Clinical Varicocele Research Articles

The effects of varicocelectomy on the patients with premature ejaculation.

Background:Premature ejaculation is one of the most problems in clinical practice. The association between varicocele and premature ejaculation was poorly understood. The effects of varicocelectomy on premature ejaculation in varicocele patient was studied.Objectives:The aim of this study was to determine the impacts of varicocelectomy on patients with both premature ejaculation and varicoceles.Patients and Methods:This was a clinical trial study, conducted on 124 patients (20-35 years old), with varicoceles and premature ejaculation (PE), since March 2011 to April 2013. Inguinal and sub inguinal varicocelectomy were performed for them. All patients had both impairment of spermiogram and PE. These patients were followed up for about 2 years and evaluated for PE, in addition to parameters of spermiogram, before and after the surgery.Results:A total number of 124 patients with varicoceles and PE were enrolled into the study. Following the surgery 46 patients (37%) were fully treated (P < 0.001), 78 patients (63%) had improvements in PE symptoms changed to early ejaculation (P < 0.05) and 89 patients (72%) had improved parameters of spermiogram (P < 0.002).Conclusions:In a significant number of patients who had clinical varicocele and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE and spermiogram parameters.

Children and adults varicocele: diagnostic issues and therapeutical strategies.

Varicocele is defined as abnormally dilated scrotal veins. It is present in 15% of normal males and in 40% of males with infertility. This disorder is a challenge for the physicians involved in the diagnosis and treatment, as the pathophysiology of varicocele is not yet completely understood. For this reason, accurate diagnostic criteria and clear indications for treatment in asymptomatic adolescents or adults with clinical or subclinical varicocele are still not defined. Ultrasonography (US) is considered the best method for calculating the volume of the testicles, measuring vein diameter and monitoring the growth of the testis in adolescent patients. Color-Doppler US is the method of choice for detecting spermatic vein reflux and for classifying the grade of varicocele. Various classification systems have been published with recommendations on how to perform US imaging of the scrotum. Currently, color-Doppler US and spectral analysis are the most effective, non-invasive diagnostic procedures as they allow detection of subclinical varicocele associated with infertility. Various techniques are used in the treatment of varicocele including open surgery, laparoscopic procedures and interventional radiology. However, there is no consensus among physicians on which technique is the most effective in terms of outcome and complication rates. This review shows that color-Doppler US is currently the most widely employed diagnostic method for detection and classification of varicocele caused by venous reflux, as it is reliable and easily performed. The review also highlights the role of varicocelectomy in the management of adult male infertility.

PD24-02 IS VARICOCELECTOMY BENEFICIAL IN MEN PREVIOUSLY DEEMED SUBFERTILE BUT WITH NORMAL SEMEN PARAMETERS BASED ON THE NEW GUIDELINES? A RETROSPECTIVE STUDY

You have accessJournal of UrologyInfertility: Therapy1 Apr 2014PD24-02 IS VARICOCELECTOMY BENEFICIAL IN MEN PREVIOUSLY DEEMED SUBFERTILE BUT WITH NORMAL SEMEN PARAMETERS BASED ON THE NEW GUIDELINES? A RETROSPECTIVE STUDY Patrick Mcgarry, Khalid Alrabeeah, Keith Jarvi, and Armand Zini Patrick McgarryPatrick Mcgarry More articles by this author , Khalid AlrabeeahKhalid Alrabeeah More articles by this author , Keith JarviKeith Jarvi More articles by this author , and Armand ZiniArmand Zini More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1993AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In 2010, the World Health Organization (WHO) released new reference values for semen parameters that are significantly lower than previously reported editions. Given this change in lower limits, some men that were considered abnormal (with semen parameters below the reference values) are now be considered normal. The aim of this study is to determine whether surgical treatment of clinical varicocele for infertility based on previous WHO reference values had benefit and whether using the new reference values will result in missed treatable causes of infertility. METHODS We conducted a retrospective review of infertile men with clinical varicocele and abnormal semen parameters by WHO 1999 standards. Patients that were abnormal by WHO 1999 standards but normal by WHO 2010 standards were identified. Of these patients, those undergoing surgery for varicocele and those opting to not undergo surgery were compared for changes in conventional semen parameters and ability to achieve spontaneous pregnancy. RESULTS A total of 445 infertile men presented with clinical varicocele and abnormal semen parameters by 1999 standards. Of these, 13% (56/445) would be now considered normal by WHO 2010 standards. 57% (32/56) of the patients now considered normal by WHO 2010 standards elected to undergo microsurgical varicocelectomy and 43% (24/55) elected not to undergo surgery. In the surgery group, postoperative sperm concentration increased significantly compared to before surgical repair (50 +/- 35 x 106/ml vs. 32 +/- 23 x 106/ml, p=0.003). However, there was no significant change in sperm parameters between the two semen samples (taken at 3-month interval) in the non-surgery group. The spontaneous pregnancy rate was higher in the surgery compared to the non-surgery group (52% vs. 38%, respectively) but the difference was not statistically significant. CONCLUSIONS The data indicate that varicocelectomy may be beneficial in the subset of men with clinical varicocele and semen parameters deemed abnormal by WHO 1999 standards but now considered normal based on the new WHO semen reference values. As such, applying the new WHO semen reference values into clinical practice may result in missed opportunities to correct potentially treatable causes of male infertility. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e731 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Patrick Mcgarry More articles by this author Khalid Alrabeeah More articles by this author Keith Jarvi More articles by this author Armand Zini More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP12-20 EFFICACY OF VALSALVA MANEUVER AND STANDING POSITION DURING SCROTAL DOPPLER ULTRASONOGRAPHY OF VARICOCELE PATIENTS

You have accessJournal of UrologyImaging/Radiology III1 Apr 2014MP12-20 EFFICACY OF VALSALVA MANEUVER AND STANDING POSITION DURING SCROTAL DOPPLER ULTRASONOGRAPHY OF VARICOCELE PATIENTS Soon Ki Kim, Yoo Seok Kim, Sung bin Kim, In-Chang Cho, and Seung Ki Min Soon Ki KimSoon Ki Kim More articles by this author , Yoo Seok KimYoo Seok Kim More articles by this author , Sung bin KimSung bin Kim More articles by this author , In-Chang ChoIn-Chang Cho More articles by this author , and Seung Ki MinSeung Ki Min More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.455AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ultrasonography is the most practical and most accurate noninvasive technique, but does not always show reflux into the spermatic veins or pampiniform plexus in resting and supine position. We investigated effectiveness of Valsalva maneuver and standing position on color Doppler ultrasound for the varicocele diagnosis and devised a new index that can improve existing diagnostic criteria. METHODS A total of 54 men (36 with clinical varicocele and 18 without clinical varicocele) who visited this hospital from January 1, 2011 until April 31, 2013 were investigated by physical examination and color Doppler ultrasound. The mean age of patient group was 21.4 years and that of control group was 21.5 years. Diameters of the largest vein in the pampiniform plexus were measured bilaterally during resting and Valsalva maneuver in the supine position followed by same examination with the subjects standing. We calculated the ratio of mean of maximal vein diameter (mMVD) during resting and Valsalva maneuver (resting-Valsalva ratio) and compared in the both position. RESULTS In patient group, 4 patients were at grade I (11%), 15 patients grade II (42%), and 17 patients grade III (47%) on physical examination. In the resting and supine position, mMVDs were 1.8mm, 2.0mm, 2.5mm (grade I, II, III, respectively) and 1.3mm (control group). Compared with control group, only grade III varicoceles showed a significant difference (P<0.05). During Valsalva maneuver in the supine position, mMVDs were 3.0mm, 3.4mm, 4.2mm (grade I, II, III, respectively) and 1.8mm (control group), and in all cases P-value was below 0.05. Average of resting-Valsalva ratio in the supine position were 0.69, 0.74, 0.74 (grade I, II, III, respectively) and 0.44 (control group), and there were no significant difference between patient and control group (p>0.05). Whereas in the resting and standing position, mMVD were 2.8mm, 3.3mm, 3.8mm (grade I, II, III, respectively) and 1.8mm (control group) (p<0.05). During Valsalva maneuver in the standing position, mMVD were 5.0mm, 5.8mm, 6.6mm (grade I, II, III, respectively) and 2.5mm (control group). And average resting-Valsalva ratio were 0.76, 0.90, 0.71 (grade I, II, III, respectively) and 0.26 (control group), which showed significant difference from all grades (p<0.05). CONCLUSIONS It is suggested that the standing position and Valsalva maneuver during scrotal Doppler ultrasonography could improve diagnostic ability for varicocele. Resting-Valsalva ratio could be a new diagnostic index for varicocele diagnosis using scrotal Doppler sonography. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e113 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Soon Ki Kim More articles by this author Yoo Seok Kim More articles by this author Sung bin Kim More articles by this author In-Chang Cho More articles by this author Seung Ki Min More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of varicocelectomy on premature ejaculation in varicocele patients

In a prospective manner, we studied the effect of varicocelectomy on premature ejaculation and testicular hormonal function in patients with varicocele. Microsurgical subinguinal varicocelectomy was carried out in 73 patients with clinical varicocele associated with premature ejaculation (group 1) and compared with 56 patients without operative intervention (group 2; control). The primary efficacy variable was the mean change in the Premature Ejaculation Diagnostic Tool. The changes in International Index of Erectile Function questionnaire, total serum testosterone and testicular size were also assessed. In group 1, the Premature Ejaculation Diagnostic Tool decreased significantly after varicocelectomy, from 15.56 to 11.37 (P<0.001), indicating improvement of premature ejaculation. Thirty patients (41.1%) showed improvement of premature ejaculation compared to 5.3% in the control group (P<0.001). In group I, but not in group II, testosterone levels and International Index of Erectile Function values increased significantly when compared with pre-operative values (P<0.001 and 0.040 respectively). Testicular size increased after varicocelectomy, but this increase was nonsignificant till the end of study (P=0.054). We concluded that varicocelectomy is clearly related to improvement of premature ejaculation and testicular hormonal function in varicocele patients.

Sperm Protamine mRNA Ratio and DNA Fragmentation Index Represent Reliable Clinical Biomarkers for Men with Varicocele after Microsurgical Varicocele Ligation

We investigated whether the sperm protamine-1/2 mRNA ratio and DNA fragmentation index are reliable biomarkers in patients with clinical varicocele. We performed a prospective study in 42 subfertile patients with left clinical varicocele and 10 normozoospermic healthy donors with proven fertility. All patients and female partners were seen 3 and 6 months after varicocelectomy for fertility examination. Real-time quantitative reverse transcriptase-polymerase chain reaction and SCSA® were performed to analyze the sperm protamine-1/2 mRNA ratio and DNA fragmentation index. The protamine-1/2 mRNA ratio and DNA fragmentation index were significantly higher in the preoperative group than in the control group (p <0.01). After varicocelectomy in the pregnant group the protamine-1/2 mRNA ratio recovered to the normal value and the DNA fragmentation index was significantly lower than in the preoperative group (p <0.01). In the nonpregnant group the protamine-1/2 mRNA ratio and DNA fragmentation index did not differ (p >0.05). However, significant differences were present preoperatively according to varicocele severity in the protamine-1/2 mRNA ratio and DNA fragmentation index (p <0.05 and <0.01, respectively) with the highest values in the grade 3 group. Nevertheless, postoperatively no difference in varicocele severity was noted (p >0.05). The protamine-1/2 mRNA ratio was strongly related to preoperative and postoperative sperm concentration (Rs -0.238, p <0.01), progressive motility (Rs -0.327, p <0.01), total motility (Rs -0.206, p <0.05) and DNA fragmentation index (Rs 0.293, p <0.01) except for normal morphology (Rs -0.064, p >0.05). The sperm protamine-1/2 mRNA ratio and DNA fragmentation index can effectively be used to evaluate male fertility. Male infertility due to varicocele may be associated with protamine deficiency and sperm DNA damage. The post-varicocelectomy protamine-1/2 mRNA ratio and DNA fragmentation index are associated with the post-varicocelectomy pregnancy rate.

Effect of varicocelectomy on male infertility.

Varicocele is the most common cause of male infertility and is generally correctable or at least improvable by various surgical and radiologic techniques. Therefore, it seems simple and reasonable that varicocele should be treated in infertile men with varicocele. However, the role of varicocele repair for the treatment of subfertile men has been questioned during the past decades. Although varicocele repair can induce improvement of semen quality, the obvious benefit of spontaneous pregnancy has not been shown through several meta-analyses. Recently, a well-designed randomized clinical trial was introduced, and, subsequently, a novel meta-analysis was published. The results of these studies advocate that varicocele repair be regarded as a standard treatment modality in infertile men with clinical varicocele and abnormal semen parameters, which is also supported by current clinical guidelines. Microsurgical varicocelectomy has been regarded as the gold standard compared to other surgical techniques and radiological management in terms of the recurrence rate and the pregnancy rate. However, none of the methods has been proven through well-designed clinical trials to be superior to the others in the ability to improve fertility. Accordingly, high-quality data from well-designed studies are needed to resolve unanswered questions and update current knowledge. Upcoming trials should be designed to define the best technique and also to define how to select the best candidates who will benefit from varicocele repair.

Varicocele: How this condition and its management affects men's health

Varicocele is a relatively common condition that can impact men’s health in various ways. Unfortunately, its prevalence and the availability of various different methods of repairing it might lead to unnecessary treatment. An understanding of the various ways that this condition can impact men’s health is necessary in order to manage it appropriately. At present, there is substantial evidence to support varicocele repair in men who present with infertility, abnormal semen parameters, clinical varicocele and a female partner with normal fertility (or one with a potentially correctable abnormality). Varicocele repair appears to improve seminal fluid quality and might improve pregnancy rates. It might also have a role in managing men with non-obstructive azoospermia. Varicocele can also be a cause of scrotal pain that is usually of a dull character. Varicocele repair is an effective method of managing this type of pain, especially once proper measures have been taken to exclude other possible causes of orchalgia. Conservative measures are generally not effective in managing varicocele-related scrotal pain. There is growing evidence to suggest that varicocele repair might have a role in improving the serum testosterone level in men with hypogonadism, especially in the subfertile population. Well-designed prospective studies are needed to support the utilization of varicocele repair in managing these patients, as well as in preventing testicular dysfunction on a prophylactic basis.

Microscopic varicocelectomy significantly decreases the sperm DNA fragmentation index in patients with infertility.

Background. Varicocele is associated with high levels of DNA damage in spermatozoa due to oxidative stress and elevated levels of sperm DNA fragmentation, which has been currently proposed to be an essential additional diagnostic test to be recommended for patients with clinical varicocele. The aim of this study was to evaluate the parameters of semen and the DNA fragmentation index (DFI) in patients with varicocele before and after varicocelectomy. Methods. The details of 92 consecutive patients were retrospectively analyzed from January 2010 to December 2012. The sperm samples were evaluated according to the World Health Organization Guidelines. Sperm DNA damage, characterized as DFI, was evaluated by sperm chromatin structure assay using flow cytometry. Results. There was a statistically significant improvement in the semen concentration, the total motile count, the total normal sperm count, and the sperm DNA fragmentation index (DFI; the percentage of sperm with denatured DNA) after varicocelectomy. There was a large decrease in DFI from a preoperative mean of 42.6% to a postoperative mean of 20.5% (P < 0.001). A higher preoperative DFI was associated with a larger decrease in postoperative DFI, and significant negative correlations were observed between the DFI and sperm motility (r = −0.42, P < 0.01). Conclusion. Our data suggest that varicocelectomy can improve multiple semen parameters and sperm DNA damage in infertile men with varicocele. The patients with preoperative defects in those parameters showed greater improvement postoperatively. Further research in this area is needed to understand the exact mechanisms of DNA damage in infertile men with varicocele.

Determination of the best position and site for color Doppler ultrasonographic evaluation of the testicular vein to define the clinical grades of varicocele ultrasonographically

Background:There are no generally accepted criteria for the ultrasonographic diagnosis and grading of varicocele. We aimed to determine the best position and site for color Doppler ultrasonographic (CDUS) evaluation of the testicular vein to define the clinical grades of varicocele ultrasonographically.Materials and Methods:This study consisted of 103 men (44 normal and 59 with clinical varicocele). First, WHO clinical grade of varicocele was determined by physical examination. Then, the diameter of largest testicular vein at four different sites was measured in both upright and supine positions with or without Valsalva maneuver. Finally, the cut-off points of venous diameter for different clinical grades were determined using the values of the position and sites that had the strongest correlation with the clinical grades.Results:The strongest correlation between venous diameter and clinical grade of varicocele was observed when the venous diameter was measured at the level of epididymal head in the upright position with Valsalva maneuver (r: 0.87, P-value < 0.0001). In aforementioned conditions, venous diameter of 2.35 mm (sensitivity 87%, specificity 87%) can distinguish normal subjects from grade 1 varicocele, venous diameter of 3.15 mm (sensitivity 58%, specificity 70%) can discriminate grade 1 from grade 2, and venous diameter of 3.75 mm (sensitivity 83%, specificity 70%) can differentiate grade 2 from grade 3. Furthermore, venous diameter of 2.65 mm (sensitivity 91%, specificity 89%) can distinguish normal subjects from patients with clinical varicocele.Conclusion:The best position for CDUS examination of patients suspected of having varicocele is the upright position with Valsalva maneuver, and the best site for venous diameter measurement is at the level of epididymal head.

Testicular Biopsy Histopathology as an Indicator of Successful Restoration of Spermatogenesis after Varicocelectomy in Non-obstructive Azoospermia.

PurposeWe aimed to evaluate the efficacy of using testicular biopsy histopathology as an indicator of the success of loupe-assisted subinguinal varicocelectomy in non-obstructive azoospermia (NOA) patients.Materials and MethodsIn a 2-year period, a prospective study was carried at Minoufiya University Hospital on 20 NOA patients with clinical bilateral varicoceles. These patients underwent loupe-assisted subinguinal varicocelectomy with simultaneous testicular biopsy. All patients were evaluated by determining their hormonal profile and performing semen analyses and scrotal Doppler and transrectal ultrasonography. Two semen analyses showing azoospermia were performed before the surgery and two semen analyses were received at 3 and 6 months post-operatively for follow-up.ResultsThe mean age was 29.9±6.7 years, and the mean follow-up duration was 17.3±8.3 months. We noted the restoration of spermatogenesis in six men (30% of all patients). Testicular biopsy results were as follows: hypospermatogenesis in 7 patients, maturation arrest in 3, and Sertoli cell-only syndrome in 10. The improvement in the sperm counts of these patients ranged from 3 million to 15 million/mL. Sperms were recovered in the hypospermatogenesis (6 patients, 85.5%) patients only, but other patients with testicular biopsy results of Sertoli cell-only or maturation arrest did not show any improvement in their semen parameters.ConclusionsTesticular biopsy results showed that hypospermatogenesis patients have a better chance of improvement in their semen analysis after varicocelectomy in contrast to NOA patients with Sertoli cell-only syndrome or maturation arrest.

Painful varicoceles: Role of varicocelectomy.

The incidence of varicocele in the general population is up to 15%. It is estimated that the prevalence of pain with varicoceles is around 2-10%. Till the year 2000, only two studies evaluated efficacy of varicocelectomy in painful varicoceles with conflicting results. Over the past decade many other studies have addressed this issue and reported on the treatment outcome and predictors of success. We critically appraised studies published from March 2000 to May 2013 evaluating surgical management in painful varicoceles to provide an evidence based review of effectiveness of varicocelectomy in relieving pain in patients with symptomatic painful varicoceles. The association between varicoceles and pain is not clearly established. Conservative treatment is warranted as the first line of treatment in men with painful clinical varicoceles. In carefully selected men with clinically palpable varicoceles and associated characteristic chronic dull ache, dragging or throbbing pain who do not respond to conservative therapy, varicocelectomy is warranted and is associated with approximately 80% success. However, surgical success does not always translate into resolution of pain and pain might persist even when no varicoceles are detected postoperatively.

Varicocèle et infertilité : où en sommes-nous en 2013 ?

While the incidence of clinical varicocele is common in infertile men (about 40%), the reasons why varicocele may affect sperm parameters is still unclear. In addition, the improvement of fertility after treatment of varicocele is also a subject of debate. The purpose of this review is to get new insight into the physiopathology of varicocele, its impact on sperm parameters and the effectiveness of varicocele treatment on fertility. Treatment is likely to be effective in infertile men with clinical varicocele and impaired spermatogenesis. Even if it does not systematically lead to an improvement in sperm parameters, it may prevent further sperm degradation. In case of non-obstructive azoospermia, few studies reported a slight improvement in the process of spermatogenesis. The critical role of an adequate methodology in order to establish clinical guidelines needs to be stressed. Indeed, the huge intra-individual variability in sperm production makes the usual analysis of sperm parameters inadequate to measure treatment effectiveness. Regarding the assessment of conception, it requires not only well designed and properly sized studies but also a multivariate analysis for weighing predictive factors of success. Thus, an active scientific research is needed to better identify pathogenic agents and appropriately assess the impact of varicocele treatment.

The Effect of Varicocelectomy on Sperm Parameters in Subfertile Men with Clinical Varicoceles Who Have Asthenozoospermia or Teratozoospermia with Normal Sperm Density

Background. To compare preoperative and postoperative sperm parameters such as sperm count, motility, and morphology in patients with normal sperm concentration with teratozoospermia and asthenozoospermia. Materials and Methods. Hundred and six patients with varicocele associated with male infertility over a 5-year period were included into the study. Pre- and postvaricocelectomy seminal fluid parameters evaluation according to the World Health Organization (WHO) criteria was performed at 4–6-month intervals. Results. One hundred and six patients met the criteria. The mean age of patients was 24.53 ± 8.13. The mean duration of infertility was 3.6 years (range: 1.5–6.3). Only the sperm motility of patients with normospermia showed a significant improvement postoperatively. Conclusions. No significant improvement in sperm morphology may be obtained in patients with clinical varicocele and preoperative normospermia.

The use of titanium ligation clips in microsurgical subinguinal varicocelectomy.

The aim of this study is to evaluate the use of titanium ligation clips for dilated spermatic veins in microsurgical subinguinal varicocelectomy. In this retrospective study, eighty-four men with clinical varicocele underwent microsurgical varicocele repair. The patients were divided into two groups according to the ligation materials used for the varicocelectomy (silk sutures vs. titanium clips). Group 1 included 43 patients; these patients underwent microsurgical subinguinal varicocelectomy with the titanium clips. The 41 patients included in Group 2 underwent microsurgical subinguinal varicocelectomy with silk sutures. Microsurgical subinguinal varicocelectomy was performed in all patients. The two study groups were compared in terms of intra-operative and postoperative parameters. The mean age of the patients was 28.6±4.6 years, and the mean follow-up was 12.3±2.7 months. The two groups exhibited comparable improvements in sperm motility and/or concentration: 79.1% and 82.9% in Group 1 and Group 2, respectively (p>0.05). The operation time in Group 1 (titanium clip) was significantly shorter than in Group 2 (silk sutures). None of the patients experienced any intra-operative complications. There were no significant differences between Group 1 and Group 2 with regard to postoperative recurrences, ligated veins, postoperative complications and hydrocele formation, hospitalization time, the requirement for postoperative analgesia or the time until the patient could return to work. Titanium ligation clips can be used for the ligation of dilated vessels during microsurgical subinguinal varicocelectomy, and the operation time is significantly reduced with the use of titanium ligation clips.

Clinical and Subclinical Varicocele Incidence in Patients With Primary Varicose Veins Requiring Surgery

The purpose of this study was to analyze the incidence of clinical and subclinical varicocele in patients with primary varicose veins requiring surgery. A total of 100 patients with primary varicose veins requiring surgery were evaluated. Clinical varicocele was found in each patient through physical examination. Each patient was also evaluated with ultrasound because of evidence of subclinical varicocele. Among the patients with varicose veins, 28 had no clinical sign of varicocele, whereas the remaining 72 had varicocele with different clinical levels (72%). Doppler ultrasound revealed that 32 patients had no reflux flow, whereas the other 68 had different grades of reflux flow (68%). Clinical or subclinical varicocele may be highly present in patients with severe venous disease. However, these types of varicoceles do not cause infertility in most patients. Nevertheless, infertility may occur in subsequent years, especially in young patients who have venous disease and undergo surgery, and they should be aware of this condition.

Relationship Between Testicular Sperm Extraction and Varicocelectomy in Patients With Varicocele and Nonobstructive Azoospermia

To evaluate the effect of varicocelectomy on sperm retrieval at testicular sperm extraction (TESE) and at spermiograms in patients with nonobstructive azoospermia. An observational study was conducted from April 2008 to December 2011. The study included men with a clinical diagnosis of nonobstructive azoospermia with a history of clinical unilateral varicocele (only grade III). After providing consent, the patients were treated with 2 different strategies according to the timing of varicocelectomy: group 1, varicocelectomy before microsurgical TESE (3 months); and group 2, varicocelectomy during microsurgical TESE. At 6 months after varicocelectomy, we evaluated the semen analysis findings for all patients. All patients underwent subinguinal microsurgical varicocelectomy. We also evaluated the percentage of sperm retrieval during TESE. During the study period, 35 patients were enrolled. Group 1 included 19 patients and group 2, 16 patients. The sperm retrieval rate during the spermiograms was significantly greater in group 1 (57.8%) than in group 2 (37.5%). The percentage of sperm retrieval during TESE between the 2 groups was significantly greater in group 1 (57.8%) than in group 2 (27%; P<.05). Our results have suggested that varicocele repair significantly increases the sperm retrieval rate in patients with clinical varicocele and nonobstructive azoospermia at both TESE and spermiogram.

The study of spermatic DNA fragmentation and sperm motility in infertile subjects

Although the pathophysiology of the testicular damage associated with varicocele remains unclear, sperm DNA damage has been identified as a potential explanation for this cause of male infertility. The current study was designed to determine the extent of sperm nuclear DNA damage in patients with varicocele, and to examine its relationship with parameters of seminal motility. Semen samples from 60 patients with clinical varicocele and 90 infertile men without varicocele were examined. Varicocele sperm samples were classified as normal or pathological according to the 1999 World Health Organizzation guidelines. Sperm DNA damage was evalutated using the Halosperm kit, an improved Sperm Chromatin Dispersion (SCD) test. The DNA fragmentation index (DFI: percentage of sperm with denatured nuclei) values was significantly higher in patients with varicocele, either with normal or abnormal (DFI 25.8 ± 3.2 vs 17.4 ± 2.8 - P < 0,01) semen profiles. In addition, an inverse correlation was found between spermatic motility and the degree of spermatic DNA fragmentation in patients with clinical varicocele. Varicocele is associated with high levels of DNA-damage in spermatozoa. In addition, in subjects with varicocele, abnormal spermatozoa motility is associated with higher levels of sperm DNA fragmentation. DNA fragmentation may therefore be an essential additional diagnostic test that should be recommended for patients with clinical varicocele.

Varicocele surgery or embolization: Which is better?

: Varicocele remains the most commonly identified correctable cause of male factor infertility. Surgical correction is the most commonly performed technique to treat varicoceles with a technical failure rate of less than 5%. An attractive alternative to surgery is the selective catheterization and embolization of the gonadal vein. This data are limited by small series. : We reviewed a total of 158 patients. These patients underwent embolization for clinical varicoceles and male factor infertility between 2004 and 2008. Of these, 56% underwent attempted bilateral embolization, 43% unilateral left-sided embolization and 1.3% unilateral right-sided embolization. : Of these patients who underwent attempted bilateral embolization, 19.3% did not experience a successful obliteration of the right gonadal vein and 2.3% (2/88) experienced a failure rate in the embolization of the left gonadal vein. Of the 2 attempts at unilateral right-sided embolization, there were no failures. Of the 68 unilateral left-sided embolization attempts, there was a 4.4% failure rate. Of all of the right-sided embolization attempts, 18.9% failed, while 3.2% of the left-sided attempts failed. : This review represents the largest contemporary series of varicocele embolization outcomes currently in the literature. Our 19.3% technical failure rate for bilateral varicocele embolization is higher than the current published rate of 13% and is largely related to failure to successfully occlude the right gonadal vein. This supports our belief that bilateral varicoceles are best managed with a primary microsurgical approach, where technical failure rates are expected to be less than 5% based on published data. Men with unilateral left-sided varicoceles should be offered both options as they have similar failure rates, but with embolization offering some clear advantages to the patient.

Varicocele surgery or embolization: Which is better?

Introduction: Varicocele remains the most commonly identifiedcorrectable cause of male factor infertility. Surgical correction isthe most commonly performed technique to treat varicoceles with a technical failure rate of less than 5%. An attractive alternative to surgery is the selective catheterization and embolization of the gonadal vein. This data are limited by small series.Methods: We reviewed a total of 158 patients. These patientsunderwent embolization for clinical varicoceles and male factorinfertility between 2004 and 2008. Of these, 56% underwentattempted bilateral embolization, 43% unilateral left-sided embolization and 1.3% unilateral right-sided embolization.Results: Of these patients who underwent attempted bilateralembolization, 19.3% did not experience a successful obliterationof the right gonadal vein and 2.3% (2/88) experienced a failure rate in the embolization of the left gonadal vein. Of the 2 attempts at unilateral right-sided embolization, there were no failures. Of the 68 unilateral left-sided embolization attempts, there was a 4.4% failure rate. Of all of the right-sided embolization attempts, 18.9% failed, while 3.2% of the left-sided attempts failed.Conclusion: This review represents the largest contemporary series of varicocele embolization outcomes currently in the literature. Our 19.3% technical failure rate for bilateral varicocele embolization is higher than the current published rate of 13% and is largely related to failure to successfully occlude the right gonadal vein. This supports our belief that bilateral varicoceles are best managed with a primary microsurgical approach, where technical failure rates are expected to be less than 5% based on published data. Men withunilateral left-sided varicoceles should be offered both options as they have similar failure rates, but with embolization offering some clear advantages to the patient.