Предикторы восстановления репродуктивной функции у субфертильных мужчин после варикоцелэктомии

Abstract

INTRODUCTION Varicocelectomy does not always lead to semen improvement and male fertility recovery. OBJECTIVES Analysis of total progressive motile sperm count (TPMSC) predictive role in fertility recovery of subfertile man after varicocelectomy in combination with other predictors. MATERIALS AND METHODS This prospective, open, multi-center study comprises 93 men from infertile couples with clinical varicocele who underwent microsurgical (inguinal or subinguinal) varicocelectomy. The changes in the standard semen analysis studied according to WHO 2010 Standards. We also evaluated spontaneous pregnancy rates. A discriminant analysis was carried out with step-by-step selection to identify reliable predictors of pregnancy after varicocelectomy. An increase in TPMSC by at least 12.5 million was considered as a good effect of varicocele repair (reference values for the number and progressive sperm motility according to WHO 2010: 39 million x 0.32 (32%) progressively motile). Patients were divided into 3 groups in regards of direction and degree of semen changes: group I included 48 patients with increase of TPMSC more or equal 12.5 million, group II comprised 20 patients with mild increase in TPMSC (0.1 - 12.5 million) and the III group comprised patients without any effect (TPMSC did not change, or became less than preoperative one) after varicocelectomy. The initial clinical characteristics of patients in the groups were compared. RESULTS A significant effect was observed in 52% of cases (n=48), a mild favorable effect in 21% (n=20), and no effect in 27% (n=25). Spontaneous pregnancy rates (in 1 year after varicocele repair) were higher in patients of group I than that of groups II and III: 46%, 10% and 12%, respectively (p 0.05). In group I, the initial semen analysis parameters were significantly better than in group II and worse than in group III: the median and 25% -75% of the quartiles for TPMSC were 15 (1-44), 0 (0-8) and 54 (19-100) million, respectively (for all p<0.001). According to discriminant analysis significant predictors of pregnancy after varicocelectomy were an increase of TPMSC, male age and the initial total sperm motility. The predictive accuracy of the prognostic model with these three predictors was 84%, specificity was 87%, and sensitivity was 76%. CONCLUSIONS The odds of fertility recovery after varicocelectomy has a U-shaped relationship: it is higher in patients with moderate semen quality impairment and it decreases in patients with initially low, and, conversely, high sperm count and motility. An increase in TPMSC by 12.5 million or more is a highly significant indicator of fertility recovery, because in this case the odds of spontaneous pregnancy can reach 50%. Predictors of fertility recovery after varicocelectomy are an increase of TPMSC, male age and the preoperative total motility.