Embolization Of Internal Spermatic Vein Research Articles

Embolization of left spermatic vein in non-obstructive azoospermic men with varicocele: role of FSH to predict the appearance of ejaculated spermatozoa after treatment.

Varicocele repair in non-obstructive azoospermia (NOA) was occasionally associated to ejaculated spermatozoa independently from clinical and laboratory measures. We performed a prospective study in infertile men affected by NOA and left side varicocele to find whether or not the appearance of ejaculated spermatozoa after varicocele repair is predicted by baseline measures. Patients with NOA and grade II, or grade III left side varicocele were submitted to hormone analysis and to scrotal color Doppler ultrasound (CDU). Azoospermia was confirmed in 23 patients aged 25-47 years who were than submitted to varicocele repair through a retrograde internal spermatic vein embolization. Patients were re-evaluated after 6 months. Six months after varicocele repair 12 patients (52.2 %) were still azoospermic (Group 1) while 11 patients (47.8 %) reported ejaculated spermatozoa (Group 2) [sperm count: 1.3 × 10(6)/mL; 0.5 × 10(6)/mL-1.6 × 10(6)/mL (median 25th-75th centiles)]. Serum baseline FSH was lower in Group 2 compared to Group 1 (p = 0.012), while no differences between groups were revealed for all other clinical and laboratory parameters. ROC analysis indicated that baseline FSH level predicted the appearance of ejaculated spermatozoa after treatment [AUC = 0.811; 95 % Confidence Interval (CI) 0.6-0.9; p = 0.0029]. A cut-off level of FSH <10.06 mIU/mL identified 82.0 % of cases with ejaculated spermatozoa with a specificity of 81.8 % and a sensitivity of 83.3 %. Selected patients with NOA may show ejaculated spermatozoa after a non-invasive repair of a left side varicocele, therefore avoiding testicular sperm extraction. Baseline serum FSH was a valuable predictor for ejaculated spermatozoa after treatment.

Technical aspects of embolization of internal spermatic vein in varicocele treatment

Varicocele is one of the most common causes of infertility in men. A large number of varicocele patients are asymptomatic and discovered after examination by physician because of infertility. This paper reviews the most recent data available on the management of varicocele. It will discuss the advantages and limitations associated with each treatment modality for varicocele. The most common therapeutic methods are surgical ligation and embolization of internal spermatic veins. Embolization of internal spermatic veins is a minimally invasive procedure, performed on outpatient basis, under local anesthesia, the recovery period of patients is short, and the risk of complications is minimal. The use of embolization can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and increase fertility.

Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction

Varicocele repair is indicated for infertile men with clinical varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from varicocelectomy.

Varicocele Repair in Patients With Nonobstructive Azoospermia: A Meta-Analysis

Multiple small case series have reported sperm in the ejaculate and spontaneous pregnancies in patients with nonobstructive azoospermia after varicocele repair. We hypothesized that men with favorable testicular histopathology on testis biopsy such as maturation arrest or hypospermatogenesis would have a higher probability of success than those with more ablative pathology, eg Sertoli-cell-only. A review of the literature on varicocele repair in patients with nonobstructive azoospermia was performed and 11 publications from the previous 20 years were evaluated. Histopathological data were presented in 8 publications, and were categorized as Sertoli-cell-only, maturation arrest and hypospermatogenesis. Maturation arrest was further differentiated by 4 publications. Early maturation arrest was defined as maturation ending at the secondary spermatocyte and late maturation arrest was defined as maturation ending at the spermatid without spermatozoa present. Success after repair was defined as having sperm in the ejaculate or spontaneous pregnancy. A total of 233 patients were analyzed. After varicocele repair 91 (39.1%) patients had motile sperm in the ejaculate and 14 spontaneous pregnancies were reported. Success rates in patients with maturation arrest (42.1%) or hypospermatogenesis (54.5%) were significantly higher than in those with Sertoli-cell-only (11.3%, p <0.001 in both groups). Patients with late maturation arrest had a higher probability of success (45.8%) than those with early maturation arrest (0%, p = 0.007). Infertile men with nonobstructive azoospermia can have improvement in semen analysis and achieve spontaneous pregnancy after repair of clinical varicoceles. This meta-analysis demonstrates that men with late maturation arrest and hypospermatogenesis have a higher probability of success and, therefore, histopathology should be considered before varicocele repair in men with nonobstructive azoospermia.

Induction of Spermatogenesis in Azoospermic Men After Internal Spermatic Vein Embolization for the Treatment of Varicocele

Induction of Spermatogenesis in Azoospermic Men After Internal Spermatic Vein Embolization for the Treatment of Varicocele

Pain experience during internal spermatic vein embolization for varicocele: comparison of two cyanoacrylate glues

The purpose of this study was to evaluate possible pain sensation differences in patients after retrograde varicocele embolization either with n-butyl-(2)-cyanoacrylate (NBCA) or with n-butyl-(2)-cyanoacrylate + methacryloxysulfolane (NBCA-MS). Transcatheter varicocele embolization was performed in 64 consecutive patients (62 left, two bilateral). Embolization was done with NBCA (n=32) or NBCA-MS (n=32). Immediately after the procedure, patients were asked to evaluate pain during embolization using a visual analog scale (VAS). Statistical analysis was done with Student's t test. Mean pain score on VAS was 3.23 (range: 0-8) for NBCA and 3.28 (range 0-9) for NBCA-MS. This difference was not significant (P=0.932). Independently of the type of glue, no difference in pain sensation (P value 0.421) was found between patients younger than 18 (n=29) and patients older than 18 years of age (n=35) (younger than18, mean 3.52; older than 18, mean 3.05). No difference in mean pain experience level (P=0.323) was seen in 11 patients with vessel wall perforation (23.4%) during the procedure (3.89; range: 0-8.5) in comparison with those without perforation (mean pain sensation level: 3.13; range: 0-9). No difference in pain experience was found after transcatheter varicocele embolization either with NBCA or NBCA-MS. Age and vessel wall perforation have no influence on pain sensation independently of the type of glue.

Induction of spermatogenesis in azoospermic men after internal spermatic vein embolization for the treatment of varicocele

To evaluate the improvement in semen quality and pregnancy rate after internal spermatic vein (ISV) embolization in men with nonobstructive azoospermia virtual azoospermia, or extremely severe oligoteratoasthenoazoospermia (OTA). A prospective cohort of 101 azoospermic or severe oligoteratoasthenospermic men of mean (+/-SD) age 34.1+/-7.7 years who underwent ISV between September 1998 and June 2003 were evaluated for semen characteristics, endocrinology profile, and conception rate. Significant improvement was noted in mean sperm concentration, motility, and morphology in 83 men (82%). Mean sperm concentration increased from 0.22+/-0.30 x 10(6)/ml total sperm in the ejaculate to 9.28+/-1.2 x 10(6)/ml after embolization (P < 0.001); mean sperm motility rose from 8.78+/-1.59 to 29.56+/-2.0% (P < 0.001), and mean sperm morphology rose from 3.79+/-0.74 to 13.72+/-1.37% (P < 0.005). Pregnancy was achieved in 34 cases (34%), 20 (20%) unassisted and 14 (14%) assisted. Based on our findings, the following statements can be made: (i) Varicocele may cause any variation of severity in OTA, including azoospermia. (ii) Since male fertility is preserved with only one testis, OTA, azoospermia or virtual azoospermia represent bilateral testicular dysfunction. (iii) Treatment of bilateral varicocele may reverse testicular dysfunction and improve spermatognesis and testosterone production in men with extremely severe OTA and induce sperm production in men with azoospermia and virtual azoospermia. (iv) If azoospermia is not too long-standing, the treatment of varicocele may significantly improve spermatogenesis and renew sperm production. (v) Adequate treatment may spare in > 50% of azoospermic patients the need for testicular sperm extraction as preparation for ICSI. (vi) Since achievement of pregnancy in IVF units is higher when spermatogenesis is better, the treatment of varicocele (bilateral) is an effective medical adjunct for the IVF units prior to the treatment. We recommend that infertile men with azoospermia or virtual azoospermia or extremely severe OTA be evaluated for varicocele, with special attention to its bilateral nature.

PHYSICAL EXAMINATION MAY MISS THE DIAGNOSIS OF BILATERAL VARICOCELE: A COMPARATIVE STUDY OF 4 DIAGNOSTIC MODALITIES

We evaluated the sensitivity of 3 noninvasive methods for detecting left and right varicoceles. Three noninvasive methods for the detection of varicocele in the left and right internal spermatic veins were evaluated in 214 infertile men, namely, physical examination, scrotal contact thermography and ultrasound Doppler. Venography was used as the reference diagnosis. Varicocele was detected in 195 patients (91.1%), on the left side in 37 (19%), on the right side in 3 (1.5%) and bilaterally in 155 (79.5%). Scrotal contact thermography using varicoscreen proved to be the most accurate method. Sensitivity, specificity, accuracy and positive predictive value were 98.9%, 66.6%, 98.5% and 100%, respectively, for left varicocele, and 95.6%, 91.6%, 94.9% and 98%, respectively, for right varicocele. Doppler sonography was associated with the highest number of false-positive results. Accuracy in evaluating retrograde flow was lowest for both sides for physical examination and highest for the combination of Doppler sonography and contact thermography, with a sensitivity, specificity, accuracy and positive predictive value of 100%, 33.3%, 99.0% and 98.9%, respectively, for the left side, and 97.4%, 58.3%, 90.3% and 91.1%, respectively, for the right side. In 165 (85%) of the 195 patients who underwent internal spermatic vein embolization sperm parameters were improved. The present study yielded 2 major findings. Thermography is more sensitive and accurate for the detection of varicocele than Doppler ultrasound and physical examination, and it can be used for screening as a single modality in infertile men. Doppler ultrasound and thermography are complementary and their combined use yields the highest sensitivity and accuracy.

Varicocele: a bilateral disease

Objective To evaluate the prevalence of varicocele in the left and right spermatic veins in infertile men by several methods of examination. Design Prospective study. Setting Andrology unit of a department of obstetrics and gynecology, and interventional radiology unit of the radiology department at a tertiary care facility. Patient(s) Two hundred eighty-six infertile men evaluated for varicocele. Intervention(s) Patients underwent evaluation for infertility. Physical examination was followed by contact thermography, Doppler sonography, and venography of both testes. Main outcome measure(s) We measured the prevalence of varicocele in the left and right spermatic veins in infertile men, and the response of semen parameters after embolization of internal spermatic vein. Result(s) Varicocele was detected by one of the noninvasive methods and confirmed by venography in 255 patients (89.2%): the left site in 45 (17.6%), the right side in 4 (1.5%), and bilaterally in 206 (80.8%). All patients were treated by embolization. Mean sperm concentration increased from 6.12 ± 1.02 to 21.3 ± 1.69 million/mL; mean sperm motility from 16.81 ± 1.51 to 35.90 ± 1.41%; and mean sperm morphology from 9.75 ± 0.85 to 16.92 ± 1.17%. Pregnancy rate was 43.5%. Conclusion(s) The present study finds that what was traditionally considered a predominantly unilateral anatomical abnormality apparently has a strikingly high bilateral prevalence (80.7%). This may suggest that we should consider varicocele a bilateral disease. The second finding is the high rate of varicocele detected by venography, thermography, and sonography when compared with physical examination results. Our study may have important implications for treatment, indicating that patients with clinical evidence of unilateral left varicocele should be carefully evaluated for bilateral varicocele.

Efficacy of varicocele embolization versus ligation of the left internal spermatic vein for improvement of sperm quality

Efficacy of surgical varicocelectomy versus embolization of the spermatic vein was studied in 137 men diagnosed as suffering from left varicocele. The men were divided randomly into three groups according to the methods of treatment: A--embolization of the internal spermatic vein (51 men); B--Ivanissevich technique of high ligation of the spermatic veins (43 men); and C--Bernardi technique of high ligation (43 men). The groups were similar in terms of age, duration of infertility and possessed semen characterized as oligoteratoasthenozoospermia. The fertility of the female partners was evaluated carefully and they were found to be potentially fertile. Varicocele was diagnosed by at least two of the following methods: physical palpation during valsalva manoeuvre, venography, or scrotal scanning using the technetium pertechnetate radioactive method. Semen quality was assessed before treatment and at 3, 6 and 9 months post-treatment. Fecundity was followed-up for 18 months. The major results were: (i) Shrinkage of the varicocele was found in all three groups studied. The same rate of recurrence was recorded in the three groups (24%, 37% and 35% in groups A, B and C, respectively). (ii) Improvement of sperm quality was significant in groups A and B, with better results in group B. (iii) The pregnancy rate was significantly higher in group B, compared with A (38.2% vs. 20.6%; P less than 0.05). Thus, high ligation of the internal spermatic vein yields better results than low ligation or embolization as far as semen quality and pregnancy is concerned.

Embolization of the internal spermatic vein in varicocele: significance of venous pressure.

Embolization of the left internal spermatic vein using spring-coils was performed in 20 patients with varicocele following pressure measurement of the left renal vein and inferior vena cava. During the follow-up of 16-24 months, there was no recurrence in 16 patients with pressure difference less than 3 mmHg; however, there were two recurrences in 4 patients with pressure difference greater than 4 mmHg and opacified adrenal or ureteral veins on venography. We conclude that a significant pressure difference between left renal vein and inferior vena cava, and opacification of adrenal or ureteral veins on left renal venography may be poor prognostic signs of recurrence of varicocele following embolization.