Microsurgical treatment of persistent or recurrent varicocele

OBJECTIVE: To examine the effectiveness of subinguinal microsurgical varicocelectomy in the treatment of persistent or recurrent varicocele. DESIGN: Retrospective chart review. SETTING: Urban, tertiary care, academic teaching hospital. PATIENT(S): Fifty-four men who presented for treatment of persistent or recurrent varicocele. INTERVENTION(S): A single surgeon using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis repaired all varicocele. MAIN OUTCOME MEASURE(S): Preoperative to postoperative changes in semen parameters (volume of ejaculate, sperm concentration, percent motility, percent morphologically normal sperm, total motile sperm concentration), serum hormone levels, and testicular volume. Pregnancy rates and surgical complications were documented. RESULT(S): Postoperative mean serum T and mean testicular volume increased significantly from prevaricocelectomy levels. Median sperm concentration, percent motility, and total motile sperm per ejaculate improved significantly following recurrent varicocelectomy. Among patients with follow-up over 24 weeks (65%, 35 out of 54), the overall pregnancy rate was 40% (14 out of 35), including 23% (8 out of 35) of pregnancies achieved through natural intercourse, 9% (3 out of 35) with IVF/intracytoplasmic sperm injection, and 9% (3 out of 35) with IUI. Complications such as hydrocele, hematoma, wound infection, and testicular atrophy were not observed during the follow-up period. CONCLUSION(S): Treatment of persistent or recurrent varicocele using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis improves semen parameters, serum T levels, and testicular volume from preoperative levels without a significant risk of postoperative complications.     

Role of varicocelectomy in men with nonobstructive azoospermia

OBJECTIVE: To evaluate the benefits of varicocelectomy in men with nonobstructive azoospermia. DESIGN: Retrospective review of effect of prior varicocelectomy on sperm retrieval rates in men with nonobstructive azoospermia. Chart review of men with nonobstructive azoospermia who underwent microsurgical varicocelectomy to determine the effect of the procedure on the need for testicular sperm extraction (TESE). SETTING: Tertiary, university-based referral center. PATIENT(S): Men with clinical varicoceles and nonobstructive azoospermia. INTERVENTION(S): Microsurgical varicocelectomy, TESE. MAIN OUTCOME MEASURE(S): Return of sperm to the ejaculate and need for TESE after varicocele repair, ability to find sperm using microdissection TESE. RESULT(S): Of 31 men who underwent varicocele repair at one institution for documented nonobstructive azoospermia, 7/31 (22%) had sperm reported on at least one semen analysis postoperatively. However, only 3/31 (9.6%) men after varicocele repair had adequate motile sperm in the ejaculate for ICSI, without TESE. Sperm retrieval rates for men with varicoceles were not affected by a history of prior varicocelectomy. CONCLUSION(S): Men with clinical varicoceles that are associated with nonobstructive azoospermia will rarely have adequate sperm in the ejaculate after varicocele repair to avoid TESE. A history of prior varicocele repair does not appear to affect the chance of sperm retrieval by TESE for men with clinical varicoceles and nonobstructive azoospermia. The benefits of varicocelectomy in men with nonobstructive azoospermia may be less than previously reported.     

Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men

In a prospective study, the outcomes of microsurgical varicocelectomy in men with primary versus secondary infertility were compared. Ninety-two infertile men with a varicocele were included. They were classified into those with primary infertility (n?=?57) and secondary infertility (n?=?35). Clinical data, semen parameters and scrotal ultrasound finding were available for all patients and microsurgical varicocelectomy was performed on all of them. Spontaneous pregnancy rates and improvement in semen parameters in those men with primary versus secondary infertility were recorded 1 year after surgery. Preoperatively, there was no significant difference in the mean semen parameters in both groups (p?>?0.05) and the mean semen parameters showed no significant difference between men with primary and secondary infertility. After microsurgical varicocelectomy, the mean semen parameters improved significantly in both group (p?p?>?0.05 for each). After adjustment for patient and partner ages, the pregnancy rate at the end of the follow-up period did not significantly differ between the primary (24/57, 42.1%) and secondary (11/35, 31.4%) infertility group (Pearson’s Chi-squared?=?1.05). We concluded from this study that semen parameters and pregnancy rates after microsurgical varicocelectomy were similar between men with primary and secondary infertility.     

Evaluation of testicular microlithiasis in varicoceles

Background:  Testicular microlithiasis is said to be characterized by calcific concretions within the seminiferous tubules. There have been reports suggesting a link between testicular microlithiasis and testicular dysfunction and tumors.
Methods:  In this study, we assessed subjects with varicoceles detected by using testicular ultrasound, and evaluated the cases of testicular microlithiasis in terms of age, seminalysis findings, and endocrinological parameters (testosterone, follicular stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL)). The subjects comprised 224 patients with varicoceles diagnosed by using testicular ultrasound, who attended this institution as outpatients between January 1998 and August 2000.
Results:  Testicular microlithiasis was detected in 15 out of 224 subjects (6.7%), bilateral in all cases. No significant differences were seen between the group with testicular microlithiasis and the group without testicular microlithiasis, in terms of age, seminalysis findings, and/or endocrinological parameters (testosterone, FSH, LH, prolactin). The incidence of testicular microlithiasis in outpatients undergoing testicular ultrasound varies between reports, but is of the order of 0.6–2.0%.
Conclusion:  In this study, we found a high proportion of testicular microlithiasis at 6.7%, strongly suggesting a link with male infertility. (Reprod Med Biol 2002; 1 : 75–79)     

Other work has highlighted the limitations of using histopathology to predict success after varicocelectomy

The morbidity associated with performing testicular biopsy on all men before varicocele repair appears to outweigh the benefit of any prognostic information obtained.     

显微外环下治疗高位结扎术后复发精索静脉曲张

目的探讨显微外环下手术处理高位精索静脉结扎术后复发的应用价值。方法对26例既往已行高位精索静脉结扎术后复发患者采用显微外环下切口处理,精索静脉曲张III度患者切口偏向阴囊,以便提出睾丸,同时处理精索外静脉。结果术后3～6个月随访,得到随访23例,随访复查未见复发。结论复发性精索静脉曲张适合采用显微技术治疗。     

Influence of varicocele embolization on the choice of infertility treatment

OBJECTIVE: To investigate whether embolization of a varicocele improves semen quality and enables use of less-invasive modes of assisted reproductive technology (ART) in infertile men with a physically palpable varicocele confirmed by phlebography. DESIGN: Retrospective chart review. SETTING: University infertility clinic. PATIENT(S): Fifty patients with varicoceles that were treated with embolization and 11 patients with untreated varicoceles (control group). In both groups the clinical varicoceles had been phlebographically confirmed. INTERVENTION(S): Phlebography and embolization. MAIN OUTCOME MEASURE(S): Semen characteristics and mode of ART before and after treatment. RESULT(S): Median improvements of semen parameters, such as concentration and motility after processing, were significantly greater in the embolization group than in the untreated group. In the embolization group, semen samples improved to levels requiring less-invasive modes of ART in significantly more patients than in the untreated group. Deterioration of semen samples, requiring more invasive techniques, was significantly more frequent in the untreated group than in the embolization group. CONCLUSION(S): Embolization of a varicocele in infertile men significantly improved semen, such that much more often a less-invasive form of ART than was planned before treatment became feasible. Embolization of a varicocele might even prevent further deterioration of semen samples to levels requiring more-invasive ART.     

Influence of microsurgical varicocelectomy on human sperm mitochondrial DNA copy number: a pilot study

Background

There is good evidence to show that varicocele repair can improve conventional sperm parameters, as well as, sperm DNA integrity, in infertile men with a clinical varicocele.

Objective

To examine the effect of varicocelectomy on sperm quality, specifically, sperm nuclear chromatin integrity and sperm mitochondrial DNA (mtDNA) copy number.

Design, Setting, and Participants

A prospective study done between March 2007 and January 2008. We evaluated a consecutive series of infertile men (n = 14) presenting to Ovo clinic with one year or more history of infertility, a clinically palpable varicocele and poor motility (<25 % rapid progressive and <50 % progressive).

Surgical Procedure

Microsurgical sub-inguinal varicocelectomy.

Outcome Measurements and Statistical Analysis

Conventional sperm parameters, sperm mtDNA copy number (by real time PCR) and sperm chromatin structure assay (SCSA) parameters (%DFI,% HDS) before and 4 months after microsurgical varicocelectomy.

Results and Limitations

Sperm concentration and SCSA parameters (%DFI and %HDS) improved significantly after surgery (P < 0.05). Sperm mitochondrial DNA copy number decreased significantly after surgery (27 ± 30 to 9 ± 6 copies per sperm, respectively, P = 0.032). There was a significant negative correlation between mitochondrial DNA copy number and sperm motility (r = − 0.71, P = 0.002).

Conclusion

These findings support the concept that correction of a varicocele can improve spermatogenesis and sperm function, as mitochondrial DNA copy number has been suggested to reflect the efficiency of spermatogenesis and has been inversely related to sperm motility.     

Testicular growth, sperm concentration, percent motility, and pregnancy outcome after varicocelectomy based on testicular histology

OBJECTIVE: To evaluate the outcome following surgery in two different patterns of testicular histology in patients with varicocele. DESIGN: Prospective study. SETTING: Academic medical center. PATIENT(S): Sixty patients underwent varicocelectomy and had a testicular histology diagnosis of germ-cell aplasia (group I, n = 28) or maturation arrest (group II, n = 32). INTERVENTION(S): Varicocelectomy. MAIN OUTCOME MEASURE(S): Preoperative hormone levels, testicular size, and sperm parameters. After varicocelectomy, variations in testicular size, semen parameters, and pregnancy rates were evaluated. RESULT(S): The mean volume of the right and left testicle was smaller in group I patients than in group II. In addition, the mean sperm concentration before treatment was lower in group I than in group II. The mean volume of the left and right testicle increased in group I after the intervention. The mean postoperative sperm concentration and motility in group II showed no increase, whereas the mean sperm concentration in group I did increase. The pregnancy rate was higher in group II (14/26, 53.8%) than in group I (4/16, 25%) (P=.02). CONCLUSION(S): Patients with germ-cell aplasia present a postoperative increase in testicular size but the pregnancy rate is higher in patients with maturation arrest following surgery.     

Diagnostic testicular biopsy before varicocele repair plays a realistic and important role

We believe that diagnostic testicular biopsy before varicocele repair is important, despite the risks.