Intense venous reflux, quantified by a new software to analyze presurgical ultrasound, is associated with unfavorable outcomes of microsurgical varicocelectomy / 亚洲男科学杂志(英文版)

The hemodynamic characteristics of venous reflux are associated with infertility in patients with varicocele; however, an effective method for quantifying the structural distribution of the reflux is lacking. This study aimed to predict surgical outcomes using a new software for venous reflux quantification. This was a retrospective cohort study of a consecutive series of 105 patients (age range: 22-44 years) between July 2017 and September 2019. Venous reflux of the varicocele was obtained using the Valsalva maneuver during scrotal Doppler ultrasonography before microsurgical varicocelectomy. Using this software, the colored reflux signals were segmented, and the gray scale of the color pixels representing the reflux velocity was comprehensively quantified into the mean reflux velocity of the green layer (MRVG) and the reflux velocity standard deviation of the green layer (RVSDG). Spontaneous pregnancy and changes from baseline in the semen parameters were assessed during a 12-month follow-up period. Data were analyzed using logistic regression analysis. An association of the high MRVG group with impaired progressive motility (odds ratio [OR] = 2.868, 95% confidence interval [CI]: 1.133-7.265) and impaired sperm concentration (OR = 2.943, 95% CI: 1.196-7.239) was found during multivariate analysis. High MRVG (OR = 2.680, 95% CI: 1.086-6.614) and high RVSDG (OR = 2.508, 95% CI: 1.030-6.111) were found to be independent predictors of failure to achieve pregnancy following microsurgical repair. In summary, intense venous reflux is an independent predictor of impaired progressive motility, sperm concentration, and pregnancy outcomes after microsurgical varicocelectomy.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment: critical assessment and systematization / 亚洲男科学杂志(英文版)

In this review, we tried to systematize all the evidence (from PubMed [MEDLINE], Scopus, Cochrane Library, EBSCO, Embase, and Google Scholar) from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment. Regarding the outcomes of varicocele repair, we considered semen improvement and pregnancy and analyzed them separately. Based on the 2011 Oxford CEBM Levels of Evidence, we assigned a score to each trial that studied the role of the predictor. We systematized the studied predictors based on the total points, which were, in turn, calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant, into three levels of significance: predictors of high, moderate, and low clinical significance. Preoperative total motile sperm count (TMSC) coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy. In addition, for semen improvement alone, scrotal Doppler ultrasound (DUS) parameters, sperm DNA fragmentation index (DFI), and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Análisis de parámetros seminales en varones subfértiles sin y con varicocele (Pre-Postquirúrgico) / Analysis of seminal parameters in subfertile males without and with varicocele (Pre-Surgical)

Introducción: Durante años, el varicocele se ha propugnado como la causa más común de infertilidad, siendo esta patología la de mayor incidencia en los varones como factor causal (19 - 41%). Material y Métodos: Se evaluaron 228 pacientes, sexo masculino (18 y 39 años) con subfertilidad primaria con o sin varicocele. Se realizó historia clínica, examen físico, laboratorio y espermograma por duplicado. Se dividieron un grupo de 120 pacientes con subfertilidad primaria, varicocele izquierdo y por lo menos un parámetro seminal alterado en dos muestras sometidos a varicocelectomía y control seminal 6 y 9 meses post-operatorio y otro grupo 108 pacientes de iguales características pero sin varicocele. Se utilizaron criterios OMS en concentración, motilidad y morfología espermática. Estudio de casos y controles. Resultados: La mejoría en la concentración de espermatozoides tras el tratamiento quirúrgico fue de 20,06% (p‹ 0,0001) a los 6 meses y 26,31% (p‹ 0,0001) a los 9 meses. La motilidad aumentó 21,32% (p‹ 0,001) a los 6 meses y 28,28% (p‹ 0,0001) a los 9 meses y la morfología mejoró un 26,8% (p‹ 0,0001) a los 6 meses y 57,38% (p‹ 0,0001) a los 9 meses. Todas las variables resultaron estadísticamente significativas tras el tratamiento quirúrgico. No hubo diferencia estadísticamente significativa en ninguna de las variables entre el grupo pre-quirúrgico y el grupo control, y si las hubo en todas las variables estudiadas entre el grupo control comparado con el post- quirúrgico, a favor de este último. Los porcentajes de mejoras entre el grupo post-quirúrgico a los 6 meses y 9 meses de la cirugía, a favor de este último fueron 7,5% (p‹ 0,0001) en la concentración, 5,28 % (p‹ 0.0001) en la motilidad y 25,32% (p‹ 0.0001) en la morfología... Conclusiones: Los parámetros seminales evidenciaron cambios positivos luego de la varicocelectomia y más aún con el transcurrir del tiempo.

Introduction: Varicocele has been proposed for years as the most common cause of infertility, and this condition is the prevalent incidence as causal factor. (19-41%) Material and methods: 228 male patients (between 18 and 39 years old) were evaluated with primary sub fertility with or without varicocele. The records included history, physical examination and two spermogram for patient. The population was divided in two groups. The first one of 120 patients with primary subfertility, left varicocele and at least one abnormal seminal parameter in two samples, with surgical resection of varicocele and final seminal post-surgical evaluation at 6 and 9 months. The other group included 108 patients with similar characteristics but without varicocele. The WHO criteria for spermatic concentration, motility and morphology were applied. Evaluation of cases and controls. Results: The improvement in spermatozoa concentration after treatment was of 20.06% (p<0,0001). The motility improved 21,32% at 6 months (p<0,0001) and 28,28% at 9 months (p<0,0001).The morphology improved 26,8% at 6 months (p<0,0001) and 57,38% at 9 months (p<0,0001)All the parameters were statistically significant after surgery. While there were no significant differences in any parameter between the pre-surgical group and the control group, there were differences in all the parameters evaluated between the control group and the post-surgical group, with best results in the latter.The percentages of improvement in the post-surgical group were 7,5%(p < 0,0001) in concentration, 5,28% in motility and 25,32% in morphology...Conclusions: The seminal parameters showed positive changes after varicocelectomy, especially over time.

Efficacy of spermatic vein ligation in patients affected by high grade left varicocele

Purpose: To study the effect of high grade varicocele treatment in infertile patients. Materials and Methods: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject’s partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. Results: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10 6 /mL compared to 19.7x10 6 /mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). Conclusion: Surgical treatment of high grade varicocele proved to effectively treat associated infertility by improving seminal parameters and pregnancy rate in our patient cohort. .

Comparación entre los efectos de la varicocelectomía microquirúrgica subinguinal bilateral vs la unilateral en los parámetros seminales / Comparison of the effects of unilateral vs bilateral microsurgical subinguinal varicocelectomy in seminal parameters

INTRODUCCIÓN: El varicocele es una causa frecuente de infertilidad en el hombre, encontrándose en el 40 por ciento de los hombres que consultan por infertilidad, existiendo diversas teorías que explican esta situación. Numerosos estudios apuntan a que la reparación del varicocele se asociaría a una mejoría en los parámetros seminales e incluso en las tasas de fertilidad. Entre las técnicas reparativas la varicocelectomía microquirúrgica (VM) se ha posicionado como la técnica gold standard dado sus mejores resultados en cuanto a éxito, recidiva y seguridad. OBJETIVO: evaluar el rol de la VM en los parámetros seminales de varones que consultan por infertilidad y que son sometidos a VM bilateral en comparación con aquellos en que se realiza VM unilateral. Materiales y método: se seleccionó a pacientes con varicocele clínico que consultaron por infertilidad y que tenían el espermiograma alterado, a los que se realizó VM uni o bilateral según tuvieran la enfermedad en uno o ambos lados. Se tomó el promedio de los parámetros seminales de 2 espermiogramas pre-operatorios y otras variables clínicas y demográficas y se comparó con los parámetros seminales a 6 meses post-cirugía. Además se comparó los resultados del grupo de VM bilateral con el unilateral. RESULTADOS: no hubo diferencias entre los grupos en el pre-operatorio, evidenciándose una mejoría en ambos grupos al analizar los resultados a los 6 meses post-VM. Esta mejoría fue significativamente mayor en el grupo de VM unilateral en cuanto a la concentración espermática (mediana de 6 mill/ml, comparado con 0.75 mill/ml en el grupo de pacientes sometidos a VM bilateral. p Value = 0.02)...

Introduction: Varicocele is a common cause of infertility in men, present in 40 percent of men with infertility, there are several theories that explain this situation. Numerous studies suggest that varicocele repair would be associated with an improvement in semen parameters and even fertility rates. Among the reparative techniques microsurgical varicocelectomy (VM) has positioned itself as the gold standard technique given the best results in terms of success, recurrence and security. Objective: To evaluate the role of the VM in semen parameters of men consulting for infertility and who undergo bilateral VM compared to those VM is performed unilaterally. Materials and Methods: We enrolled patients with clinical varicocele who consulted for infertility and had altered semen analysis, in which VM was performed unilateral or bilateral depending if they had the disease in one or both sides. The average of 2 pre-operative semen parameters was used and other clinical and demographic variables and they were compared with semen parameters at 6 months post-surgery. We also compared the results of the group with unilateral versus that with bilateral VM. Results: There were no differences between groups in the pre-operative, evidence-dose improvement in both groups in analyzing the results at 6 months post-VM. This improvement was significantly greater in the group of unilateral VM regarding sperm concentration (median of 6 mill / ml, compared with 0.75 million / ml in the group of patients undergoing bilateral VM. P Value = 0.02).Discussion: VM improves seminal parameters in patients with unilateral or bilateral varicocele, being unilateral VM group that benefits the most. This could be explained by a greater cumulative damage spermatogenesis in the case of bilateral varicocele. Randomized controlled prospective studies are needed, allowing to determine the real effect of unilateral vs. bilateral VM.

Preparation of infertile male rabbits by local electron beam irradiation for intratesticular transplantation of autologous bone marrow stem cells

PURPOSE: To explore an efficient and safe protocol for the preparation of infertile male rabbits from which bone marrow stem cells (BMSCs) could be isolated and cultured. METHODS: Autologous BMSCs could be used for intratesticular transplantation and male infertility research. For this model, various doses (e.g., 6, 8, 10, or 12 Gy) of electron beam irradiation from a linear accelerator were locally applied to the scrotum of 5-month-old male New Zealand white rabbits. The effects of irradiation were compared between treatment groups, and with age-matched normal controls. Both morphology and hollow ratios of seminiferous tubules (HRST) were examined two, four, six, eight and 12-weeks post-irradiation. RESULTS: The seminiferous epithelium showed varying degrees of damage in all treatment groups compared with unirradiated controls, yet Sertoli and Leydig cells appeared unaffected. A dose-dependent response in spermatogenesis was also observed. BMSCs that were isolated and cultured from rabbits of the normal control group and the 12 Gy treatment group were compared with respect to morphology and growth. Starting at 6 weeks, HRST of the 12 Gy-treatment group were stable, and were the highest among all the groups. BMSCs from rabbits treated with 12 Gy also exhibited similar growth as the control group. CONCLUSION: Local dose of 12 Gy to the testes of 5-month-old male New Zealand rabbits is a protocol with which to obtain autologous bone marrow stem cells.

Outcome of varicocele surgery and infertility at Prince Hussein Urology Center

To describe the outcome of surgical techniques for the treatment of testicular varicosity to improve fertility among infertile males at Prince Hussein Urology Center. This descriptive study was conducted on a total of 844 patients who underwent Varicocele surgery at Prince Hussein Urology Center, for infertility between the period of June 2003 and June 2008, surgery was performed for patients upon presenting to our clinic complaining of infertility for one year or more in the absence of female factor for infertility. Patients were non-randomly selected. Sperm concentration, motility and morphology was assessed by analysis of at least two different semen specimens each obtained after a 5 days period of sexual abstinence and separated by three weeks interval. Post surgery patients were classified as responders [more than 50% increases in sperm parameters] and non-responders. Simple descriptive statistical methods [frequency, mean and percentage] were used to describe the study variables. Surgical treatment of clinical palpable Varicocele successfully cured over 95% of Varicocele. Post surgery spermatogenesis was improved among 256 patients [30.3%]. Sperm concentration increased to variable degrees from 6.23 to 12.1 million among these patients with mean of 9.2 million, sperm motility improved from 5.2% to 18.7% with mean of 8.3%. Spontaneous pregnancy was achieved in 194[23%] couples within 12 months following surgery. Varicocelectomy is a safe, effective and associated with a rapid recovery and minimal morbidity. Varicocelectomy resulted in the induction or enhancement of spermatogenesis in several men with clinical Varicocele and abnormal semen parameters. Despite the absence of definitive studies on the infertility outcome of varicocele surgery, it is reasonable to be considered as an option in selective patients with semen abnormalities

Does the duration of infertility affect semen parameters and pregnancy rate after varicocelectomy?: a retrospective study

OBJECTIVES: The most common indication for treatment of varicocele is still male subfertility. The aim of this study was to explore the effect of infertility duration on semen parameters and spontaneous pregnancy rate after varicocelectomy. MATERIALS AND METHODS: The medical records of 183 infertile patients with clinical varicocele were retrospectively reviewed. The patients were divided into three groups according to the duration of infertility (group I, 1-3 years, group II, 3-6 years and group III, > 6 years). Total sperm motility counts (TMCs) before and after varicocelectomy and spontaneous pregnancy rate among these groups were statistically compared. RESULTS: The greatest changes, regarding preoperative and postoperative TMCs and spontaneous pregnancy rate were noticed between group I and III. Preoperative TMCs in group I and III was 15.2 ± 1.2, 7.8 ± 1.4, respectively (p < 0.05). Postoperative TMCs in group I and III was 33.7 ± 2.5, 25.2 ± 1.9, respectively (p < 0.05). An overall spontaneous pregnancy rate of 34.4 percent was achieved after inguinal varicocelectomy. The greatest spontaneous pregnancy rate was achieved in Group I (37.3 percent), and the lowest pregnancy rate in Group III (26.3 percent) (P < 0.05). CONCLUSIONS: Surgical varicocelectomy improves the total sperm motility counts especially in patients who have a TMCS more than 5 million and improves the spontaneous pregnancy rates. The improvement in the spontaneous pregnancy rates after varicocelectomy correlates negatively with the duration of infertility. Therefore, duration of infertility should be considered in treating a patient with a varicocele as a cause of infertility.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

Laparoscopic varicocelectomy for bilateral varicoceles in infertile males

Varicoceles, present in 15% to 20% of men, are the most common abnormal finding among men presenting with infertility.Despite the very long history of the disease and many records on different surgical and radiological solutions, the ideal method of spermatic vein ligation for varicocele is still a matter of controversy. The perfect technique would be one that preserves testicular function and eliminates the varicocele with a low rate of recurrence, hydrocele formation and any other complications. To assess the efficacy of laparoscopic Varicocelectomy for management of bilateral palpable varicoceles in infertile males. We analysed the result of 25 patients presented with history of infertility and diagnosed to have bilateral palpable varicoceles treated in our department with Bilateral laparoscopic ligation of the spermatic vessels between January 2009 and November 2010. The average operative [Bilateral Laparoscopic Varicocelectomy] time was 34 minutes. There were no intra operative complications in the study group. Hydrocele formation was seen in 3 [6%] patients recurrence was seen in one [2%] patient .The average hospital stay was 18 hours. postoperative analgesics [1-2] doses, daily activities initiation usually started after 48 hrs and physical exercise 72 hrs . non of the patient has developed an atrophic testis as a result of the laparoscopic procedure. eighteen patients [72%]of the patients had improvement of the seminal fluid parameters During follow up period [6 months],with seminal fluid analysis, clinical and ultrasonic examination. Laparoscopic varicocele ligation is a simple and safe technique, causing minimal morbidity and enabling rapid return to normal activity

Sub-inguinal varicocelectomy in the treatment of infertile males with varicoceles

Varicocele is an abnormal dilatation of pampiniform plexus within the spermatic cord. Varicoceles are present in 15% of the normal male population and in up to 35-40% of patients with infertility. In approximately 70-81% of patients with secondary infertility, a varicocele is an underlying cause. It is a disease of puberty and is only rarely detected in boys less than ten years of age. Is to evaluate the sub inguinal approach of varicocelectomy in infertile males with grade II and III varicoceles. A total of 150 patients were included in the study from 2004 to May 2010. Their ages ranged from 18 to 42 years. Fifty patients [33.3%] had grade II while 100 [66.6%] patients had grade III varicoceles. All the patients had history of more than one year infertility [ranging from 14 to 36 months] and all of them were sexually competent. Physical examination was performed with no apparent other clinical cause of infertility. Although varicoceles were diagnosed primarily by physical examination, color Doppler ultrasound was done for further documentation of the patient's condition. Only patients with grade II and grade III primary varicoceles were included in the study with exclusion of those with grade I varicoceles. Seminal fluid analysis and hormonal assay were done for all patients. Any patient with sperm concentration below 10 millions/milliliter was also excluded. Sub inguinal varicocelectomy was done for each patient. The operative time ranged from 20-25 minutes. The patients were followed for one year. The overall pregnancy rate at one year was 66, 6% .The time from the operation till pregnancy was ranged from 4 to 12 months. Ten patients [6.6%] developed recurrence, 2 patients [1.3%] developed scrotal pain for 3 weeks postoperatively and then disappeared, and only 4 patients [2.6%] developed hydrocele . Whereas most male infertility surgeons now use the microsurgical approach, varicocele repairs can be achieved with successful results and minimal complications without microsurgery as long as they are carefully performed. Although microscopic sub inguinal varicocelectomy is better than non microscopic one, the later can be done successfully with shorter operative time

Attenuation of oxidative stress & DNA damage in varicocelectomy: Implications in infertility management.

Sperm DNA integrity is of vital importance for foetal development and birth of healthy offspring. Oxidative stress and consequent DNA damage are the major cause of decline in semen quality in men with varicocele. A preliminary study was conducted on 11 men with clinical varicocele who also had high levels of reactive oxygen species (ROS), to assess DNA damage in sperms and ROS levels before and after varicocelectomy. Varicocelectomy resulted in rapid (1 month) significant (P<0.001) decline in free radical levels and slow (3-6 months) significant decline in DNA damage levels. Thus men undergoing varicocelectomy should try concieving only 6 months following surgery.

Embolization of testicular vein for treatment of recurrent varicocele

To assess the efficacy of embolization of testicular vein for the treatment of recurrent varicocele. Between January 2002 and December 2005, a total of 64 patients with a mean age of 28 [18-40 years] were treated by embolization of testicular vein for management of recurrent varicocele at Prince Hussein Bin Abdullah II Center in King Hussein Medical Center. Indication for treatment was as either infertility or presence of dragging pain in the left testicle. Embolization was accomplished successfully in 53 patients [82.8%], whereas it was difficult in eleven patients because of venous spasm and anomalous collaterals which could not be cannulated. One patient required transfusion of blood due to bleeding from the internal spermatic vein. Embolization technique for internal spermatic vein for treatment of recurrent varicocele is a safe technique with low morbidity. It is also minimally invasive with high success rate

The role of varicocele repair in the new era of assisted reproductive technology: [review]

Infertility affects 10-15 percent of couples who are trying to conceive, and half of the cases are due to male infertility. Intracytoplasmic sperm injection is increasingly being used to overcome multiple sperm deficiencies. Due to its effectiveness, some have proposed ICSI as a solution for all cases of male infertility, regardless of the cause. Hence, even men with potentially treatable causes of infertility have sought the aid of assisted reproductive technology, rather than undergo specific therapies to treat their infertility. Varicoceles are the most frequent physical finding in infertile men; indeed, they may be responsible for nearly one-third of cases of male infertility. Varicocele management, however, has always been a controversial issue because very few randomized, controlled studies have been performed to examine varicocelectomy as an infertility treatment. Significant evidence suggests that varicoceles have a harmful effect on the testis and that varicocelectomy can not only prevent progressive decline in testicular function but also reverse the damage. However, the degree to which varicocele repair improves pregnancy rates and the success of assisted reproductive technology remains controversial.

Extragondal germ cell tumor and male infertility

Over recent decades a possible decrease in sperm quality and an increase in the incidence of testicular cancer have been reported in many populations. Some recent findings, as cohort studies, showed an increased risk of testicular cancer in men with abnormal semen analysis. A 30 years old man referred to our clinic with chief compliant of infertility for 3 years. Spermogram revealed azoospermia and right extratesticular intrascrotal mass was detected by ultrasound examination. Right inguinal surgical approach showed intact small sized atrophic right testis and an intrascrotal mass. In microscopic examination of the mass mixed germ cell tumor with teratoma, yolk sac and embryonal components were reported. Extragonadal germ cell tumors, like their testicular counterparts are associated with primary germ cell defects. The higher incidence of antecedent infertility suggests that either congenital or acquired primary germ cell defect contributes to defective spermatogenesis and therefore, there is higher risk of cancer development in incompletely migrated germ cells. We recommend complete evaluation of cancer in patients with infertility and azoospermia

A microcirurgia no tratamento da infertilidade masculina / Microsurgery in the treatment of male infertility

Duzentos e cinquenta e seis pacientes com azoospermiaforam estudados. Desses, 81 (36,6 por cento) eram portadores de azoospermia excretora. Dos pacientes com azoospermia excretora, 25 apresentavam agenesia bilateral do deferente, 28 obstruçäo ao nível do epidídimo e 28 azoospermia pós-vasectomia. Três pacientes com agenesia dos deferentes foram tratados através da confecçäo de espermatocele artificial. Os pacientes com obstruçäo do epidídimo foram submetidos a anastomose microcirúrgica ipidídimo-deferencial término-terminal e os pacientes vasectomizados à reconstruçäo microcirúrgica em dois planos. Nos casos de espermatocele näo houve gravidez. Nos doentes submetidos à epidídimo-vasostomia houve 60 por cento de recanalizaçäo e 30 por cento de gravidez. Nos pacientes submetidos à reversäo microcirúrgica da vasectomia houve 100 por cento de restabelecimento da permeabilidade e 78,5 por cento de gravidez