Time to improvement of semen parameters after microscopic varicocelectomy: When it occurs and its effects on fertility

While ligation of clinical varicoceles has been clearly shown to improve semen parameters in subfertile men, evidence describing when to expect improvement and the potential effects on fertility following surgery are sparse. A chart review was undertaken to identify men who had undergone a microscopic subinguinal varicocelectomy from January 1, 2006, to June 30, 2018. Semen analyses were reviewed to determine if a significant improvement occurred post-operatively and when the improvement was seen. Pregnancy data were reviewed to determine if fecundity rates were affected by semen parameter improvement or the interval at which improvement occurred. A total of 170 men met criteria for inclusion, including pregnancy data on 140. 69.4% of patients experienced a significant improvement in total progressive sperm count (TPSC), 78.8% of which occurred after 3 months. The overall pregnancy rate was 40.7%. When comparing men whose TPSC improved to those who did not, there was an odds ratio (OR) of 5.89 (2.28–15.28, 0.0003) for achieving pregnancy, while an OR of 2.05 (0.80–5.28, 0.13) was found when comparing pregnancy rates between early and late improvement in semen parameters. Pregnancy rates were not affected by time to improvement, but were higher in men who had a significant improvement in TPSC after surgery.     

低位显微外科与腹腔镜两种精索静脉结扎术治疗精索静脉曲张性不育疗效比较

目的 比较低位显微外科与腹腔镜精索静脉结扎术治疗精索静脉曲张性不育患者的疗效.方法 40例精索静脉曲张性不育患者,随机分为两组,低位显微外科精索静脉结扎术组(A组,20例)和腹腔镜精索静脉结扎术组(B组,20例),比较术前、术后第1、6、12月的精液质量,并且追踪术后2年内配偶临床妊娠结果.结果 两组术后精子密度、精子总数和(a+b)级精子数均较术前有显著提高(P<0.05),但组内术后第1、6、12月的精液质量各主要参数间对比,无统计学差异(P>0.05).组间术前、术后第1、6、12月精液质量各主要参数进行对比,无统计学差异(P>0.05).术后随访2年配偶临床妊娠A组为13例(65%),B组为12例(60%).结论 低位显微外科精索静脉结扎术对精索静脉曲张(VC)伴有男性不育患者是一种经济、简单、有效、便于推广的手术治疗方式.     

Prediction of reproductive function recovery after microsurgical varicocelectomy in men from infertile couples: Clinical and laboratory predictors

The objective was to reveal predictors for fertility recovery after varicocelectomy in subfertile men. This retrospective study recruited 93 men with clinical varicocele and pathozoospermia who underwent microsurgical varicocelectomy. Stepwise discriminant analysis was performed to identify predictors of spontaneous pregnancy (SP) after surgery. ‘Clinically significant improvement’ (CSI) following varicocelectomy was defined as an increase in total progressively motile sperm count (TPMSC) by at least 12.5 million (calculated from WHO-2010 reference values). 52% of patients showed CSI, and 28% reported SP after surgery. Patients who reported SP (group II), compared to that remained infertile (group I), were younger (27.3 ± 2.9 versus 30.2 ± 4.2 years; p < .01), had less infertility period (24.1 ± 14.0 versus 44.4 ± 32.9 months; p < .05) and had initially higher TPMSC (median (25% −75%) = 34 (11–67) versus 9.5 (0–33) mln; p < .05). The stepwise discriminant analysis showed that male age (coefficient value = −0.157), total sperm motility (0.024) and postoperative increase in TPMSC (0.010) were the significant predictors of SP. The predictive ability, sensitivity and specificity of the discriminant function were 84%, 87%, 76% respectively. This algorithm can be recommended after varicocelectomy in decision-making on natural conception or the ART protocols usage.     

The effects of subinguinal varicocelectomy on Kruger morphology and semen parameters

Purpose

We studied the effect of varicocele ligation on Kruger strict morphology criteria and semen parameters in patients with infertility.

Materials and Methods

A total of 90 patients diagnosed with varicoceles and a normal morphological sperm ratio of less than 14% were evaluated before and 6 months after varicocelectomy. Preoperatively and postoperatively sperm density, motility and morphology using Kruger strict criteria were analyzed. The Wilcoxon test was used to measure levels of statistical significance in all analyses.

Results

Significant improvement in sperm concentration and motility was evident after varicocele ligation (p <0.0002 and <0.0001, respectively). Using the Kruger classification sperm morphology evaluation revealed a significant increase in the percent of normal forms, and of forms with head and acrosome defects (p <0.0001, <0.0014 and <0.0028, respectively). There were no concomitant changes in strict morphology in forms with mid piece and tail defects or immature forms (p >0.05). Of the 90 patients 18 (20%) achieved a successful full-term pregnancy, including 14 via natural cycle intercourse and 4 by intrauterine insemination.

Conclusions

Surgical correction of varicocele was associated with significant improvement in density, motility and sperm morphology evaluated using the Kruger classification.     

Prognosis of varicocelectomy in the treatment of infertility, based on pre-surgery characteristics

The semen characteristics, before and after varicocelectomy, were studied in 220 husbands from infertile couples, whose wives had no significant abnormalities. All couples were followed for one year or until the wife became pregnant. Sperm density, vitality, motility and percent with normal morphology were analysed before surgery. Based on these results, subjects were divided into 2 groups according to whether their semen had normal or abnormal characteristics. The group with semen parameters within normal limits showed significantly less improvement after surgery, and the posttreatment pregnancy rate was independent of the effect of surgery on the characteristics of sperm. Between 71 and 84% of the subjects with abnormal semen characteristics showed improvement after surgery, and between 56 and 72% of those who improved, impregnated their wives. Subjects whose abnormal semen characteristics did not improve after surgery, had a very low pregnancy rate.     

Early varicocelectomy by percutaneous scleroembolization improves seminiferous tubules spermatozoa release in the adolescent phase of testicular growth

Varicocele is a rather common andrological condition in adolescents, which can adversely affect testicular growth and seminal parameters, leading to infertility in about 20% of adults. The aim of this study was to investigate if treating varicocele before the age of 18 is a beneficial option to improve testicular hypotrophy and seminal parameters and if minimally invasive techniques could be an appropriate treatment choice for adolescent varicocele associated with spermatic vein reflux. A percutaneous scleroembolization was performed in sixty‐four consecutive young patients (13–19 years old) with left varicocele, preceded by a fluoroscopy. In thirty‐four of them, semen samples were also collected. We examined semen samples and testicles dimensions before and after percutaneous varicocelectomy, compared to a nonoperated control group, with a six‐month follow‐up. Total sperm count and sperm morphology were significantly increased in the intervention group. Left testicular volume significantly increased in both groups, while only correction of varicocele improved spermatozoa release per unit of testis volume. We conclude that early varicocelectomy by percutaneous scleroembolization significantly ameliorates seminiferous tubules activity in the critical adolescent phase of testicular growth. It is suggested that adolescents should be; offered varicocele repair as soon as possible in order to improve reproductive potential.     

Microsurgical varicocelectomy: a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele(s), with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.     

Single-port laparoscopic surgery: initial experience in children for varicocelectomy

OBJECTIVE

To present our initial experience in children undergoing single‐port laparoscopic varicocelectomy (SPLV) using a new approach in which the entire procedure is performed through a multichannel single laparoscopic port inserted in the umbilicus rather than the traditional LV performed through three abdominal ports.

PATIENTS AND METHODS

We reviewed our experience with all paediatric patients who had undergone transumbilical SPLV [Uni‐X^TM Single Port Access Laparoscopic System, Pnavel Systems, NJ, USA]. This novel 20‐mm laparoscopic port has three working channels and gas insufflation access. The system also includes a variety of curved laparoscopic instruments that can be introduced through the SP. A Hassan technique through an incision within the inferior aspect of the umbilicus is used to obtain laparoscopic port access to the abdominal cavity. The SP is then fixed into position with pre‐placed rectus facial sutures. Using a curved laparoscopic grasper and scissors, an incision is made within the posterior peritoneum on the medial and lateral aspects of the left testicular artery and veins, proximal to the vas deferens. The vessels, both artery and veins, are transected leaving clips both proximally and distally.

RESULTS

Transumbilical SPLV was completed in three consecutive adolescents (aged 13, 15 and 16 years) without placing any additional ports or conversion to open surgery. All procedures were performed for left‐sided grade III varicoceles. The operative duration was <1 h for each procedure. All patients were discharged on the same day as their surgery and none required re‐hospitalization. At a mean (range) follow‐up of 8.7 (6–10) weeks there was a good cosmetic result, with no varicocele recurrence, or intraoperative or postoperative complications including wound infection, hydrocele, or incision site herniation.

CONCLUSION

We report the first use of a multicannula single laparoscopic port in children and for SPLV. This new laparoscopic approach, similar to any new technique, requires further experience to fully evaluate its benefits and limitations.     

Review of current varicocelectomy techniques and their outcomes

What’s known on the subject? and What does the study add? The relationship between varicocele and infertility is well established, and several surgical and radiological techniques for varicocelectomy are currently used in practice. The postoperative benefits of the surgery is also well established. The AUA has set forth guidelines on the evaluation and indications for treatment of varicocele; however, to date, there is no consensus as to which surgical technique should be considered the gold standard. This paper evaluates the current methods in practice and evaluates them based on specific and stringent criteria. All surgical and radiological methods that are frequently used were included. We suggest that by using either of the two microsurgical techniques, inguinal or subinguinal, that there would be better outcomes across all parameters postoperatively with better long term outcomes. We also investigated several new techniques and made recommendations for further research.

OBJECTIVES

• ? To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique
• ? To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery.

PATIENTS AND METHODS

• ? A PubMed English literature review of literature from 1995 to present.

RESULTS

• ? Pregnancy rates were highest with microsurgical subinguinal technique
• ? Varicocele recurrence rates were lowest with microsurgical subinguinal technique
• ? Hydrocele formation rates were lowest with microsurgical inguinal technique
• ? Surgical complications were highest in the laparoscopic technique
• ? Varicocelectomy by itself or in conjunction with IVF is cost effective

CONCLUSIONS

• ? Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes
• ? Varicocelectomy is a cost effective treatment modality for infertility
• ? Further research is needed to explore new developments in varicocelectomy

     

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

BackgroundVaricocele (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.MethodsIn 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.ResultsThe 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.ConclusionsMSV 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.     

Umbilical laparoendoscopic single site surgery versus inguinal varicocelectomy for bilateral varicocele: A comparative study

We aimed to determine the efficacy of umbilical laparoendoscopic single site surgery (LESS) bilateral varicocelectomy on the basis of a comparative study versus open inguinal bilateral varicocelectomy. We enrolled 39 patients who underwent bilateral varicocelectomy with predetermined surgical indications at two hospitals with either the LESS (n = 19) or the open inguinal approach (n = 20). Operative time, operation‐related pain (10‐point visual analog pain scale), catch‐up growth of the testes, semen parameters, and complications after surgery between the LESS group and the open group at 3 months after surgery were compared. Operative times were 46.8 and 72.8 min (P < 0.001) in the LESS and open surgery groups, respectively. Patients in the LESS group reported lower surgery‐related pain than those in the open surgery group at 3 months (2.5 vs 1.2, P = 0.029). A significant improvement in terms of semen concentration, motility, catch‐up growth of the bilateral testes was observed in both groups, although no significant differences were detected between the groups. Postoperative complications were also similar between the two groups. LESS varicocelectomy required a shorter operative time than inguinal varicocelectomy for bilateral cases. In addition, the LESS procedure showed less postoperative pain and cosmetic benefits with similar seminal outcomes. Thus, LESS for patients undergoing bilateral varicocelectomy represents a promising surgical approach.     

Evaluation of clinical effects of microsurgical subinguinal varicocelectomy with and without testicular delivery

The aim of this study was to access whether microsurgical subinguinal varicocelectomy (MSV) with testicular delivery has a better therapeutic effect than MSV without testicular delivery, including semen quality, serum testosterone (T) level and International Index of Erectile Function (IIEF)-5 score in infertility male patients with varicocele. In this prospective study, 181 patients were included and they chose the treatment by themselves. A total of 114 patients who received MSV without testicular delivery (TD) and 67 patients who received MSV with TD were followed-up 6 months after the operation. Semen parameters, serum T level and IIEF-5 scores were recorded before and 6 months after the operation. Results showed that MSV with or without TD could improve semen quality, serum T level and IIEF-5 score. For semen quality 6 months after the operation, there was no significant difference between patients received MSV with or without TD. But in patients with varicocele of grade III, MSV without testicular delivery improved the sperm concentration and motility more. And patients received MSV without TD have a higher T level 6 months after the operation, especially in patients ≤27 years. MSV with TD is not superior to that without, but this should be verified in more samples and a better designed randomised controlled study in the future.     

Summary evidence on the effects of varicocele treatment to improve natural fertility in subfertile men

The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.     

Inguinal and subinguinal micro-varicocelectomy,the optimal surgical management of varicocele: a meta-analysis

Conventional meta-analyses have shown inconsistent results for the efficacy of various treatments of varicoceles. Therefore, we performed a multiple-treatment meta-analysis to assess the effectiveness and safety of 10 methods of varicocelectomy and embolization/sclerotherapy. We systematically reviewed 35 randomized controlled trials and observational studies, from 1966 to August 5, 2013, which compared any of the following treatments for varococeles: laparoscopic, retroperitoneal, open inguinal and subinguinal varicocelectomy, microsurgical subinguinal and inguinal varicocelectomy, percutaneous venous embolization, Tauber antegrade sclerotherapy, retrograde sclerotherapy and expectant therapy (no treatment). Inguinal and subinguinal microsurgery, open inguinal, laparoscopic varicocelectomy showed a significant advantage over expectant therapy in terms of pregnancy rates (odds ratio (OR): 3.48, 2.68, 2.92 and 2.90, respectively). Compared with retroperitoneal open surgery, inguinal microsurgery showed an improvement of sperm density (mean difference (MD): 10.60, 95% confidence interval (CI): 1.92–19.60) and sperm motility (MD: 9.09, 95% CI: 4.88–13.30). Subinguinal and inguinal microsurgery outperformed retroperitoneal open surgery in terms of recurrence (OR: 0.05, 0.06 respectively). Tauber antegrade sclerotherapy and subinguinal microsurgery were associated with the lowest risk of hydrocele formation. The odds of overall complication, compared with retroperitoneal open varicocelectomy, were lowest for inguinal microsurgery (OR = 0.07, 95% CI: 0.02–0.19), followed by subinguinal microsurgery (OR = 0.09, 95% CI: 0.02–0.19). Inguinal and subinguinal micro-varicocelectomy had the highest pregnancy rates, significant increases in sperm parameters, with low odds of complication. These results warrant additional properly conducted randomized controlled clinical studies with larger sample sizes.     

Clinical study of varicocele: Statistical analysis and the results of long-term follow-up

BACKGROUND: The results of clinical examinations of varicocele and the clinical outcome of varicocelectomy conducted at Tsukuba University Hospital, Tsukuba City, Japan were analyzed. METHODS: The subjects of the present study were sixty-four infertile male patients with varicocele who visited our hospital from 1991 to 1999. A physical examination, semen analysis and hormonal evaluation were performed for each patient. Patients selected their preferred type of treatment (varicocelectomy or conservative treatment) after providing their informed consent. RESULTS: The age of the patients was 34.1 +/- 5.1(mean +/- standard deviation [s.d.]) years, and the infertile duration was 4.2 +/- 3.0 (mean +/- s.d.) years. Fifty-one cases were left-sided; 13 were bilateral. Mean sperm density ( yen 106/mL) was 37.2 for Grade I, 21.3 for Grade II and 9.4 for Grade III. Sperm density was significantly lower in the higher-graded patients (P = 0.008). Varicocelectomy was performed in 31 cases; the postoperative/preoperative ratio of sperm density was significantly higher in the higher-graded varicocele (P = 0.04), and the peak/base ratio of follicle-stimulating hormone (FSH) after luteinizing hormone-releasing hormone (LH-RH) stimulation was significantly decreased after varicocelectomy (P = 0.007). The pregnancy rate in the partners of the varicocelectomized group (60%) was significantly higher than in the conservatively treated group (28%) P = 0.04; the mean follow-up duration was 76.2 months. CONCLUSION: These results show that varicocele should influence spermatogenesis, therefore altered spermatogenesis could be effectively treated by varicocelectomy, and varicocelectomy should induce a higher probability of pregnancy.     

精索静脉曲张显微手术及腹腔镜手术疗效对比

目的对比评价显微技术精索静脉结扎术和腹腔镜精索静脉高位结扎术治疗精索静脉曲张引起不育症患者的临床疗效。方法分析65例应用显微技术精索静脉结扎术和64例应用腹腔镜精索静脉高位结扎术的不育症患者。结果两组患者手术均正常完成,未发生术后并发症。显微手术组双侧精索静脉曲张的手术时间长于腹腔镜手术时间,两者差别具有统计学意义(P0.05)。129例患者均得到术后3个月复诊:84例精子活力改善(提高20%以上),其中显微手术组45例(45/65),腹腔镜手术组39例(39/63)(P0.05)。107例患者术后6个月复诊结果:21例精子活力改善(与上次复查结果对比提高20%以上),其中显微手术组17例(17/52),腹腔镜手术组6例(6/55)(P0.05)。术后12个月与6月数据接近。结论显微技术精索静脉结扎术在术后疗效方面优于腹腔镜手术。     

Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: A prospective randomized study

BACKGROUND: The purpose of the study was to compare the effect of varicocelectomy with that of clomiphene citrate on seminal improvement and pregnancy rates in patients with subclinical varicocele. METHODS: A total of 42 infertile men with left subclinical varicocele were randomized to group I (21 patients, surgery) and group II (21 patients, medical therapy). The patients in group I were treated with varicocelectomy and those in group II with clomiphene citrate, 50 mg/day, orally. Sperm parameters (sperm density, motility and morphology) were recorded before and 6 months after beginning the treatment and pregnancy rates were estimated. In statistical analysis, paired and independent-samples t-tests, Kaplan-Meier and Log rank tests and Fisher's exact test were used. RESULTS: Mean +/- SD age of the series was 32.7 +/- 6.1 years, that of group I was 32.2 +/- 5.5 years and that of group II was 33.1 +/- 6.7 years (P = 0.680). All seminal parameters increased after both surgical and medical treatment, but only increases in sperm density and motility following varicocelectomy were statistically significant. Changes in seminal parameters between groups I and II were statistically insignificant. Pregnancy was seen in two cases in group I and in one in group II (P = 0.500). The cumulative pregnancy rates were 12.5% in group I and 6.7% in group II (P = 0.589). CONCLUSIONS: Clomiphene citrate did not increase sperm density and motility as effectively as subclinical varicocelectomy, but there was no statistically significant difference between surgical and medical therapy methods in terms of seminal improvement and pregnancy rate.     

Clinical significance of subclinical varicocelectomy in male infertility: systematic review and meta‐analysis

Recent meta‐analysis by the Cochrane collaboration concluded that treatment of varicocele may improve an infertile couple's chance of pregnancy. However, there has been no consensus on the management of subclinical varicocele. Therefore, we determine the impact of varicocele treatment on semen parameters and pregnancy rate in men with subclinical varicocele. The randomised controlled trials that assessed the presence and/or treatment of subclinical varicocele were included for systematic review and meta‐analysis. Random effect model was used to calculate the weighted mean difference of semen parameters and odds ratio of pregnancy rates. Seven trials with 548 participants, 276 in subclinical varicocelectomy and 272 in no‐treatment or clomiphene citrate subjects, were included. Although there was also no statistically significant difference in pregnancy rate (OR 1.29, 95% CI 0.99–1.67), surgical treatment resulted in statistically significant improvements on forward progressive sperm motility (MD 3.94, 95% CI 1.24–6.65). However, the evidence is not enough to allow final conclusions because the quality of included studies is very low and further research is needed.