Grade 3 varicocele in fertile men: a different entity.

PURPOSE: Although varicocele size has an inverse relationship with baseline semen parameters and a direct relationship with seminal reactive oxygen species in infertile patients, to our knowledge the effect of varicocele grade in fertile men is unknown. We evaluated the impact of varicocele grade on seminal parameters, testicular size and seminal reactive oxygen species in fertile men. MATERIALS AND METHODS: We prospectively evaluated 194 men from July 2004 to April 2010. Of the men 156 were fertile and classified by presence of varicocele. A total of 38 infertile patients with varicocele as the only identifiable cause of infertility comprised the control group. Physical examination, semen parameters and seminal reactive oxygen species were compared between the groups. RESULTS: Of 156 fertile men 43 (24.3%) had clinical varicocele, which was grade 1 to 3 in 22, 11 and 10, respectively. The remaining 113 men (72.7%) had no varicocele. Infertile men had smaller testes, decreased semen parameters and higher seminal reactive oxygen species than the fertile groups. Testicular size, reactive oxygen species and semen parameters did not differ between fertile men with vs without varicocele. Fertile men with varicocele grade 3 had higher seminal reactive oxygen species than those with lower grade varicocele. As varicocele grade increased, seminal reactive oxygen species increased and sperm concentration decreased. CONCLUSIONS: Although fertile men have more efficient defense mechanisms to protect against the consequences of varicocele on testicular function, these mechanisms may not be sufficient in those with varicocele grade 3. Further research is needed to clarify whether they are at increased risk for future infertility.

Organ-sparing microsurgical resection of incidental testicular tumors plus microdissection for sperm extraction and cryopreservation in azoospermic patients: surgical aspects and technical refinements.

INTRODUCTION: The management of nonpalpable testicular masses is a challenging task, and coexisting infertility can further complicate the treatment decisions. We present our technique for microsurgical organ-sparing resection of incidental nonpalpable testicular nodules combined with microdissection for testicular sperm extraction and tissue cryopreservation in azoospermic patients. TECHNICAL CONSIDERATIONS: Five infertile patients with azoospermia presented with nonpalpable hypoechoic testicular masses that were detected by ultrasonography and underwent organ-sparing surgery. The testis was delivered through an inguinal incision, and the blood circulation was interrupted with a vascular clamp placed on the spermatic cord. Sludged ice was used to prevent warm ischemia, and a temperature probe was used to control the temperature at 12 degrees-15 degrees C. Real-time reflex ultrasonography was used to locate the tumor, and a stereotaxic hook-shaped needle was inserted under ultrasound guidance. The needle was placed adjacent to the tumor to guide the microsurgical resection. The tunica albuginea was incised over the tumor, which was dissected and removed, along with the adjoining parenchymal tissue. Frozen section studies were performed and, if malignancy was confirmed, biopsies of the tumor cavity margins and remaining parenchyma were obtained to ensure the absence of residual tumor. Microdissection was performed for excision of selected enlarged tubules that were processed and cryopreserved. CONCLUSIONS: We present a technique for microsurgical organ-sparing resection of testicular tumor and sperm extraction that can be used in selected infertile patients with azoospermia in whom incidental masses have been diagnosed by ultrasonography. This conservative approach should be especially considered for patients with a solitary testis or bilateral tumors.

Use of subinguinal incision for microsurgical testicular biopsy during varicocelectomy in men with nonobstructive azoospermia.

OBJECTIVE: To describe a subinguinal technique of microsurgical testicular biopsy performed during subinguinal varicocelectomy in men with nonobstructive azoospermia. DESIGN: Prospective clinical study. SETTING: Andrology laboratory at tertiary care hospital. Male infertility section, department of urology, at tertiary care hospital. PATIENT(S): Ten azoospermic men with clinical varicocele. INTERVENTION(S): Subinguinal microsurgical testicular biopsy and microsurgical varicocele repair. MAIN OUTCOME MEASURE(S): Safety, feasibility, and effectiveness of subinguinal testicular biopsy during varicocele repair. RESULT(S): All testes were easily delivered through the subinguinal incision, and testicular biopsies were successfully performed under microscopic view. After a median follow-up of 9 months, none of the patients had any discomfort, pain, or presented with testicular atrophy. No intraoperative or postoperative complications were observed. There was no incidence of wound infection or scrotal hematoma. CONCLUSION(S): The subinguinal approach is a safe and effective option for testicular biopsy during varicocele repair in men with nonobstructive azoospermia. This technique may be an attractive alternative to traditional biopsy because it obviates scrotal violation.

Age-related increase of reactive oxygen species in neat semen in healthy fertile men.

OBJECTIVES: The effects of advancing paternal age on the male reproductive system are well known, but its effects on fecundity remain controversial. Although oxidative stress is associated with poor semen quality and function, a relationship with advancing male age has not been established. The objective of this study was to analyze the relationship between male age and seminal reactive oxygen species (ROS) levels in men presenting for voluntary sterilization. METHODS: We prospectively evaluated 98 fertile men who were candidates for vasectomy. These were divided into 2 age groups: less than 40 years (n = 78) and 40 or more years (n = 20). We used 46 infertile patients as positive controls. Standard semen analysis, seminal leukocyte count and ROS levels were measured in all samples. Fertile men with leukocytospermia were excluded. RESULTS: The mean age of the men was 35.1 +/- 5.6 years. Men 40 years and older had significantly higher ROS levels compared with younger men (P <0.001). We observed a positive correlation between seminal ROS levels and age (r = 0.20; P = 0.040). In addition, ROS was negatively correlated with sperm concentration (r = -0.48; P <0.001) and motility (r = -0.21; P = 0.030). CONCLUSIONS: Reactive oxygen species levels are significant higher in seminal ejaculates of healthy fertile men older than 40 years. ROS levels in whole ejaculate are significantly correlated to age among fertile men. Because ROS are clearly implicated in the pathogenesis of male infertility, these data suggest that delayed fatherhood may reduce the chances of pregnancy as men become progressively less fertile with age.

Impact of clinical varicocele and testis size on seminal reactive oxygen species levels in a fertile population: a prospective controlled study.

OBJECTIVE: To investigate: 1) the impact of clinical varicocele on reactive oxygen species (ROS) levels in neat and washed semen in a proven fertile population; and 2) the correlation between ROS levels, testicular volume, and varicocele grade in the same population of fertile men. DESIGN: Prospective controlled clinical study. SETTING: Andrology laboratory at tertiary-care hospital. PATIENT(S): One hundred fourteen healthy fertile men (81 normal fertile and 33 fertile with clinical varicocele) and 30 infertile patients (control subjects). INTERVENTION(S): Standard semen analysis and measurement of sperm ROS production. MAIN OUTCOME MEASURE(S): Seminal parameters, seminal ROS levels, seminal leukocyte levels, clinical varicocele, and testis size. RESULT(S): Thirty-three of the 114 (29%) fertile men had clinical varicocele (grade 1, n = 14; grade 2, n = 11; and grade 3, n = 8), and the remaining 81 (71%) had a normal physical examination. Levels of ROS and semen quality did not differ significantly between the fertile men with or without varicocele. No significant differences in ROS levels in neat and washed semen were observed compared with fertile men with grades 2 and 3 varicocele and with fertile men with varicocele grade 1. The ROS levels in neat and washed semen were not significantly correlated with varicocele grade in fertile men. No significant correlations between ROS levels and testis volume were observed between the fertile groups. CONCLUSION(S): The presence of clinical varicocele in fertile men is not associated with higher seminal ROS levels or abnormal semen parameters. Levels of ROS are not correlated with varicocele grade or testis volume in the same population of fertile men.

Clinical relevance of oxidative stress and sperm chromatin damage in male infertility: an evidence based analysis.

Oxidative stress (OS) in the reproductive tract is now a real entity and concern due to the potential harmful effects of high levels of reactive oxygen species (ROS) on sperm number, motility, quality, and function including damage to sperm nuclear DNA. Evaluation of OS related damage to non-functional sperm is highly relevant as intracytoplasmic sperm injection (ICSI) technique, an effective therapy for severe male factor infertility, bypasses the majority of reproductive tract deficiencies. Despite the controversial findings in the existing literature, there is now enough evidence to show that sperm DNA damage is detrimental to reproductive outcomes. In addition, spermatozoa of infertile men are suggested to carry more DNA damage than do the spermatozoa from fertile men. Besides impairment of fertility such damage is likely to increase the transmission of genetic diseases during the assisted reproductive procedures. Standardization of protocols to assess reactive oxygen species and DNA damage is very important in introducing these tests in such clinical practice. Thus evaluation of seminal ROS levels and extent of sperm DNA damage especially in an infertile male may help develop new therapeutic strategies and improve success of assisted reproductive techniques (ART).

Clinical relevance of oxidative stress and sperm chromatin damage in male infertility: an evidence based analysis

Oxidative stress (OS) in the reproductive tract is now a real entity and concern due to the potential harmful effects of high levels of reactive oxygen species (ROS) on sperm number, motility, quality, and function including damage to sperm nuclear DNA. Evaluation of OS related damage to non-functional sperm is highly relevant as intracytoplasmic sperm injection (ICSI) technique, an effective therapy for severe male factor infertility, bypasses the majority of reproductive tract deficiencies. Despite the controversial findings in the existing literature, there is now enough evidence to show that sperm DNA damage is detrimental to reproductive outcomes. In addition, spermatozoa of infertile men are suggested to carry more DNA damage than do the spermatozoa from fertile men. Besides impairment of fertility such damage is likely to increase the transmission of genetic diseases during the assisted reproductive procedures. Standardization of protocols to assess reactive oxygen species and DNA damage is very important in introducing these tests in such clinical practice. Thus evaluation of seminal ROS levels and extent of sperm DNA damage especially in an infertile male may help develop new therapeutic strategies and improve success of assisted reproductive techniques (ART).

Development of normal reference values for seminal reactive oxygen species and their correlation with leukocytes and semen parameters in a fertile population.

Although reactive oxygen species (ROSs) are clearly implicated in the pathogenesis of male infertility, few studies have attempted to define the basal levels of ROSs in fertile men. Levels of ROSs are highly influenced by the presence of leukocytes and are associated with decreased seminal parameters. The objective of our study was to determine the normal ROS reference values in neat and washed semen of a fertile population and to correlate the leukocyte concentrations with seminal parameters. We evaluated 114 fertile men seeking vasectomy and 47 subfertile patients as a positive control. All samples were subjected to semen analysis and Endtz testing; chemiluminescence assay was used to determine ROS levels. All seminal parameters were significantly higher in the fertile men than in the subfertile patients. In nonleukocytospermic samples, ROS levels were lower in the fertile men than in the subfertile patients in neat (0.29 [0.18, 0.54] vs 0.94 [0.38, 1.51]) (P = .001) and washed semen (5.73 [1.90, 14.71] vs 23.4 [9.46, 115.55]) (P = .001). Similarly, in samples with leukocytes (Entdz, less than 1 x 10(6)/mL), ROS levels were lower in the fertile men in neat (0.75 [0.27, 1.71] vs 2.0 [0.97, 27.41]) (P = .001) and washed semen (15.85 [4.18, 62.16] vs 239.83 [33.4, 1193.75]) (P < .0001). As expected, samples with leukocytes had significantly higher ROS values in washed and neat semen. In the fertile population, ROSs were positively correlated with leukocytes and negatively correlated with sperm count and motility. In semen samples without leukocytes, the normality cutoff of ROSs was 0.55 x 10(4) counted photons per minute with 76.4% area under the curve (AUC) in the neat samples and 10.0 x 10(4) counted photons per minute with 77% AUC in the washed samples. In semen samples with leukocytes, the cutoff for ROSs in neat samples was 1.25 with 72.7% AUC and 51.5 with 81% AUC in the washed samples. We defined the cutoff levels of ROSs in a fertile population. Seminal leukocyte levels below 1 x 10(6)/mL were associated with increased ROSs. ROS levels were positively correlated with leukocytes and negatively correlated with sperm motility and concentration. Patients with normal seminal parameters and lower seminal leukocyte levels may benefit from therapeutic interventions that improve semen quality.