Should azoospermic patients with varicocele disease undergo surgery to recover fertility? / Pacientes com azoospermia e varicocele devem ser submetidos à cirurgia para recuperar a fertilidade?

Summary Introduction: Varicocele disease is well-known cause of infertility in men. The presence of spermatic varices veins create a hostile environment to spermatogenesis. It results in reduced quality of the sperm production and in some cases can determine a total absence of sperm. The varicocelectomy procedure in patients with non-obstructive azoospermia (NOA) can raise the rates of sperm in the semen analysis. A positive rate for sperm, even if very low, may be sufficient to enable the capture of sperm intended for in-vitro fertilization without the use of donor sperm. Objetive: To evaluate the raise of sperm in NOA patients with varicocele disease who were submitted to a bilateral procedure to recovery sperm production. Method: We analized the sperm results of 25 NOA patients who undergone to a bilateral varicocelectomy procedure. Results: From a total of 25 patients, three (12%) recovered sperm count four months after procedure. One year after the procedure, five (20%) patients recovered sperm production. Conclusion: Patients with varicocele disease and azoospermia, without genetic changes or obstruction of the spermatic tract, should undergo surgical procedure to recover sperm.

Resumo Introdução: A varicocele é sabidamente uma das causas de infertilidade nos homens. A presença de veias espermáticas dilatadas pode criar um ambiente hostil para a espermatogênese. Isso é causa de baixa qualidade e quantidade da produção do esperma; em alguns casos, pode determinar uma ausência total de espermatozoides. O procedimento de varicocelectomia em pacientes com azoospermia não obstrutiva pode aumentar as taxas de espermatozoides na análise do sêmen. Uma taxa positiva para o esperma, mesmo se muito baixa, pode ser suficiente para permitir a coleta e destinar-se ao processo de fertilização in vitro. Isso sem a necessidade de usar esperma de doador. Objetivo: Avaliar o aumento de espermatozoides em pacientes com varicocele associada à azoospermia não obstrutiva. Método: Foram analisados os espermas de 25 pacientes azoospêrmicos não obstrutivos submetidos a procedimento de varicocelectomia bilateral com magnificação microcirúrgica. Resultados: De um total de 25 pacientes, em três (12%) ocorreu recuperação da contagem de espermatozoides quatro meses após o procedimento. Após um ano de procedimento, em cinco (20%) ocorreu a recuperação. Conclusão: Pacientes com ausência de espermatozoides e varicocele, sem alterações genéticas, devem ser submetidos a tratamento cirúrgico a fim de recuperar a produção de espermatozoides.

Chronology of meiosis & synaptonemal complex abnormalities in normal & abnormal spermatogenesis.

Background & objectives: The study was taken up to define criteria of normality for meiosis by assessing the frequency of meiotic prophase cell types, the frequency of pachytene substage in normal and abnormal spermatogenesis and to determine what synaptonemal complex. Methods: A quantitative and qualitative analysis of the first meiotic prophase was performed in 10 patients presenting with non-obstructive infertility and 10 controls, using dual colour immunocytochemistry with SCP3 and BRCA1 which visualise axial elements and synaptonemal complexes (SC). The respective frequencies of the leptotene, zygotene and pachytene stages as well as the frequencies of the four substages of pachytene were evaluated. The frequencies of the main types of meiotic abnormalities at pachytene were also assessed. Results: The frequencies of leptotene and zygotene stages were significantly higher in patients (7.95 and 9.75%) than in controls (2.30 and 1.45%), whereas the frequency of pachytene was significantly higher in controls than in patients (96.25 vs. 75.30%). Detailed analysis of the sex chromosomes revealed that the controls showed a presence of late pachytene substages (P3 + P4 = 64.40%), whereas the patients showed a early pachytene substages (P1 + P2 = 63.40%). From these results, a new index was defined to evaluate spermatogenesis: the Pachytene Index, or PI (PI = P1 + P2 / P1 + P2 + P3 + P4). The same abnormalities (asynapsis, fragmented SC, dotted SC, thin SC) were observed in controls and in patients, but with different frequencies. The most frequent abnormality was fragmented SC, with a significant difference between patients and controls (15.28 vs. 9.74%). There was a significant difference between patients and controls for the frequency of asynapsed nuclei (7.97 vs. 2.95%) while the difference in other abnormalities were not significant. Interpretation & conclusion: The accumulation of early primary spermatocytes is an indication that progression of meiosis is defective in spermatogenesis failures. The value of the PI less than 0.50 indicates that the kinetic of meiosis is normal at pachytene. There is no normal spermatogenesis when the frequency of one or several SC abnormalities is significantly higher than in controls and/ or when the PI is more than 0.50.

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.