精索静脉曲张患者精子运动速度和ATP含量的比较研究

为了探究精索静脉曲张患者不育的原因，采用多次曝光法和生物发光法测定精索静脉曲张患者精子运动速度和三磷酸腺苷（ＡＴＰ）含量，并与有生育能力的健康男性精子进行比较，结果显示静索静脉曲张患者精子运动速度和ＡＴＰ含量显著低于正常对照组（Ｐ〈０．００１，Ｐ〈０．０１）。８例精索静脉曲张患者在作精索内静脉高位结扎术后６个月，其精子运动速度和ＡＴＰ含量与正常对照组无显著性差异（均Ｐ〉０．０５）。精子的ＡＴＰ含量     

Factors affecting fertility after varicocelectomy

We performed high ligation of the internal spermatic vein in 27 cases of left varicocele with disturbance of spermatogenesis, and studied postoperative fertility. The results indicated that the cases were divided into three groups, namely group I in which pregnancy occurred after ligation: group II in which the sperm count increased but no pregnancy occurred, and group III in which there was no improvement in the sperm count. The age, size of varicocele, preoperative volume of bilateral testicle, bilateral testicular histologies, serum LH, serum FSH, peak responded value after LH-RH administration, plasma testosterone and response after HCG administration were evaluated. We detected that the volume of bilateral testicles, bilateral testicular histologies, serum FSH and the response after LH-RH administration served as good indicators for postoperative evaluation of fertility.     

Effect of spermatic vein ligation on seminal total antioxidant capacity in terms of varicocele grading

We aimed to assess the effect of spermatic vein ligation on seminal total antioxidant capacity (TAC) in patients with varicocele. Twenty infertile male patients with varicocele and 20 normal fertile men (control group) were included in the study. All the male patients were diagnosed with primary infertility and varicocele. The patients with varicocele were divided into two groups as nonpalpable (GI) (eight patients) and palpable (GII-III) (12 patients) varicocele groups. All the patients underwent microsurgical spermatic vein ligation. Seminal TAC levels and sperm parameters were evaluated in all the patients. Preoperative sperm count, sperm motility, sperm morphology and seminal TAC levels with equivalent figures 3-6 months after spermatic vein ligation and the same values of the control group were compared. There was a statistically significant increase in the total seminal antioxidant capacity level after spermatic vein ligation, and there was a statistically significant increase in the sperm count, sperm motility and spermatozoa with normal morphology. However, evaluation of the patients for varicocele grade showed a statistically significant increase in the TAC level only in the GII-III varicocele group. Spermatic vein ligation can improve the total seminal antioxidant capacity levels especially in patients with middle and high grade varicocele.     

精索静脉曲张不育患者手术前后血浆性激素变化

将６４例单纯精索静脉曲张源性不育患者随机分为手术组３３例与非手术组３１例，分别于术前及术后６个月测血浆卵泡刺激素（ＦＳＨ）、黄体生成素（ＬＨ）、睾酮（Ｔ），同时测４６名正常生育力男性性激素作为正常值对照，对两组不育患者还进行了睾丸体积测定和精液分析。手术组采用经髂窝腹膜外单纯精索内静脉高位结扎术。结果：６４例精索静脉曲张源性不育患者精子密度、精子存活率、睾丸体积低于正常组，ＦＳＨ、ＬＨ、Ｔ均在正常值范围，与正常组对照无明显差异。两组手术前后对照分析，手术组与非手术组手术前后血浆性激素虽无统计学差异，但手术组患者术后精液质量、睾丸体积明显改善，随访一年手术组妊娠率（２７％）显著高于非手术组（１３％）。术前ＦＳＨ较高的患者术后精液质量、睾丸体积无明显改善，而术前ＦＳＨ正常者有显著差异。认为，精索静脉曲张不育患者通过手术治疗确能提高其生育能力，而术前根据血浆ＦＳＨ、ＬＨ、Ｔ测定结合睾丸检查、精液分析可以初步估计睾丸受损程度，对手术预后的判断有一定参考价值。     

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.     

Varicocele ligation on free testosterone levels in infertile men with varicocele

We have analyzed the effects of varicocele ligation on free testosterone levels, and investigated the interrelationships between free testosterone and fertility. The records were retrospectively evaluated for 42 infertile patients who underwent varicocele ligation, with serum free testosterone levels, follicle stimulating hormone (FSH), lutenizing hormone (LH), testosterone, estradiol, prolactin, ejaculated volume, sperm concentration and motility before and after surgery. Serum free testosterone levels increased from 12.97+/-4.16 to 13.59+/-3.93 pg/mL, but the difference was insignificant. The differences before and after surgery of patients in sperm concentration and motility were also insignificant. However, in free testosterone increasing group, the sperm concentration and motility increased significantly, from 4.05+/-4.35 to 7.90+/-8.19 million/mL (P=0.01) and from 30.64+/-21.87% to 41.00+/-22.00%, respectively (P=0.03). The increase in serum free testosterone level by varicocele ligation results in a significant improvement in sperm concentration and motility.     

Incidence and clinical significance of subclinical scrotal varicoceles

A total of 40 infertile men with a normal physical examination underwent gonadal venography to determine the presence of a subclinical varicocele. Of the patients 19 had a left and 3 had a right subclinical varicocele. A total of 21 patients underwent radiographic occlusion of the varicoceles, while 1 required surgical ligation of the internal spermatic vein. Of the 22 patients 13 have been followed for greater than 6 months after correction of the varicocele. In these patients there has been a small but significant increase in sperm number after varicocele occlusion. No significant changes in either sperm motility or morphology have occurred. Although most patients do not have any major improvement after occlusion of a subclinical varicocele, some may experience a significant improvement in sperm number after occlusion. The effect on pregnancy rates is not yet known.     

Specialized sperm function tests in varicocele and the future of andrology laboratory

Varicocele is a common medical condition entangled with many controversies. Though it is highly prevalent in men with infertility, still it marks its presence in males who do have normal fertility. Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who benefitted the most from surgery. Since conventional semen analysis has been limited in its ability to evaluate the negative effects of varicocele on fertility, a multitude of specialized laboratory tests have emerged. In this review, we examine the role and significance of specialized sperm function tests with regards to varicocele. Among the various tests, analysis of sperm DNA fragmentation and measurements of oxidative stress markers provide an independent measure of fertility in men with varicocele. These diagnostic modalities have both diagnostic and prognostic information complementary to, but distinct from conventional sperm parameters. Test results can guide management and aid in monitoring intervention outcomes. Proteomics, metabolomics, and genomics are areas; though still developing, holding promise to revolutionize our understanding of reproductive physiology, including varicocele.     

Sperm ultramorphology as a pathophysiological indicator of spermatogenesis in males suffering from varicocele

Varicocele of spermatic veins is considered to be one of the major causes of male infertility associated with reduction of sperm quality. The pathophysiology of this condition is not yet completely understood. The aim of this study was to shed light on the pathophysiology of varicocele by identifying semen parameters, especially sperm ultramorphology, which improve following high ligation of the spermatic vein. Seventy-five males with diagnosed varicocele were included in this study. Semen parameters were assessed prospectively using light microscopy, semen biochemistry and sperm quantitative ultramorphological analysis, before high ligation and 3-9 months after high ligation. The control group consisted of twenty-five untreated varicocele patients who underwent two semen examinations within 3-9 months. No statistical difference in any of the examined variables was found between the two examinations in the control group. The treated patients exhibited a significant improvement in sperm density, progressive motility, percentage of normally formed spermatozoa, agenesis of sperm acrosome, chromatin condensation and incidence of amorphous heads compared with the pretreatment condition (P < or = 0.01). In contradiction, no significant improvement was observed following treatment in any of the sperm tail subcellular organelles. It is concluded that varicocele may cause deleterious alterations in early spermatid head differentiation during spermiogenesis and that varicocele patients with a high incidence of sperm acrosome and nucleus malformations are appropriate candidates for varicocele correction.     

Varicocele in Children and Adolescents: A Challenge for Diagnosis and Treatment Indications

Varicocele, fertility, and paternity are terms that are frequently used in a common topic of clinical and pathologic conditions; however, any form of direct relationship has not been found. Is the high incidence and presence of a varicocele in boys, adolescents, and adults a normal variant? The hypotheses for a possible association between varicocele and fertility are based on issues such as temperature, volume, and growth of the testis, and sperm count, and indirect evidence indicating improved semen parameters after varicocele repair. However, what it comes down to, is the chance to father a child—to introduce pregnancy rather than a sperm count difference. This article highlights evidence-based findings and recent observations for a better understanding of which boys and adolescents would benefit from treatment or reassurance.     

Induction of varicocele in the dog: I. Partial ligation of the left renal vein does not induce a varicocele in the dog

Induction of varicocele was attempted by partial ligation of the left renal vein in 10 male dogs. The effects on sperm count, sperm motility, and sperm morphology, as well as on hemodynamics, were assessed. Furthermore, testicular, vascular, and kidney morphology was studied. Changes in the diameter and consistency of the left spermatic cord were found to be temporary. Total sperm count, sperm motility, and the total number of oval forms were not significantly altered. Hemodynamic studies revealed a renocaval pressure gradient, but retrograde flow in the distal part of the left testicular vein could not be observed by arteriography. A collateral network was found to compensate for the restricted left renal vein. Histologic examination revealed no damage to the seminiferous epithelium. Changes were not found in the kidney and left pampiniform plexus. Although some temporary changes induced by the partial ligation of the left renal vein are suggestive of varicocele, this hemodynamic study shows that the presented dog model does not mimic varicocele as encountered in man.     

Semen cahracteristics before and after ligation of the left internal spermatic veins in men with varicocele.

The semen from 20 men with varicocele was studied before and after surgical correction of the varicocele. The effect on sperm quality was only marginal and could not explain the fairly high conception rate (20%) after operation. The recommendation that varicocele in men with long-term infertility should be eliminated by ligation of the internal spermatic veins is still justified despite the absence of positive effects on sperm quality.     

Effect of Varicocelectomy on Sperm Parameters and Pregnancy Rate in Patients with Subclinical Varicocele: A Randomized Prospective Controlled Study

Purpose

We assessed whether subclinical varicocele ligation improves fertility and/or semen parameters.

Materials and Methods

A total of 85 patients with a subclinical varicocele diagnosed by scrotal thermography presented with infertility. Patients were randomly assigned to groups 1 (high ligation of the internal spermatic vein) and 2 (followed without any treatment). At least 3 semen samples were obtained at study entry and 1 year later in both groups.

Results

The pregnancy rate in group 1 was 6.7 percent compared to 10 percent in group 2, and the difference was not statistically significant. Group 1 had significantly higher levels of sperm density and total motile sperm count at 1 year. There were no significant differences between groups 1 and 2 regarding change in seminal volume, sperm motility and abnormal sperm morphology.

Conclusions

Subclinical varicocelectomy has some effect on spermatogenesis but no beneficial effect on pregnancy rate.     

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.     

Prognosis of subfertility in men with corrected or uncorrected varicocele

To evaluate whether correction of varicocele improves fertility, pregnancy rates were compared in 115 varicocele patients consulting for infertility and having oligozoospermia, asthenospermia, or teratozoospermia, in any combination, and FSH levels within the normal range. Ninety of these patients had corrected, and 25 had uncorrected varicoceles, respectively. The value of clinical and seminal parameters for predicting the eventuality of pregnancy for varicocele patients was also studied. Although both groups were comparable in terms of duration of infertility, mean age, sperm density, motility or fertility index, cumulative pregnancy rates over 12 months were similar, whether or not the varicocele was corrected. The value of clinical or seminal parameters, in any combination, for the prediction of outcome for varicocele patients was poor. The prognosis was poor for men with less than 15% of spermatozoa with normal morphology, FSH levels higher than the mean + 3 SD of those values found in young fathers, and a fertility index below 3. In subjects who achieved pregnancy within one year, pretreatment sperm characteristics were similar in both the corrected and uncorrected groups. Correction of varicocele slightly improved sperm characteristics. It seems likely that in most men with subfertility and varicocele, other factors besides venous reflux are responsible for their infertility.     

Improvement of male fertility through ligation of varicocele? A study of 100 subfertile varicocele patients three months after ligation (author's transl)]

With 100 subfertile varicocele patients, three months after ligation (high ligation of the left internal spermatic vein in accordance with Bernardi) had control spermiograms made. An improvement of sperm count (upgrade in a higher class according to MacLeod's partition) was found in 28% of the cases, whereas an improvement of progressive motility was found only in 13%. The percentage of patients reaching the normal value in sperm count of over 40 mill./ml increased from 23% to 39%. The increase in these patients came primarily from the class of 20--40 mill./ml. In progressive motility, there was an increase of patients reaching the standard value of over 40%, from 6 to 11. However, if sperm count and progressive motility together were evaluated in the individual patients after ligation, only 6 patients presented a normospermia, i.e. a sperm count of more than 40 mill./ml with normal progressive motility. Thus 94 of the 100 patients must be considered as subfertile three months after ligation. A significant fertility improvement through ligation of varicocele has not yet taken place.     

Current management of varicoceles

In spite of all that has been written about the varicocele, it is still not clear who will benefit from occlusion of the spermatic vein or why improvement in semen takes place in some patients but not in others. Because fertility is usually assessed in the framework of a couple who are trying to establish a pregnancy, it is important to evaluate both partners before making any recommendations regarding therapy. If the man is found to have a varicocele and semen analyses that indicate deficits in either the quantity or quality of the sperm, surgical ligation or transvenous occlusion should be considered as one appropriate form of therapy. Varicocele ligation and embolotherapy both can be performed as an outpatient procedure with minimal morbidity and equal effectiveness regarding pregnancy outcome. The cost, if the procedures are done in an outpatient facility, should be approximately equal. The obvious benefits of the percutaneous technique are a slightly lower recurrence rate and a more rapid return to full physical activity. The surgical procedure described by Marmar and associates appears to have a similar rate of recurrence and short postoperative period of recovery. Greater experience by more urologists using this technique needs to be gained to compare it adequately with the other methods described. Varicocele ligation by the inguinal or retroperitoneal routes is familiar to most urologists and does not require the operating microscope or other special instruments. With greater understanding of the venous anatomy and with careful dissection, the persistence and recurrence rate can be acceptably low and the postoperative recovery relatively rapid and smooth.     

精索静脉曲张不育患者的精液质量和精子形态学观察

目的:观察不育伴精索静脉曲张(VC)患者的精液质量和精子形态学变化。方法:98例不育伴VC患者精液按WHO标准常规分析并对精子形态学进行评价。130例正常供精者精液检测结果作为对照。结果:VC患者正常形态精子和前向运动精子明显低于对照组(P<0.001),精子畸形的类型以梨形、锥形和不定型头部畸形为主。结论:VC可导致精子畸形率升高,后者可能是男性生育力受损的重要标志之一,经染色后的精子形态学分析是判定VC患者精子受损的一个敏感指标。     

Improvement of semen characteristics after surgical repair of bilateral testicular varicocele as compared to unilateral varicocele patients

The operative treatment for surgical repair of bilateral testicular varicoceles was evaluated in terms of the improvement achieved in the sperm density and percentage progressive motile sperm. These parameters were compared for 27 cases of bilateral varicocele diagnosed by palpation and subjected to bilateral high ligation of the internal spermatic vein and for 40 cases of left unilateral testicular varicocele. There were no significant differences in preoperative values (such as sperm density; progressive motile sperm; serum levels of luteinizing hormone, follicle-stimulating hormone, and testosterone; and Johnson's score count) between the bilateral and unilateral testicular varicocele groups. The improvement in postoperative sperm density in the cases with bilateral testicular varicocele was apparently less satisfactory than in the cases with testicular varicocele only on the left side.     

Sperm binding and ultrasound changes after operative repair of varicocele: correlation with fecundity

Summary. The study was conducted to evaluate the changes in sperm binding capacity and ultrasound measurements of the internal spermatic vein, after operative repair of a varicocele. In order to clarify the effect of a varicocele on fertility, these changes were correlated to pregnancy achievement. Twelve infertile males with subnormal semen parameters and varicocele, underwent operative repair. Pre- and post-operatively, all had semen analysis, hemizona assay and ultrasound of the internal spermatic veins. The patients were divided into three subgroups according to pregnancy outcome, and the changes in the different evaluation tests after the operation were compared. Sperm concentration and motility improved post-operatively in all three subgroups, whereas the hemizona index and ultrasonographic measurements improved significantly only in the subgroup that achieved early pregnancies (the mean post-operative percentage of normal morphology was significantly higher), compared to the subgroup without pregnancies. Unlike sperm parameters which improve after operative repair of the varicocele, but have no correlation to conception, sperm binding and ultrasound measurements of the internal spermatic veins improve significantly in cases that achieve early pregnancies. The use of these tests, as well as measuring the percentage of normal morphology, are recommended in all cases of infertility-related varicocele.