

Varicocele is a common disease of the male reproductive system and is the main cause of male infertility; however, the pathological mechanisms of varicocele remain unclear. The anchoring junctions (AJs) in the testies are located between Sertoli cells, or between Sertoli cells and germ cells. Intact and functional AJs are crucial for spermatogenesis. In the present study, the histomorphology, ultrastructure of AJ, cell cycle, expression of AJ structural proteins, and the level of AJ-associated signaling molecules were investigated in the left testes of experimental varicocele rats at 8 and 12 weeks after surgery. The results revealed that varicocele induced the loss of premature germ cells from the seminiferous epithelium. Furthermore, the results of the present study also revealed damage to the AJ ultrastructure, disorientation of the spermatid head, deregulation of the cell cycle, downregulation of AJ structural proteins, enhanced phosphorylation of focal adhesion kinase (FAK) at Tyr³⁹⁷ and its downstream adapter Src at Tyr⁴¹⁶, and activation of the extracellular signal-regulated protein kinase 1 (ERK1) signaling pathway. Thus, the present study demonstrated that varicocele disrupted the structure and function of AJs in the left testes of rats, and that enhancement of FAK phosphorylation may contribute to AJ damage by activating ERK1 signaling, disrupting actin-based filament networks, and altering the balance of the apical ectoplasmic specialization-blood testis barrier functional axis. These findings provide important insights into the pathological mechanisms through which varicocele contributes to male infertility and could help to identify new therapeutic targets for varicocele.

A preliminary study of shear-wave elastography for the evaluation of varicocele in adolescents and young adults

PURPOSE

The purpose of this study was to use shear-wave elastography (SWE) to assess testicular stiffness changes during the Valsalva maneuver in adolescents and young adults with varicocele, to compare these changes according to clinical severity, and to evaluate the role of SWE in the diagnosis of varicocele.

METHODS

This study included patients undergoing testicular ultrasonography for the diagnosis of varicocele or for post-varicocelectomy follow-up between June 2016 and February 2017. Fifty-four testicles of 27 consecutive patients (mean age, 15.9 years) were classified by clinical grade (grade 0-3). Using SWE, mean testicular stiffness (Emean) was measured at rest and during the Valsalva maneuver. The correlations between multiple ultrasonographic parameters (volume asymmetry, Emean at rest, and absolute and percentage changes in Emean during the Valsalva maneuver) and clinical grade were assessed using the Spearman correlation test.

RESULTS

The Emean at rest was similar across clinical grades. During the Valsalva maneuver, increased testicular stiffness was frequently observed in patients with grade 2 or 3 varicocele but rarely observed in those with grade 0 or 1 varicocele. The changes in Emean were positively correlated with the clinical grade (all P<0.001), whereas the Emean at rest and volume asymmetry were not (all P>0.05).

CONCLUSION

A transient, reversible increase in testicular stiffness during the Valsalva maneuver was observed in adolescents with high-grade varicocele, and the degree of stiffness change was correlated with the clinical grade. Stiffness change identified using SWE during the Valsalva maneuver is a potential surrogate indicator of venous congestion.

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.

Gui-A-Gra Attenuates Testicular Dysfunction in Varicocele-Induced Rats via Oxidative Stress, ER Stress and Mitochondrial Apoptosis Pathway

Gui-A-Gra, a commercial insect powder from Gryllus bimaculatus, is registered as an edible insect by the Korean food and drug administration. The aim of this study was to investigate the effect of Gui-A-Gra on testicular damage induced by experimental left varicocele in male Sprague Dawley rats. A total of 72 rats were randomly divided into the following six groups (12 rats in each group): a normal control group (CTR), a group administrated with Gui-A-Gra 1.63 gm/kg (G1.63), a group administrated with Gui-A-Gra 6.5 gm/kg (G6.5), a varicocele (VC)-induced control group (VC), a VC-induced group administrated with Gui-A-Gra 1.63 gm/kg (VC + G1.63), and a VC-induced group administrated with Gui-A-Gra 6.5 gm/kg (VC + G6.5). Rats were administrated 1.63 or 6.5 gm/kg Gui-A-Gra once daily for 42 days. Indicators of sperm parameters, histopathology, reproductive hormones, oxidative stress, endoplasmic reticulum (ER) stress, inflammation, and mitochondrial apoptosis were analyzed to evaluate effects of Gui-A-Gra on VC-induced testicular dysfunction. Gui-A-Gra administration to VC-induced rats significantly (p < 0.05) increased sperm count and sperm motility, Johnsen score, spermatogenic cell density, serum testosterone, testicular superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase, GPx4, and steroidogenic acute regulatory protein (StAR) level. Moreover, pretreatment with Gui-A-Gra significantly (p < 0.05) decreased terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) positive cells/tubules, serum luteinizing hormone (LH), serum follicle-stimulating hormone (FSH), testicular tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), malondialdehyde (MDA), reactive oxygen species (ROS)/reactive nitrogen species (RNS) level, glucose-regulated protein-78 (Grp-78), phosphorylated c-Jun-N-terminal kinase (p-JNK), phosphorylated inositol-requiring transmembrane kinase/endoribonuclease 1α (p-IRE1α), cleaved caspase-3, and BCL2 associated X protein: B-cell lymphoma 2 (Bax: Bcl2) ratio in VC rats. These results suggest that protective effects of Gui-A-Gra on VC-induced testicular injury might be due to its antioxidant, anti-inflammatory, and androgenic activities that might be mediated via crosstalk of oxidative stress, ER stress, and mitochondrial apoptosis pathway.

The effects of varicocelectomy on the DNA fragmentation index and other sperm parameters: a meta-analysis

Background

Varicocele is one of the most common causes of reversible male infertility, and 15% of the varicocele patients with normal semen analysis are diagnosed as infertile. According to the current guidelines, varicocelectomy is indicated based on abnormal sperm parameters and not abnormal DNA fragmentation index (DFI) values. Thus, in this study, we performed a meta-analysis of the effects of varicocelectomy on the DFI and other conventional sperm parameters, and determined whether DFI could be used to indicate varicocelectomy for varicocele patients.

Results

Through an electronic search of the PubMed, Scopus, EBSCO, and Cochrane databases, we included 7 prospective studies including a total of 289 patients in this meta-analysis. The results showed that varicocelectomy significantly reduced DNA fragmentation (mean difference: − 6.86; 95% confidence interval [CI]: − 10.04, − 3.69; p < 0.00001) and improved sperm concentration (mean difference: 9.59; 95% CI: 7.80, 11.38; p < 0.00001), progressive motility (mean difference: 8.66; 95% CI: 6.96, 10.36; p < 0.00001), and morphology (mean difference: 2.73; 95% CI: 0,65, 4.80; p = 0.01).

Conclusion

Varicocelectomy reduced DNA fragmentation and improved sperm concentration, progressive motility, and morphology. Additionally, the analysis showed that an abnormal DFI measurement should be considered as an indication for varicocelectomy.

Evaluation of the role of reflux pattern in Color Doppler Ultrasound on spermogram improvement after varicocelectomy

PURPOSE

Many attempts are being made to find an association between varicocele characteristics and sperm parameters. In this study, we investigated the association between a newly introduced varicocele reflux grading pattern and sperm parameters, as well as its effect on spermogram improvement after varicocelectomy.

METHODS

In a prospective study, 73 patients with a clinical single-sided varicocele who underwent corrective varicocelectomy were included. Reflux pattern was determined on Color Doppler Ultrasound (CDUS) and categorized into four grades: grade 1 (retrograde), grade 2 (augmentation), grade 3 (enhancement), and grade 4 (stasis). The association of pre- and postoperative spermogram with the patients' reflux pattern was evaluated.

RESULTS

A significant positive association was found between the venous diameter and reflux pattern. Higher grades of the reflux pattern were associated with the more severe hemodynamic pattern of the reflux (shunt type). A significant association was found between the reflux pattern and preoperative semen characteristics, and this association was more prominent in constant venous diameter. In this respect, the enhancing reflux type was associated with the most impaired preoperative sperm count, motility, and morphology. The enhancing type also revealed the most improvement in spermogram after varicocelectomy.

CONCLUSION

Patients with a higher reflex grade, particularly enhancing pattern, will most benefit from the surgical correction of varicocele. These findings suggest reflux pattern as a promising prognostic factor for a favorable outcome after varicocelectomy.

Microsurgical varicocelectomy effect on sperm telomere length, DNA fragmentation and seminal parameters

Varicocele is one of the main causes of male infertility and microsurgical varicocelectomy (MV) seems to be the best procedure for its repair and to reduce testicular oxidative stress (ROS). As ROS causes guanine modifications, we postulated that DNA damage could be more intense in telomeres due to their G-rich nature. We studied the effect of MV on sperm telomere length (TL), single- and double-strand DNA fragmentation (ssSDF and dsSDF) and seminal parameters. Sperm telomeres from 12 fertile donors and 20 varicocele patients before and nine months after MV were labelled using FITC-PNA qFISH (a new method to obtain absolute TL from relative fluorescence intensity using FITC-fluorescent spheres). Both ssSDF and dsSDF were analysed using the alkaline and neutral Comet assays, respectively. The results showed that varicocele and MV had no effect on TL. Seminal parameters, ssSDF and dsSDF of varicocele patients were altered. Although these parameters improved after MV, values did not reach those seen in fertile donors. A good estimation of absolute TL was developed based on FITC-fluorescent spheres. The results showed that TL is not affected by varicocele or surgery. However, MV is able to partially reduce altered seminal parameters, ssSDF and dsSDF values in varicocele patients.

Semen parameter improvements after microsurgical subinguinal varicocele repair are durable for more than 12 months

INTRODUCTION

Varicoceles account for the most common correctable cause of male infertility, with varicocele repair leading to improvements in semen quality. However, there is little evidence to establish the durability of varicocele repair. We analyzed the durability of improvements in postoperative semen parameters following microsurgical subinguinal varicocele repair.

METHODS

We evaluated all men who underwent microscopic subinguinal varicocelectomy from 2015-2019. Patients were included if they desired fertility and had a followup of at least 12 months. We assessed the baseline characteristics of these patients, as well as semen volume, total motile sperm count (TMSC), concentration, percent motility, and morphology. Semen parameters were analyzed at baseline (preoperative) and at approximately three months and ≥12 months postoperatively.

RESULTS

Of 105 men who underwent varicocelectomy, 18 men had a followup of at least 12 months. These men presented with median age of 34.5 (27-38) years for a median followup duration of 14.5 (13-22.5) months. TMSC levels increased from 6.4 (1.1-24.5) million at baseline to 11.1 (2.4-38.4) million at approximately three months and remained similar at 12.5 (1.6-31.5) million at ≥12 months. The study is limited by its retrospective nature and limited sample size.

CONCLUSIONS

Microscopic subinguinal varicocele repairs can result in durable improvements of semen quality beyond one year, as demonstrated by upgrade in median TMSC. Further studies should be performed to confirm our findings.

Semen and reproductive hormone parameters in fertile men with and without varicocele

Although varicoceles are a widely accepted identifiable male factor in infertile couples, the benefit of varicocele repair in improving pregnancy and live birth rates remains uncertain. The Study for Future Families obtained semen and reproductive hormone samples from US men whose partners were currently pregnant. In our analysis cohort of 709 men, a varicocele was detected by clinical examination in 56 (8%) of men. Men with varicocele had smaller left testis, and lower total and total motile sperm counts than men without varicocele. Gonadotropin levels were higher as well in men with varicocele. Interestingly, testosterone levels were also slightly higher in men with varicocele. Despite these differences, there was no difference between the groups in the time to achieve the study pregnancy or percentage of men with a previous pregnancy. We conclude that even in fertile men, varicoceles are associated with some degree of testicular hypofunction. This would support current recommendations to consider varicocele repair in male partners in infertile couples who demonstrate both a varicocele and abnormal semen parameters and after evaluation for treatable female factors.

Isolated Right-Sided Varicocele: Is Further Workup Necessary?

OBJECTIVE

Unilateral left varicoceles are common and considered benign. Unilateral right varicoceles are reportedly associated with a pathologic process, namely malignancy affecting the retroperitoneum, for which further imaging is often recommended. The purpose of this study was to test the hypothesis that this correlation between unilateral right varicocele and malignancy may be weaker than once suggested, particularly in the absence of other clinical signs of malignancy.

MATERIALS AND METHODS

Medical charts and imaging at one institution were reviewed for all patients reported to have right varicocele. Follow-up cross-sectional imaging and clinical records and surgical and medical history were reviewed for possible nonmalignant or malignant causes of varicocele.

RESULTS

Ninety-six patients with unilateral right varicocele diagnosed by means of ultrasound were identified. Twenty-nine (30.2%) patients were excluded because of confounding factors (infection, testicular mass, intrascrotal surgery). Among the other 67, 55 had available follow-up information, 39 with cross-sectional imaging. Right-sided varicocele was attributable to nonmalignant causes in 16 of the 55 subjects (29.1%) and to malignancy in two subjects: one with metastatic disease of undetermined primary and one with confluent liver masses. Both patients presented with other signs of malignancy and represented only 3.6% of the cohort who underwent follow-up.

CONCLUSION

In this cohort, patients with right-sided varicocele attributable to malignancy presented with additional signs of metastatic disease. Nonmalignant causes were more common. Therefore, confounding conditions should be considered when incidental isolated right varicocele is identified. Health care costs, patient anxiety, and unnecessary harm can be substantially reduced through modulation of follow-up recommendations based on additional findings at presentation.

The clinical usefulness of a novel grading system for varicocoeles using duplex Doppler ultrasound examination based on postsurgical modifications of seminal parameters

BACKGROUND

The existing classifications of varicocoeles have poor predictive value regarding the effects of surgery on sperm count.

OBJECTIVE

To develop a new grading system for varicocoeles, useful as an indication for surgery.

MATERIALS AND METHODS

This is a three-center prospective study which examined 173 men having clinically detectable left varicocoeles and oligo ± astheno ± terato-spermia. The patients underwent medical history collection, objective examination, duplex Doppler ultrasound scrotal examination, hormonal profiles, two semen analyses before surgery, and two semen analyses after surgery. Sperm concentration, motility, and morphology (standard semen parameters) were evaluated 6 months after surgery in function of the following preoperative variables: patient age, follicle-stimulating hormone, clinical grade of varicocoele, right and left testicular volume, extension of venous reflux, and semen parameters. The venous reflux was graded in two centers using duplex Doppler ultrasound: reflux visible only with Valsalva and continuous reflux. Spearman's rank semiquantitative analysis was used. All patients had their varicocoeles corrected according to the Colpi technique.

RESULTS

The variables capable of determining an improvement in semen parameters after varicocoele correction were in order of decreasing importance: venous reflux extent assessed by scrotal duplex Doppler ultrasound examination, varicocoele clinical grade, basal semen parameters, and follicle-stimulating hormone. Male age did not influence postoperative semen quality. Only patients with continuous reflux had their standard semen parameters improved after surgery.

DISCUSSION

Venous reflux extent is the most critical variable capable of predicting semen improvement after varicocoelectomy.

CONCLUSIONS

A correct duplex Doppler assessment of venous reflux is mandatory for predicting postoperative improvement of the sperm count.

Current Issues in Adolescent Varicocele: Pediatric Urological Perspectives

While varicocele is the most common cause of surgically correctable infertility in adult males, with repair resulting in improved semen parameters in 60% to 80% of men and a higher likelihood of conception in up to 60% of men, the rationale for varicocele repair in the pediatric population is less clear. Additionally, prepubertal varicoceles are much less common and their management is controversial. Adolescents with a varicocele are often in the midst of a progressive disease process. Despite the high prevalence of varicocele and its association with progressive disease processes, the indications for adolescent varicocele repair and the effects thereof on paternity have been persistently challenging to study. This review will briefly present some of the current issues regarding adolescent varicocele from a pediatric urological point of view, including the evaluation of adolescent varicocele, the optimal surgical indications, the optimal choice of surgical intervention to be performed, and outcomes.

Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

Varicocele is characterized by an abnormal dilatation and retrograde blood flow in the spermatic veins. Varicocele is the leading correctable cause of male infertility. Although it is highly prevalent in infertile men, it is also observed in individuals with normal fertility. Determining which men are negatively affected by varicocele would enable clinicians to better select those men who will benefit from treatment. To assess the functional status of the testes in men with varicocele, color Doppler sonographic parameters were evaluated. Testicular arterial blood flow was significantly reduced in men with varicocele, reflecting an impairment of spermatogenesis. An improvement in the testicular blood supply was found after varicocelectomy on spectral Doppler analysis. Testicular contrast harmonic imaging and elastography might improve our knowledge about the influence of varicocele on intratesticular microcirculation and tissue stiffness, respectively, providing possible information on the early damage of testicular structure by varicocele. Magnetic resonance imaging (MRI), with measurement of apparent diffusion coefficient has been used to assess the degree of testicular dysfunction and to evaluate the effectiveness of varicocele repair. Large prospective studies are needed to validate the possible role of functional sonography and MRI in the assessment of early defects of spermatogenesis in testes with varicocele.

Varicocele and male infertility: current concepts and future perspectives

This Special Issue of Asian Journal of Andrology is fully dedicated to the thematic area of Varicocele, which has been one of the most controversial issues in the field of Urology, Andrology, and Reproductive Medicine. Recognized as a clinical entity for over a century, varicocele from Latin: varix (dilated vein) and from Greek: kele (tumor) still elicits heated debate among scientists and clinicians on an arguable negative effect on male fertility and gonadal function and has fueled thousands of scholarly articles since its first report in the 18^th century.

Afterword to varicocele and male infertility: current concepts and future perspectives

We summarize and comment on the topics discussed by the contributors to this Special Issue of Asian Journal of Andrology. The scope of varicocele covers a wide spectrum, including proteomics and metabolomics, hormonal control, interventional therapy, and assisted reproductive technology (ART). The selection of topics demonstrates the exciting breadth of this thematic area and the opportunity research holds for both increasing the understanding and improving the reproductive health of males with varicocele.

The Varicocele: Clinical Presentation, Evaluation, and Surgical Management

A varicocele is an abnormal dilatation and tortuosity of the veins of the spermatic cord. Although varicoceles are common in the general population and are frequently found on routine physical examinations, they represent the most common correctable cause of male factor infertility. Varicoceles are also often incidental findings on imaging studies, particularly scrotal ultrasound. Importantly, not all varicoceles should be treated equally (or at all), and basic guidelines on the evaluation and indications for treatment of adult varicoceles should be reviewed before counseling and treatment. A semen analysis should be obtained for any male patient of reproductive age considering intervention. The adolescent varicocele is managed much differently than the adult varicocele and remains a source of controversy. This review describes the clinical presentation and the evaluation of adult and pediatric varicoceles, and provides guidance on their diagnosis and workup. It also describes options for surgical repair and the success and complication rates associated with each surgical approach, ultimately supporting microsurgical subinguinal varicocele repair as the current surgical standard.

Clinical Outcomes of Varicocele Repair in Infertile Men: A Review

Varicoceles are a major cause of impaired spermatogenesis and the most common correctable cause of male infertility. They are found in approximately 40% of men with primary infertility and 80% of men with secondary infertility, although they also occur in 12% of men with normal semen parameters. The presence of a varicocele does not always affect spermatogenesis, as it has been reported that only 20% of men with documented varicoceles suffer fertility problems. However, varicocele repair appears to have beneficial effects in men with impaired semen parameters and palpable varicoceles. Currently, the main procedures employed for varicocele repair are microsurgical subinguinal or inguinal varicocelectomy, laparoscopic varicocelectomy, and radiological percutaneous embolization. Microsurgical varicocelectomy appears to be the optimal treatment in most cases, whereas the other procedures are useful only in specific cases. After treatment, it typically takes 3 to 6 months for patients' semen parameters to improve; thus, other therapies, including assisted reproductive technology, should be considered if infertility persists after this interval, especially in older couples. Controversies still remain regarding how varicoceles in certain subgroups, such as adolescents or men with azoospermia, should be treated. Due to their relatively high prevalence rate among the general population, varicoceles can occur concomitantly with other conditions that cause impaired spermatogenesis. Further studies are necessary in order to identify the patients who are most likely to benefit from treatment. In this review, we sought to summarize the issues currently associated with varicocele treatment in infertile men.