Preoperative parameters related to the improvement of semen characteristics after surgical repair of varicocele in subfertile men

To know the parameter related to improvement of each semen characteristic (sperm density and percentage of progressive motile sperm) after high ligation of the left internal spermatic vein, 119 men from infertile couples were investigated. In each individual, the semen characteristic was considered to be different from the postoperative mean value if it was over or below 2 SD of the preoperative mean. Although no relationship was detected with the age of the patient, the duration of infertility or the preoperative semen characteristics, a definite relationship was found between the degree of varicocele and the improvement in each semen characteristic. For improvement of the sperm density, each of the volume and the score count by Johnsen's scale of the affected and unaffected testes and the serum hormone values (LH, FSH and testosterone) showed correlations. Meanwhile, for the improvement of the percentage of progressive motile sperm, correlations were found only with each of the testicular volume on the unaffected side and the serum testosterone level.     

The effect of varicocele repair on testicular volume in children and adolescents with varicocele

PURPOSE: We investigated the effect of varicocele repair on testicular volume according to age in children and adolescents and review the long-term results of varicocele surgery. MATERIALS AND METHODS: The study included 39 boys 11 to 19 years old with clinical palpable varicocele who underwent varicocele surgery with at least 1 year of postoperative followup. Preoperative and postoperative testicular volumes were monitored and measured with an ellipsoid Prader orchidometer. Physical examination findings (testicular volumes and testicular consistency) in all boys, and serum hormone values and semen parameters in 16 adolescents were recorded and compared before and after surgery. RESULTS: Left unilateral varicocelectomy was done in 29 boys (74%) and bilateral varicocelectomy in 10 (26%). While no postoperative hematoma, infection or testicular atrophy was observed, 1 boy (2.5%) had varicocele recurrence and 2 boys (5.1%) had minimal hydroceles that required no intervention. Significant increases were observed in postoperative sperm concentration (p = 0.01), total motile sperm count (p = 0.009), testis volume (p = 0.000) and serum testosterone level (p = 0.014). All 15 boys with preoperative soft testis had normal testicular consistency postoperatively. Of the 19 boys with preoperative testicular atrophy 10 (53%) did regain normal testicular growth, while 9 (47%) retained testicular volume loss after surgery. When comparing preoperative to postoperative increase in testicular volume according to age in all boys, the mean was statistically significantly higher in boys younger than 14 years (left testis p = 0.037, right testis p = 0.000). CONCLUSIONS: Testicular consistency achieved normal firmness after varicocelectomy in all boys with preoperative soft testis. While there was catch-up growth in comparison to the contralateral testis, testicular consistency improved but testicular volumes may not increase significantly after varicocele repair at ages older than 14 years. However, in these adolescents postoperative semen parameters and serum hormone values may significantly improve regardless of testicular volume. Therefore, boys with varicocele and their families should be fully informed in light of these findings.     

Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study

Purpose

The purpose of this study is to compare the effect of bilateral versus unilateral varicocelectomy on seminal response and spontaneous pregnancy rates in infertile male patients with left clinical and right subclinical varicocele.

Methods

A total of 358 infertile men with left clinical and right subclinical varicocele were randomized to group that underwent bilateral (n = 179) and group that underwent unilateral microsurgical subinguinal varicocelectomy (n = 179). Baseline data regarding male age, female partner age, grade of varicocele body mass index, bilateral testicular volume and serum follicle-stimulating hormone, luteinizing hormone, total testosterone levels and infertility duration and semen parameters were gathered. One year after the surgery, semen parameters including sperm volume, sperm concentration, normal sperm morphology, progressive motility and sperm DNA fragmentation index were recorded and any pregnancy was also documented via telephone calls and hospital visits.

Results

We found the baseline characteristics were comparable between the two groups. The seminal parameters had significant improvements 1 year postoperatively in both groups. However, the bilateral group showed significantly greater improvements than the unilateral group in sperm concentration, normal sperm morphology and progressive motility. Besides, the pregnancy rate was statistically higher in the bilateral group after the surgery (42.5 versus 26.0%, bilateral versus unilateral group).

Conclusion

In conclusion, our study indicated that bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele, which is associated with greater improvements in sperm concentration, normal sperm morphology and progressive motility and spontaneous pregnancy rate after the surgery.

     

Predictors of improved seminal characteristics by varicocele repair

The aim of this study was to investigate predictors of the improvement of semen characteristics after low ligation for patients with varicoceles. The records of 97 oligozoospermic patients who underwent microsurgical left or bilateral inguinal varicocele repair were retrospectively evaluated. We assessed factors that could be predictors of the improvement of semen characteristics using logistic regression analysis. We evaluated age, testicular volume, varicocele grade, serum follicle-stimulating hormone (FSH), luteinising hormone, testosterone, sperm concentration and motility before low ligation. Among the 97 patients, sperm concentration improved from 6.4 ± 5.8 to 24.2 ± 35.1 million ml⁻¹ and sperm motility increased from 32.8 ± 24.9% to 41.0 ± 14.6% in 55 patients (57%). In logistic regression analysis, pre-operative serum FSH and testosterone concentration were predictors of sperm concentration improvement. Varicocele repair improved sperm concentration and motility. Low serum FSH and high testosterone are significant factors predicting the improvement of semen characteristics before low ligation.     

Effects of aescin on testicular repairment in rats with experimentally induced varicocele

This study was conducted to investigate the effects of aescin treatment in a rodent model treated with an experimentally induced varicocele. Experimental varicocele was induced by partial ligation of the left renal vein of rats. Aescin administration was performed daily for 4 weeks after the varicocele induction. Seven weeks later, a contrast‐enhanced ultrasound was performed of the rats' testis to assess testicular blood flow. The animals were sacrificed, and H&E staining was then used to evaluate testicular pathological changes and polymorphonuclear leucocytes density. Cauda epididymal sperm counts and motility were evaluated. Blood was collected for the measurement of follicle‐stimulating hormone, luteinising hormone and testosterone. Contrast‐enhanced ultrasound showed that there were significant decreases in testicular blood flow in the aescin‐treated groups compared with those in control varicocele group. Testicular oedema was detected in those rats treated with a varicocele but without aescin, while no oedema was found in the experimental group. H&E staining showed dysfunctional spermatogenesis in both cohorts; however, polymorphonuclear leucocytes density was significantly reduced in aescin‐treated groups. There was an increase in sperm counts of the aescin‐treated groups. Our study demonstrated that aescin could exert therapeutical effects on reversal of testicular lesions in varicocele rats.     

Induction of spermatogenesis by inguinal varicocele repair in azoospermic men

13 infertile patients who had complete azoospermia and clinical varicocele underwent inguinal varicocele repair. Semen analyses were obtained starting 3 months after varicocele repair. Bilateral varicocele repair in 2 men and unilateral in 11 men were performed. Induction of spermatogenesis was achieved in 3 (23%) patients. Two of them had hypospermatogenesis and one had maturation arrest at spermatid stage. No pregnancies by natural intercourse resulted. Although one couple used fresh ejaculate for intracytoplasmic sperm injection, the result was unsuccessful. All men with Sertoli cell-only and early maturation arrest remained azoospermic after surgery. No association between successful outcome and patient age, sex hormone analysis, varicocele grade, testicular volume, unilateral or bilateral varicocele repair were apparent. Varicocele repair can result in the induction of spermatogenesis for men with hypospermatogenesis and late maturation arrest. No other related factor could be detected.     

Clinical observations on fertile males with varicocele

During the clinical observation of 32 fertile cases with varicocele interesting findings were made. Normal semen, a sperm density above 40 million/ml and a motile sperm rate of over 60% were observed in 46.9% of the cases. Furthermore, a sperm density of more than 40 million/ml was found in 75% and a motile sperm rate of more than 50% was detected in 81.3%, indicating normal or adequate spermogram data. A difference in right-left testicular size was recognized in 35.5% (11 cases). Only 2 of the cases had oligospermia and 9 cases had normospermia. Two cases had low testosterone values and low motile sperm rates were also detected. Secondary infertility occurred in 33.3%. In 25% of the cases, scrotal scintigraphy revealed an accumulation of high radioactivity indicating venous blood pooling over the affected site in the early phase of dynamic images. In the other cases, different venous flow characteristics were detected visually.     

The effects of unilateral, experimental varicocele are not mediated through the ipsilateral testis

Unilateral varicocele has been associated with diminished male fertility in humans and with bilateral physiologic and histologic changes in the testis of humans and laboratory animals. In particular, left varicocele in Sprague-Dawley rats results in bilateral increases in testicular temperature and blood flow. The mechanism by which unilateral varicocele can cause testicular changes is not known. The purpose of the present study was to determine whether or not the presence of either the ipsilateral or contralateral testicle is necessary for these effects of the varicocele to occur in the opposite testis. Varicoceles were created in adult, male rats by partial constriction of the left renal vein. Bilateral testicular blood flow was measured by a radiolabelled microsphere distribution technique and testicular temperature was taken with a needle probe thermometer. Right or left orchiectomies were performed on selected animals at the time of surgery to establish the unilateral left varicocele. Animals were studied 30 days after surgery. Mean testicular blood flow was significantly increased (P less than 0.01) in all animals having a left varicocele when compared with animals not having a varicocele regardless of whether a unilateral orchiectomy was performed. Likewise, the mean difference between intraabdominal temperature and intratesticular temperature (delta T) was significantly decreased in all groups of animals having varicoceles when compared with groups without varicoceles whether or not an orchiectomy had been performed. Thus, the studied bilateral effects of left-sided, experimental varicocele in the rat are not dependent upon the presence of a left testicle.     

Effects of surgical repair of first degree varicocele on gonadal function and testicular atrophy

Varicocele is one of the main causes of male infertility. This pathology, in fact, is responsible for progressive anatomical and functional testicular damage. Constant monitoring of subjects suffering from varicocele is therefore necessary. In the present study, we evaluated the effect of varicocele surgical treatment on seminal parameters, testicular growth and pregnancy rate in patients with grade I varicocele. We operated on 47 patients with left grade I varicocele associated with sperm abnormalities and with testicular hypotrophy. A high ligation of the internal spermatic vein and all its collaterals was performed in all patients. The postoperative follow-up showed a significant improvement in seminal parameters (motility, morphology and sperm count) and in testicular volumes. Moreover, a pregnancy rate of 58% was observed. These results confirm the observations of other investigators and suggest that surgical therapy of varicocele is capable of improving seminal parameters, of reversing varicocele-related testicular hypotrophy and of achieving high pregnancy rates even in patients with grade I varicocele.     

不育男性双侧Ⅰ度精索静脉曲张对睾丸体积和生殖激素水平的影响

目的 评价不育男性双侧I度精索静脉曲张对睾丸体积和生殖激素水平的影响.方法 185例不育男性双侧I度精索静脉曲张(A组)和149例正常生育男性(B组),比较其睾丸体积、卵泡刺激素(FSH)、黄体生成素(LH)和睾酮(T)水平.结果 A组患者两侧睾丸体积均小于B组,但睾丸体积绝对差异和睾丸体积相对差异与B组比较,无统计学意义.A组患者血清FSH水平高于B组,而LH、T与B组相比,差异无统计学意义.结论 不育男性双侧I度精索静脉曲张可导致患者双侧睾丸体积减小,血清FSH水平升高.     

Ipsilateral Testicular Hypotrophy is Associated With Decreased Sperm Counts in Infertile Men With Varicoceles

Purpose

The presence of ipsilateral testicular growth retardation (hypotrophy) is the most common indication for prophylactic varicocele repair in adolescents in an effort to prevent future infertility. We examined the relationship between semen parameters and ipsilateral versus contralateral testicular size in men with unilateral varicoceles to determine whether testicular size is an appropriate parameter for predicting future fertility.

Materials and Methods

We studied the records of consecutive patients with palpable unilateral left varicoceles for whom a history, physical examination and semen analysis were available. Total motile sperm counts of men with and without ipsilateral testicular hypotrophy were compared.

Results

We identified 611 patients with unilateral clinical left varicoceles, including 305 (50%) with ipsilateral testicular hypotrophy. Mean total motile sperm counts plus or minus standard error of mean were significantly less in the patients with than without testicular hypotrophy (80 +/− 5.2 versus 126 +/− 7.8 × 10⁶ sperm, p = 0.0018). Hypotrophy was more common in patients with large varicoceles (73%) than in those with medium (53%) or small (43%) varicoceles.

Conclusions

Infertile patients with testicular hypotrophy associated with unilateral varicoceles have worse semen parameters than those without hypotrophy. These data support the practice of varicocele repair in adolescents with varicocele associated testicular growth retardation.     

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.     

Predictive factors associated with successful varicocele repair a study of 139 infertile men with valicocele

PURPOSE: To determine pretreatment parameters which predict improvements following varicocele repaire in semen quality. MATERIALS AND METHODS: We retrospectively evaluated a total of 139 infertile patients who underwent varicocelectomy from February 1995 to March 2000. A logistic regression analysis was performed to identify parameters associated with improvements in semen quality. Parameters evaluated included varicocele grade, age, testicular volume, serum testosterone, liteinizing hormone (LH), follicle-stimulating hormone (FSH), preoperative sperm density and sperm motility. RESULTS: Of 139 patients 71 (51.0%) improved sperm concentration and 59 (42.4%) improved sperm motility postoperatively. Overall, median sperm density significantly increased from 10 x 10(6)/ml preoperatively to 30 x 10(6)/ml postoperatively. Sperm motility also significantly increased 33% to 45%. In logistic regression analysis, varicocele grade (odds ratio [OR] = 5.7; 95% confidential interval [CI : 1.9-17), FSH level ([OR] = 0.76; [CI]: 0.60-0.96) and sperm motility ([OR] = 1.03; [CI]: 1.0-1.1) were independent predictive factors for improvement in sperm concentration. CONCLUSION: Varicocelectomy improves sperm concentration and motility. Our data suggest that patients with grade 3 varicocele, low serum FSH level and high sperm motility are more likely to benefit from varicocele repair in sperm concentration.     

Effects of varicocele after unilateral orchiectomy and sympathectomy

An experimental varicocele was created in the adult rat by partial ligation of the left renal vein. There was a significant bilateral elevation of both testicular blood flow and temperature in the varicocele animals (p less than 0.01). Mean testicular blood flow for control and varicocele animals was 29.6 +/- 1.0 and 39.8 +/- 2.0 ml./min./100 gm. tissue, while mean testicular temperature was 34.4 +/- 0.1 and 35.3 +/- 0.2C, respectively. A left orchiectomy was combined with a left varicocele to determine if the left testis is essential for the right testicular response to a varicocele. Elevation of right testicular blood flow was not altered by left orchiectomy (p less than 0.05); however, right testicular temperature was no longer significantly increased. Mean right testicular blood flow and temperature for this group was 39.0 +/- 1.5 ml./min./100 gm. tissue and 34.2 +/- 0.15C, respectively. A left sympathectomy was combined with a left varicocele to ascertain if the right testicular response to the left varicocele was mediated through a neural pathway. A significant bilateral increase in testicular blood flow was noted with a left sympathectomy alone, and thereby masked the ability to evaluate the right testicular response to the simultaneous left sympathectomy and varicocele. Elevation of right testicular blood flow in response to the left varicocele is independent of the presence of a left testis and any immune response it may stimulate. The role of the sympathetic nervous system as a mediator of the bilateral varicocele effect remains undetermined.     

Preserved testicular artery at varicocele repair

Whether or not varicocele causes infertility is a contentiously debated issue. This study aimed to compare semen parameters and pregnancy rate in infertile males who underwent varicocelectomy with preserved or accidentally ligated testicular artery. Ninety-five infertile oligoasthenozoospermic patients with left-sided varicocele were subjected to subinguinal varicocelectomy with trial of preserving testicular artery. According to absence or presence of testicular artery in the histological excised pedicle the cases were divided into two groups; group 1 ( n  = 60) with preserved testicular artery and group 2 ( n  = 35) where the artery was accidentally ligated being not defined or injured. Semen analysis was carried out after 4, 8 and 12 months and post-operative pregnancy rate was assessed after 1 year. Serum follicle-stimulating hormone (FSH), luteinising hormone (LH) and total testosterone (T) were estimated pre- and post-operatively. Semen parameters (total sperm count, sperm concentration and sperm motility) showed significant increase post-operatively compared with pre-operative parameters but were comparable in both groups with no significant difference. Serum FSH, LH, T hormones and pregnancy rate (23.3% versus 22.9%) 1 year post-operatively showed no significant difference. It is concluded that accidental ligation of testicular artery has no deleterious effect on semen parameters during primary varicocele repair if the testicular arterial supply was not compromised.     

Surgical repair of varicocele at puberty: preventive treatment for fertility improvement

In 40 pubertal boys with a varicocele a comparative followup study was performed to evaluate the efficacy of surgical correction of the varicocele in this age group in regard to improvement of fertility after completion of sexual maturation. The varicocele was corrected surgically in 24 patients and it was left uncorrected in 16. Testicular atrophy was noted in all cases at the initial visit and after followup. Of the 24 corrected patients 16 had atrophy of at least 1 testis before surgical treatment, whereas only 7 demonstrated atrophy after followup. Of the 16 uncorrected patients testicular atrophy was noted in 8 at the initial visit but 12 had atrophy after followup. Semen examination of 23 patients who had completed sexual maturation demonstrated a higher quality of routine seminal parameters, for example sperm density, sperm motility and percentage of morphologically normal spermatozoa, in the corrected group than in the uncorrected group.     

The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents

OBJECTIVE: To determine the prevalence and site of varicocele and varicocele-related testicular atrophy in children and adolescents. PATIENTS AND METHODS: The study included 4052 boys aged of 2-19 years, divided into four age groups; the findings of a physical examination, any testicular atrophy and testicular volume were recorded. RESULTS: Varicocele was detected in 293 (7.2%) of the 4052 boys; the prevalence was 0.79% in those aged 2-6 years, 0.96% at 7-10 years, 7.8% at 11-14 years and 14.1% at 15-19 years. The prevalence was 0.92% in 1232 children aged 2-10 years and 11.0% in 2531 adolescents aged 11-19 years (P < 0.001). The prevalence increased significantly at age 13 years (P < 0.005). The varicocele was unilateral in 263 of the 293 (89.7%) boys with varicocele; of these, one (0.38%) was on the right and the others on the left side. Varicoceles were bilateral in 30 of 279 boys (10.8%) aged 11-19 years but none were detected in those aged < 11 years. Varicocele-related testicular atrophy was not present in those aged < 11 years, but seven boys (7.3%) aged 11-14 years and 17 (9.3%) aged 15-19 years had testicular atrophy. The difference in prevalence between the last two age groups with atrophy was not significant. CONCLUSION: These findings support the view that varicocele is a progressive disease and that the prevalence of varicocele and testicular atrophy increases with the puberty.     

Effects of surgical repair of experimental left varicocele on testicular temperature, spermatogenesis, sperm maturation, endocrine function, and fertility in rabbits.

To evaluate the effectiveness of surgical correction of varicocele in restoring the function of the varicocelized testicle, experimental varicoceles were created in 16 male rabbits by partly ligating the left lumbotesticular trunk. Five control rabbits received a sham operation (group A). Two months later, eight of the varicocelized rabbits underwent surgical repair by ligation and cutting of the dilated left testicular vein (group B). The remaining eight varicocelized animals did not receive any additional treatment (group C). Five months after the initial operation, group C animals had a significantly lower sperm concentration, sperm motility, bilateral testicular androgen-binding protein activity, bilateral testicular vein testosterone concentration, bilateral testicular versus intraabdominal temperature difference, and fertility when compared with groups A and B. These findings suggested that the surgical repair of an experimental varicocele in the rabbit can significantly improve the parameters indicating the harmful effects of the varicocele on the testicles.     

Predictive parameters of successful varicocele repair

A total of 130 men presenting with oligospermia and clinically identifiable scrotal varicoceles was evaluated, treated surgically and followed for 1 year for pregnancy rate. The treatment outcome was compared to an age-matched cohort of 83 oligospermic men who had received empirical medical therapy with clomiphene citrate (25 mg. per day) for the same 1-year interval. This study was done to contrast treatment modalities in infertility and not as a strict control. Only eugonadotropic patients in both groups were used for comparison. In the varicocele group the over-all pregnancy rate was 38.5 per cent. Four variables (a lack of testicular atrophy, sperm density greater than 50 million per ejaculate, sperm motility 60 per cent or more and serum follicle-stimulating hormone values less than 300 ng. per ml.) proved to be accurate preoperative predictors of postoperative pregnancy success. Four other variables (varicocele size and laterality, sperm forward progression greater than 2 and normal sperm morphology 60 per cent or more) did not yield statistically significant rates of improvement in pregnancy postoperatively. The pregnancy rate of the eugonadotropic patients undergoing varicocele repair was 45.8 per cent. Despite statistical similarity in patient age, sperm density and mean gonadotropin levels the medically treated patients had a pregnancy rate of only 25.5 per cent, significantly lower than the surgically treated patients. In summary, patients with an identifiable varicocele had a greater chance of achieving a pregnancy following surgical correction than did those treated with empirical drug therapy. In addition, certain preoperative variables in the physical and laboratory analyses appeared to portend a greater surgical response.     

Left varicocele at puberty

A study was made of 160 cases of left varicocele treated during 1979-1980; there were 35 patients under sixteen years old. Also 74.3 per cent of patients already had mono- or bilateral testicular hypotrophy. Testicular biopsy revealed 90 per cent had histologic lesions of varying nature and degree. We believe varicocele formation is related to physiologic changes during puberty. These data suggest that early recognition of varicocele and its correction before the appearance of irreversible testicular lesions may prevent male sterility.