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.

Effect of varicocele repair on sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia / 亚洲男科学杂志(英文版)

Varicocele adversely affects semen parameters. However, the effect of varicocele repair on the sperm retrieval rate and testicular histopathological patterns in men with nonobstructive azoospermia has not been widely reported. We retrospectively assessed the sperm retrieval rates and testicular histopathological patterns in men with nonobstructive azoospermia who were referred to the Urology Clinic in Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) and Bunda General Hospital (Jakarta, Indonesia) between January 2009 and December 2019. We compared patients who had undergone a surgical sperm retrieval procedure for assisted reproductive technology no earlier than three months after varicocele repair and those who had not undergone varicocele repair. The study included 104 patients (age range: 26-54 years), 42 of whom had undergone varicocele repair before the sperm retrieval procedure and 62 who had not. Motile spermatozoa were found in 29 (69.1%) and 17 (27.4%) patients who had undergone varicocele repair before the sperm retrieval procedure and those who had not undergone the repair, respectively (relative risk: 2.51; 95% confidence interval: 1.60-3.96; P < 0.001). A predicted probabilities graph showed consistently higher sperm retrieval rates for patients with varicocele repair, regardless of their follicle-stimulating hormone levels. Patients who underwent varicocele repair showed higher testicular histopathological patterns (P = 0.001). In conclusion, men with nonobstructive azoospermia and clinical varicocele who underwent varicocele repair before the sperm retrieval procedure had higher sperm retrieval rates compared to those who did not undergo varicocele repair.

Microsurgical subinguinal varicocelectomy with spermatic cord double traction and vein stripping / 亚洲男科学杂志(英文版)

We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital (Shanghai, China). In this surgical approach, the testis was delivered, and the gubernacular and external cremasteric veins were stripped. In addition, the spermatic cord was delivered downward with continuous double traction away from the external ring. The remaining procedure was similar to the conventional approach. We followed patients for at least 3 months and evaluated postoperative semen parameters, pain symptoms, and complications. We excluded data for 32 men due to inadequate follow-up (<3 months). Of the remaining 254 patients, 73 had oligoasthenospermia, 121 had nonobstructive azoospermia, and 60 had symptomatic varicoceles. Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15 × 106 ml-1 to 25.33 × 106 ml-1 (n= 34), and 35.6% (26/73) initially oligoasthenospermic men contributed to unassisted pregnancies. Sperm returned to the ejaculate in 12.4% (15/121) azoospermia patients. In patients with scrotal pain (n = 60), 43 (71.7%) reported complete resolution of pain, 16 (26.7%) reported partial resolution, and 1 (1.7%) reported no change. No patients experienced varicocele recurrence. This double-traction strategy avoids opening the external oblique aponeurosis, and results in less damage and faster recovery. In addition, the stripping strategy eliminates potential damage to the testis caused by the varicose veins. Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.

Effects of percutaneous varicocele repair on testicular volume: results from a 12-month follow-up / 亚洲男科学杂志(英文版)

Varicocele is a common finding in men. Varicocele correction has been advocated for young patients with testicular hypotrophy, but there is a lack of morphofunctional follow-up data. We assessed whether percutaneous treatment of left varicocele is associated with testicular "catch-up growth" in the following 12 months by retrospectively reviewing data from an electronic database of 10 656 patients followed up in our clinic between 2006 and 2016. We selected all young adults (<35 years) with left varicocele who underwent percutaneous treatment, had a minimum of 12 months' ultrasound imaging follow-up, and had no other conditions affecting testicular volume. One hundred and fourteen men (mean±standard deviation [s.d.] of age: 22.8 ± 5.4 years) met the inclusion and exclusion criteria. Left testicular hypotrophy (LTH), defined as a ≥20% difference between left and right testicular volume at baseline, was observed in 26 (22.8%) men. Participants with LTH (mean±s.d.: 14.5 ± 2.7 ml) had lower baseline testicular volume compared to those without LTH (mean±s.d.: 15.7 ± 3.8 ml; P = 0.032). Repeated measures mixed models showed a significant interaction between LTH and time posttreatment when correcting for baseline left testicular volume (β = 0.114, 95% confidence interval [CI]: 0.018-0.210, P = 0.020), resulting in a catch-up growth of up to 1.37 ml per year (95% CI: 0.221-2.516). Age at intervention was also associated with reduced testicular volume (-0.072 ml per year, 95% CI: -0.135--0.009; P = 0.024). Percutaneous treatment of left varicocele in young adults with LTH can result in catch-up growth over 1 year of follow-up. The reproductive and psychological implications of these findings need to be confirmed in longer and larger prospective studies.

The history of varicocele: from antiquity to the modern ERA

ABSTRACT Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: "The veins are swollen and twisted over the testicle, which becomes smaller". Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and "cirsocele" (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

Seminal plasma miR-192a: a biomarker predicting successful resolution of nonobstructive azoospermia following varicocele repair / 亚洲男科学杂志(英文版)

This study was performed to investigate a potential marker for the presence of spermatozoa in the ejaculate following varicocelectomy in Chinese men with nonobstructive azoospermia and varicoceles. The micro-RNA (miR)-192a levels in seminal plasma and testicular tissue were evaluated by quantitative real-time polymerase chain reaction from 60 men with nonobstructive azoospermia and varicoceles (Group A: 27 men with spermatozoa found in the ejaculate after surgery; Group B: 33 men without spermatozoa found in the ejaculate after surgery) and 30 controls. The seminal plasma and testicular tissue miR-192a levels were higher in Group B than in Group A and the controls (P < 0.001), and there was no significant difference between Group A and the controls (P > 0.05). Apoptosis and proliferation assays with miR mimics and inhibitors showed that miR-192a induced GC-2 cell apoptosis through the activation of Caspase-3 protein. Thus, seminal plasma miR-192a appears to be a potential marker for successfully indicating spermatozoa in the ejaculate following microsurgical varicocelectomy in men with nonobstructive azoospermia and varicoceles. Seminal plasma miR-192a may be a useful clinical marker for prescreening to determine which patients with nonobstructive azoospermia and varicoceles would benefit from varicocelectomy.

A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy / 亚洲男科学杂志(英文版)

We report the largest single-center experience with robotic-assisted microscopic varicocelectomy (RAMV) in male infertility. From August 2012 to February 2015, men with infertility of at least a year and varicoceles underwent RAMV by a single surgeon. Varicocele was diagnosed on physical examination and confirmed by ultrasound by a single ultrasonographer. Preoperative hormone panel, semen analyses, and testicular Doppler ultrasound were obtained from all men and repeated at 3 months. One hundred and forty consecutive men (258 varicocelectomies) were included. Mean age and duration of infertility was 36.4 and 2.8 years, respectively. Median total and free testosterone increased by 145 ng dl-1 and 4.3 pcg ml-1 (44.3%), respectively (P < 0.0001). Median sperm concentration increased by 37.3% (P < 0.03). Median sperm motility and morphology did not significantly change. Median left and right testicular volume increased by 22.3% (P < 0.0001) and 12.6% (P < 0.0006), respectively. Hydroceles occurred 0.8% of procedures. We had no testicular artery injuries. Persistence of varicocele by Doppler ultrasound was 9.6%. Only 37.3% of patients required pain medications postoperatively. We concluded that RAMV is a safe and effective alternative for varicocele repair with outcomes comparable to historical traditional microsurgical approach.

Use of indocyanine green angiography in microsurgical subinguinal varicocelectomy - lessons learned from our initial experience

ABSTRACT Microsurgical subinguinal varicocelectomy (MSV) is generally considered the gold standard nowadays in view of the lower risk of complications and recurrence. To achieve complete ligation of veins while preserving testicular artery (TA) during the procedure remains challenging despite the application of high power optical magnification and micro-Doppler ultrasonography. The use of intraoperative indocyanine green angiography (ICGA) with infrared fluorescence operative micro-scope in MSV potentially lowers the incidence of TA injury and shortens the learning curve of novice surgeons. We present our initial experience in the application of the technique in nine patients and explore the potential of the new adjunct.

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.

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. .

Effectiveness of tamsulosin in prevention of post-operative urinary retention: a randomized double-blind placebo-controlled study

Purpose: Urinary retention is one of the most common complications contributing to surgical procedures. Recent studies have shown the benefits of alpha-adrenergic blockers in preventing post-operative urinary retention (POUR). The aim of this prospective study was to compare the prophylactic effect of tamsulosin with placebo on postoperative urinary retention. Materials and Methods: In this randomized placebo controlled, clinical trial, 232 male patients aged 18 to 50 years old admitted to Razi University Hospital for varicocelectomy, inguinal herniorrhaphy, and scrotal surgery were randomly assigned to receive either three doses of 0.4mg tamsulosin (n = 118) or placebo (n = 114), 14 and 2 hours before, and 10 hours after surgery. Patients were closely monitored for the development of urinary retention 24 hours after surgical intervention. The primary endpoint was to investigate the effect of tamsulosin in prevention of post-operative urinary retention during the first 24 hours after surgical intervention. Collected data were analyzed using SPSS software version 18 and the P < 0.05 was considered statistically significant. Results: One hundred and eighteen patients were included in tamsulosin arm and 114 in placebo arm. POUR in patients who received tamsulosin was significantly lower than placebo, as 5.9% of the patients treated with tamsulosin and 21.1% placebo group, reported urinary retention following surgery (P = 0.001). No serious adverse effects were seen in both groups. Conclusions: This study suggests that short perioperative treatment with tamsulosin can reduce the incidence of urinary retention and the need for catheterization after varicocelectomy, inguinal herniorrhaphy, and scrotal surgery. .

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.

The role of varicocele treatment in the management of non-obstructive azoospermia

The literature on male reproductive medicine is continually expanding, especially regarding the diagnosis and treatment of infertility due to non-obstructive azoospermia. The advent of in vitro fertilization with intracytoplasmic sperm injection has dramatically improved the treatment of male infertility due to nonobstructive azoospermia. Assisted reproduction using testicular spermatozoa has become a treatment of hope for men previously thought to be incapable of fathering a child due to testicular failure. In addition, numerous studies on non-obstructive azoospermia have reported that varicocelectomy not only can induce spermatogenesis but can also increase the sperm retrieval rate; however, the value of varicocelectomy in patients with non-obstructive azoospermia still remains controversial. The purpose of this review is to present an overview of the current status of varicocele repair in men with non-obstructive azoospermia.

Manejo ortopédico de la extrofia vesical / Orthopedic management of bladder exstrophy

La extrofia vesical es una deformidad congénita compleja, que incluye el aparato músculo esquelético, en la parte anterior de la pelvis se observa diastasis del pubis, y la parte posterior se muestra en rotación externa. Está demostrada la importancia de la osteomía pélvica en estos casos para permitir la relajación de los tejidos blandos y as¡ el éxito en la reconstrucción urológica. Se describen los resultados del manejo ortopédico de la extrofia vesical en el Hospital Nacional de Niños, donde se destacan dos aspectos, la intervención quirúrgica ortopédica temprana, en etapa neonatal, y el tipo de osteotomía, la cual se considera muy propia del centro. Los resultados obtenidos son muy buenos, con escasas complicaciones, se incluyen 9 pacientes, con 9 a 18 años de evolución de su cirugía, se analizan los resultados radiológicos y funcionales.

Microsurgical Ligation for Painful Varicocele: Effectiveness and Predictors of Pain Resolution

PURPOSE: We evaluated the effectiveness of microsurgical ligation for painful varicocele and predictive factors of pain resolution. MATERIALS AND METHODS: Between January 2006 and March 2009, a total of 114 patients (mean age, 30.2+/-8.9 years), who underwent microsurgical inguinal varicocelectomy for painful varicocele, were included and followed up for 1 year after the surgery. The quantity of preoperative and postoperative pain was assessed by means of 11-point numeric rating scale (NRS). We retrospectively analyzed the outcome of surgical ligation and predictive factors of pain resolution using patient age, height, weight, body mass index, grade and location of varicocele, duration, quantity and quality (dull, dragging, aching) of pain, and postoperative pain resolution. RESULTS: In 104 patients (91.2%), complete or marked resolution of pain was reported at follow-up 1 year after surgery. Only 10 patients (8.8%) had recurrent or persistent pain (> or =3 points in NRS scores). On multivariate analysis, low quantity (< or =6 points in NRS scores) and dull or dragging natured preoperative pain were independent factors associated with surgical success rates (p=0.004; odds ratio=1.62, p=0.012; odds ratio=1.76, respectively). CONCLUSION: Microsurgical ligation is an effective treatment of painful varicocele. The quantity and quality of preoperative pain are independent predictive factors of pain resolution after surgery.

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.

Novel concepts in male infertility

Extraordinary advances have been achieved in the field of male infertility in the last decades. There are new concepts in sperm physiology and several modern tools for the assessment of spermatogenesis kinetics in vivo. New tests using molecular biology and DNA damage assays allow the clinician to correctly diagnose men so far classified as having idiopathic male infertility. In the field of treatment, microsurgery has increased success rates either for reconstruction of the reproductive tract or the retrieval of spermatozoa for assisted conception. Emerging evidence suggests that life-style and environmental conditions are of utmost importance in male fertility and subfertility. This review discusses several concepts that have changed over the last years, such as the duration of the spermatogenic cycle in humans, Y-chromosome infertility, the reproductive potential of non-mosaic Klinefelter syndrome men, the impact of paternal age and sperm DNA in male infertility, the role of antioxidants in the treatment of infertile men, the predictive factors and techniques for sperm retrieval in non-obstructive azoospermia, and the microsurgical treatment of clinical varicoceles. Whenever possible, levels of evidence are provided as suggested by the Oxford Center of Evidence-based Medicine.

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.