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.     

Seminal Improvement Following Repair of Ultrasound Detected Subclinical Varicoceles

Purpose

We determined whether repair of subclinical varicoceles detected by scrotal duplex ultrasonography results in significant seminal improvement and identified the best ultrasonographic criteria to use in the selection of patients for subclinical varicocelectomy.

Materials and Methods

Of 256 consecutive infertile men being evaluated by physical examination and color duplex scrotal ultrasonography 76 underwent varicocele repair and were followed with serial semen analyses. All subclinical varicoceles were confirmed by venography. The outcome of varicocelectomy was determined by changes in total motile sperm count and compared among patients with different clinical grades of varicoceles and ultrasonographically measured vein sizes.

Results

A significant overlap was observed between ultrasonographically measured venous diameter and clinical grade of varicocele. There was no correlation between venous diameter and postoperative outcome when controlled for clinical grade. Significant postoperative improvement in semen parameters was noted in 67 percent of patients with clinical and only 41 percent with subclinical varicoceles (p less than 0.05). The best ultrasonographic cutoff to predict a positive outcome after subclinical varicocelectomy was venous diameter greater than 3 mm. Patients with larger clinical varicoceles had greater postoperative seminal improvement than those with small or subclinical varicoceles regardless of baseline sperm count.

Conclusions

Varicocele size has a direct impact on the probability and amount of seminal improvement after varicocelectomy. Outcome following subclinical varicocelectomy is significantly less than after repair of clinical varicoceles. Although 41 percent of patients with subclinical varicoceles had significant postoperative improvement in semen parameters, an equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group. The results of our study suggest that subclinical varicocelectomy is of questionable benefit.     

Relationship between Grade of Varicocele and the Response to Varicocelectomy

Background: Although several studies indicate that larger varicoceles are associated with greater impairment of spermatogenesis, others suggest that the response to surgery is independent of varicocele size. In order to elucidate these seeming contradictions, correlations between the preoperative evaluation of varicoceles and improvement in semen quality after varicocelectomy were investigated.
Methods: Forty men with left unilateral varicocele, followed for at least 6 months after varicocelectomy, were included in this study. The relationships between the grade of varicocele by palpation, Doppler examination, ultrasound, or scintigraphy were correlated with a postoperative improvement in sperm density or sperm motility.
Results: Greater improvement in sperm density was observed in the patients with a large varicocele graded by palpation or measured by ultrasound, and greater improvement in sperm motility was observed in the patients with high uptake of radioactivity in the left side by scrotal scintigraphy.
Conclusion: An improvement in semen quality after varicocelectomy is greater in patients with a large varicocele than in the patients with a small one. The significance of surgical repair of a small varicocele should be reconsidered.     

亚临床精索静脉曲张的诊治体会

对７５例体检正常的男性不育患者行高分辨彩色多普勒血流显像（ＣＤＦＩ）检查，发现亚临床精索静脉曲张（ＳＣＶ）４０例，其中左侧者２６例（６５％），双侧者１４例（３５％），行精索静脉高位结扎术３３例，行经皮精索胸脉栓塞术７例，术后３５例获得６个月随访，结果显示术后精子密度，精子活动率及正常形态精子率均明显改善，认为ＣＤＦＩ是诊断ＳＣＶ的一种简便，可靠的方法，其治疗应依据患者具有情况而定。     

Varicocle in oligospermic patients: pathophysiology and results after ligation and division of the internal spermatic vein.

We have followed for up to 32 months 51 oligospermic patients with varicoceles who underwent high ligation and division of the left spermatic vein. Of these patients 59.9 per cent had improvement in total sperm count, 47.1 per cent in sperm motility and 42.1 per cent in the morphological pattern of the spermatozoa. Pregnancies were reported by 13 patients. Improvement in sperm motility occurred first, followed by improvement in morphology. The last improvement was in total sperm count. We suggest that the observation period after a varicocele operation be restricted to 9 months, in which time about 75 per cent of the expected improvement takes place. A clinical classification for the degree of varicocele is proposed. No correlation between size of the varicocele and treatment results could be observed. A classification of sperm analysis is proposed, using a 3-digital index that might enable better comparison of sperm analysis and better communication among physicians. We could not define a specific group of oligospermic patients who might benefit more than other groups from a varicocele operation. Pathophysiological pathways leading to impaired spermatogenesis in patients with varicoceles are discussed.     

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.     

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.     

Clinical outcome of microsurgical subinguinal varicocelectomy in infertile men

The present study assesses the clinical outcome of microsurgical subinguinal varicocelectomy in infertile men, especially with regard to sperm count, motility and fertility. Between June 1990 and October 1998, 272 patients had subinguinal microsurgical varicocelectomy operations for clinical varicoceles, and their long-term results were assessed. In nearly all the patients there was a significant improvement in sperm count and sperm motility after 3 and 6 months. Very few complications arose from this procedure. We concluded that microsurgical subinguinal varicocelectomy is an effective treatment for clinical varicoceles in infertile men. The significant improvement in the quality of spermatozoa, the low complication rates and the remarkably high pregnancy rates make this a valuable alternative to in vitro reproduction techniques.     

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.     

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.     

Age is a significant predictor of early and late improvement in semen parameters after microsurgical varicocele repair

Accumulating evidence indicates that varicocele repair improves sperm quality. However, longitudinal changes in sperm parameters and predictors of improved semen characteristics after surgery have not been fully investigated. We retrospectively reviewed data from 100 men who underwent microsurgical subinguinal varicocele repair at a single centre. Follow‐up semen examinations were carried out at 3, 6 and 12 months post‐operatively. Logistic regression was used to identify predictors of early (3 months) and late (≥6 months) improvement in semen parameters after varicocele repair. At 3 months post‐operatively, 76.1% of the patients had improved total motile sperm counts, which continued to improve significantly up to 12 months post‐operatively (p = .016). When comparing changes in semen parameters between younger (<37 years) and older (≥37 years) men, post‐operative improvements in sperm concentration and motility were greater among younger men. Multivariate analysis showed that younger age was associated with early (p = .043) and late (p = .010) post‐operative improvement in total motile sperm count. Our findings indicate that early varicocele repair improved semen parameters after surgery.     

Subclinical varicocele: the effectiveness of varicocelectomy

To investigate the controversial concept that subclinical varicoceles are detrimental to spermatogenesis, we undertook a prospective study of the effectiveness of surgery in 56 infertile men with clinical and subclinical varicoceles. Our statistical approach specifies improvement as a change from individual baseline level. The over-all variability in sperm counts precluded the demonstration of significant changes in sperm density consequent to surgery. Improvement in sperm motility was seen in both groups, being slightly greater in the subclinical group. The changes were inversely related to baseline levels and increased with time from surgery. Therefore, it appears that the detection of subclinical varicoceles may be warranted in infertile men with abnormal semen parameters.     

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique,complications, and results

Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 10⁶ to 21 × 10⁶ ml⁻¹ (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.     

The role of Doppler ultrasonography in determining the proper surgical approach to the management of varicocele in children and adolescents

In a study from Italy, colour-Doppler ultrasonography was a reliable diagnostic tool in the preoperative assessment of patients with varicocele. The authors also found that it helped to distinguish those who could be treated laparoscopically from those who should be treated by microsurgical subinguinal ligature. OBJECTIVE: To investigate whether colour Doppler ultrasonography (CDUS) is a reliable diagnostic tool for selecting patients with varicocele to undergo either laparoscopy or open microsurgical subinguinal ligation. PATIENTS AND METHODS: In a 3-year period, 42 boys affected by left varicocele were evaluated before surgery by inguinal and scrotal CDUS. Using this method it was possible to distinguish Coolsaet type-1 varicocele (due to isolated renal-internal spermatic vein reflux) and Coolsaet type-3 varicocele (due to associated renal-internal spermatic reflux and iliac-deferential reflux). Boys with Coolsaet type-1 varicocele were treated by a laparoscopic transperitoneal Palomo procedure, whereas those with Coolsaet type-3 varicoceles were treated by lymphatic-sparing microsurgical subinguinal ligation. RESULTS: The varicocele was Coolsaet type-3 in six patients (14%), who had microsurgical open surgery, and the remaining 36 (86%) had Coolsaet type-1 and had laparoscopic surgery. At the follow-up there was no venous scrotal reflux. In two patients in the laparoscopic group a hydrocele developed after surgery, which resolved spontaneously. CONCLUSIONS: This study showed that CDUS was a reliable diagnostic tool for assessing boys with varicocele. It clearly distinguished Coolsaet-type 1 varicoceles that can be treated laparoscopically, from Coolsaet type-3 varicoceles that should be treated with microsurgical subinguinal ligature.     

Pressure flow pattern of varicocele veins and its correlation with testicular blood flow and semen parameters

The pressure pattern in varicocele veins of infertile patients and its correlation with semen quality and testicular blood flow was determined. Consecutive patients at andro‐urology clinic of a teaching hospital undergoing microsurgical varicocelectomy were included. Their semen quality and testicular blood flow were determined. Peak systolic velocity (PSV) and resistive index (RI) of subcapsular and intraparenchymal branches of testicular artery were noted by colour Doppler ultrasonography. During surgery before ligation of varicocele veins, intravenous pressures of internal spermatic (ISV) and external spermatic (ESV) veins were determined at baseline and after Valsalva manoeuvre. Thirty patients, 20–45 years old, were evaluated. Baseline pressure for maximum dilated ISV (A), less dilated ISV (B) and ESV was 15.93 ± 6.34, 12.38 ± 4.60 and 12.92 ± 5.65 mm. Hg, respectively, which increased after Valsalva by 104.4%, 116.2% and 38.22% respectively. Correlation (r = ?.71; p < .05) was appreciated between percentage increase in pressure of ISV B with PSV of intraparenchymal testicular arteries and progressive motility (r = ?.759; p < .05), nonprogressive motility (r = ?.738; p < .05) and morphology (r = ?.653; p = .07) of spermatozoa. In conclusion, ISV develops higher pressure on Valsalva as compared to ESV and has correlation with semen quality and testicular blood flow.     

Effect of microsurgical varicocelectomy on fertility outcome and treatment plans of patients with severe oligozoospermia: An original report and meta-analysis

Varicocele ligation has been proven to restore semen parameters and improve pregnancy rates in men with clinical disease. However, its effect in men with severe oligozoospermia (SO) is less clearly elucidated. This original report and meta-analysis examined the impact of subinguinal microsurgical varicocelectomy on semen parameters and fertility outcomes of men with SO. A retrospective chart review of 85 patients was conducted on patients with SO who underwent microsurgical subinguinal varicocelectomy. A literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 8 studies investigating the effects of varicocele ligation in men with SO were included for the meta-analysis. The original study reported significant improvements in semen parameters following surgery. 78 patients had a pre-operative TMSC < 5 million. Following surgery, 9 (11.5%) patients had a total motile sperm count (TMSC) between 5 and 9 million, while 14 (17.9%) patients had a TMSC > 9 million. Furthermore, the meta-analysis demonstrated a statistically significant increase in sperm count, total motility and TMSC following surgery. The reported natural pregnancy rate was 27.5%. Varicocelectomy does present as an important treatment option for SO patients because improvements in TMSC can broaden their fertility treatment options.     

Relationship of spermatozoal DNA fragmentation with semen quality in varicocele‐positive men

The aim of the study was to assess the semen quality and levels of spermatozoal nuclear DNA fragmentation in subfertile subjects clinically diagnosed with varicocele, subfertile subjects without varicocele and healthy fertile controls. Semen samples were obtained from 302 subjects. Of them, 115 were healthy fertile controls having normal semen characteristics, 121 subfertile men diagnosed with varicocele, both, clinically and on ultrasonography, while 66 subjects were subfertile with no varicocele. Spermatozoal concentration, percentage motility, morphology and DNA fragmentation were measured. In the study population, deterioration in semen quality‐decreased spermatozoal concentration, percentage motility and normal morphology was seen in subfertile subjects, especially with varicocele. Highest spermatozoal DNA fragmentation was observed in varicocele‐positive subjects as compared with varicocele‐negative subjects and healthy fertile controls. Significant negative correlation was seen between spermatozoal DNA fragmentation and concentration (r = ?0.310), motility (r = ?0.328) normal morphology, WHO method (r = ?0.221) and Tygerberg strict criteria (r = ?0.180) in the varicocele‐positive subfertile subjects. In conclusion, this study suggests existence of a negative relationship between spermatozoal DNA fragmentation and semen quality in varicocele‐positive subfertile subjects.     

Recurrences, testicular growth and semen parameters after laparoscopic Palomo varicocelectomy

The aim of this study was to evaluate the influence of laparoscopic Palomo varicocelectomy on testicular volume and sperm parameters. Laparoscopic Palomo varicocelectomy was performed on 91 patients for left-sided grade II and grade III varicoceles. Ultrasound-derived testicular volumes, semen volume, sperm concentration, percentage sperm motility and total motile sperm count were compared before and after the procedure. Postoperative complications and recurrence rate were also assessed. There were no surgical complications. Four patients (5%) had a mild hydrocele, but did not need hydrocelectomy. No patients presented signs of testicular atrophy and the left testicular volume increased in the adolescents (p < 0.05), but not in the adults. Our data suggest that laparoscopic high mass ligation of both the testicular artery and vein is a highly effective, reliable method for the treatment of varicocele. It is associated with very low complication and recurrence rates and with an objective improvement in fertility parameters.     

Predictors of improved seminal parameters and fertility after varicocele repair in young adults

The aim of our study was to determine hormonal or biochemical markers in patients with clinically palpable left varicocele but without a history of infertility, with especial emphasis on nitric oxide, related with improved seminal parameters after varicocelectomy. Semen samples were obtained from 202 patients with left varicocele grade II or III. Nitric oxide levels in seminal plasma were determined by the Griess technique. Testicular volume was determined ultrasonographically in both testes and hormonal profile was measured. The post-operative sperm concentration increased significantly in patients with normal sperm count or moderate oligozoospermia, but we did not find an increment in sperm count in patients with mild and severe oligozoospermia after surgery . The mean percentage of normal motility significantly increased after surgery, but we did not observe a significant increment in morphologically normal sperm count and testicular volume after varicocele repair. Moreover, we did not find any correlation between nitric oxide concentrations and severity of oligozoospermia, asthenozoospermia or abnormal sperm morphology in this population. It is concluded that in the general male population, varicocele repair is not associated with an improved semen profile in all cases. We did not observe a significant correlation between nitric oxide concentrations and semen profile.     

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.