Varicocele Size Research Articles

Decision-making in pediatric varicocele surgery: use of color Doppler ultrasound.

Although varicoceles are common in adolescence, the indications for surgery as well as the procedure of choice are controversial. We have evaluated the use of color Doppler ultrasound (CDUS) as an objective tool in the assessment of such patients in a 5-year prospective study for determination of varicocele size, venous flow patterns, testicular volume, and resistance index. A high ligation was performed only when reverse blood flow was demonstrable in the varicocele during a Valsalva maneuver, and a low approach when this finding was absent. Twenty-six boys underwent low ligation and 53 high ligation based on the findings of CDUS. The incidence of recurrence (3.8%) was lower than that encountered by the same surgical team prior to introduction of CDUS (20.5%) (P = 0.004). These results are even more striking when contrasted with published recurrence rates of 12% to 15% (P = 0.015 to 0.003). Thus, CDUS proved to be a useful tool in selecting the proper surgical approach for varicocele in adolescence. The incidence of recurrence was significantly reduced following the introduction of this procedure.

Treatment of varicocele: a comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy

Objectives. To present our experience with the results of three different methods of treatment of idiopathic varicoceles. Methods. A total of 301 patients with 417 varicoceles were retrospectively assigned into three groups according to the method of treatment. Group 1 included 94 patients with 131 varicoceles treated by open surgery. Group 2 consisted of 120 patients with 163 varicoceles treated by percutaneous retrograde sclerotherapy, and in group 3, 87 patients with 123 varicoceles were treated by laparoscopic varicocelectomy. Of all patients, 222 (73.8%) were closely followed up with clinical and Doppler ultrasound examinations 6 and 12 months after the treatment. Seminal analysis was carried out before treatment and repeated in 172 patients with subfertility or infertility 4 to 6 months after treatment. Results. Patients in the three treatment groups were balanced regarding the different variables. The mean operative time was significantly shorter among patients with open surgery. The cost of sclerotherapy is one fourth to one fifth that of surgery and the cost of laparoscopy is double. Sclerotherapy was successful in 96 (82.8%) of 116 left varicoceles and in only 24 (51%) of 47 right varicoceles. The recurrence rate at follow-up was not significantly different among the three groups. The recurrence rate increased progressively with the increase of varicocele size from grade I to grade III in all groups. The overall incidence of postoperative complications was significantly higher among patients with open surgery. Postoperative spermiogram showed a significant increase in the density and motility and a significant reduction in the percentage of abnormal forms in all groups. The pregnancy rate was approximately similar in all groups. Conclusions. First, sclerotherapy is best used for isolated left-sided varicoceles. Second, laparoscopy is the treatment of choice for bilateral varicoceles. Finally, open surgery still has a role in isolated right-sided varicoceles and in left-sided cases with failed sclerotherapy.

Long-term results of microsurgical drainage for idiopathic varicocele.

The long-term results of microsurgical shunts for idiopathic varicocele are reported in the present paper. Sixty-two patients with a total of 65 varicoceles (three were bilateral) were followed up for 1 to 8 years. Pre- and postoperative ultrasonographic evaluation of varicocele size was considered of great importance in order to reduce the bias of subjective clinical diagnosis and to achieve a reliable and objective follow-up. Microsurgical shunts were tailored to the type of reflux: renospermatic (76.9%), iliospermatic (10.8%) or mixed type (12.3%), 94% of patients experienced a complete morphologic disappearance of varicosities, while in 6% of the cases a consistent reduction of size was objectified although varicosities were still detectable at ultrasonographic examination. In patients with severe infertility a significant increase of seminal parameters was observed postoperatively and this improvement showed a higher statistical significance in patients aged < 30 years.

Relationship between grade of varicocele and the response to varicocelectomy.

Although several studies indicate that larger varicoceles are associated with greater impairment of spermatogenesis, others suggest that the response to surgery is independent of varicocele size. In order to elucidate these seeming contradictions, correlations between the preoperative evaluation of varicoceles and improvement in semen quality after varicocelectomy were investigated. Forty men with left unilateral varicocele, followed for at least 6 months after varicocelectomy, were included in this study. The relationships between the grade of varicocele by palpation, Doppler examination, ultrasound, or scintigraphy were correlated with a postoperative improvement in sperm density or sperm motility. Greater improvement in sperm density was observed in the patients with a large varicocele graded by palpation or measured by ultrasound, and greater improvement in sperm motility was observed in the patients with high uptake of radioactivity in the left side by scrotal scintigraphy. An improvement in semen quality after varicocelectomy is greater in patients with a large varicocele than in the patients with a small one. The significance of surgical repair of a small varicocele should be reconsidered.

Seminal Improvement Following Repair of Ultrasound Detected Subclinical Varicoceles

Purpose We determined whether repair of subclinical varicoceles detected by scrotal duplex ultrasonography results in significant seminal improvement and identified the best ultrasonographic criteria to use in the selection of patients for subclinical varicocelectomy. Materials and Methods Of 256 consecutive infertile men being evaluated by physical examination and color duplex scrotal ultrasonography 76 underwent varicocele repair and were followed with serial semen analyses. All subclinical varicoceles were confirmed by venography. The outcome of varicocelectomy was determined by changes in total motile sperm count and compared among patients with different clinical grades of varicoceles and ultrasonographically measured vein sizes. Results A significant overlap was observed between ultrasonographically measured venous diameter and clinical grade of varicocele. There was no correlation between venous diameter and postoperative outcome when controlled for clinical grade. Significant postoperative improvement in semen parameters was noted in 67 percent of patients with clinical and only 41 percent with subclinical varicoceles (p less than 0.05). The best ultrasonographic cutoff to predict a positive outcome after subclinical varicocelectomy was venous diameter greater than 3 mm. Patients with larger clinical varicoceles had greater postoperative seminal improvement than those with small or subclinical varicoceles regardless of baseline sperm count. Conclusions Varicocele size has a direct impact on the probability and amount of seminal improvement after varicocelectomy. Outcome following subclinical varicocelectomy is significantly less than after repair of clinical varicoceles. Although 41 percent of patients with subclinical varicoceles had significant postoperative improvement in semen parameters, an equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group. The results of our study suggest that subclinical varicocelectomy is of questionable benefit.

Relationship Between Varicocele Size and Response to Varicocelectomy

We studied the relationship between varicocele size and response to surgery in 86 men with a unilateral left varicocele who reported either infertility (83), pain (1) or pain and testicular atrophy (2). Varicoceles were graded according to size: grade 1—small (22 patients), grade 2—medium (44) and grade 3—large (20). Sperm count, per cent motility, per cent tapered forms and fertility index (sperm count times per cent motility) were measured preoperatively and postoperatively.Preoperatively, men with grade 3 varicocele had lower sperm counts and poorer fertility indexes compared to men with grades 1 and 2 varicocele. Sperm concentration improved significantly in men with grade 2 (33 ± 5 million per cc preoperatively to 41 ± 6 million postoperatively, p <0.04) and grade 3 (18 ± 5 million preoperatively to 32 ± 7 million postoperatively) varicocele after microsurgical ligation of the varicocele. Motility improved significantly in men with grade 3 varicocele. Decrease in per cent tapered forms was significant in all groups. A comparison of per cent change in fertility index among the groups revealed that men with grade 3 varicocele improved to a greater degree (128%) than men with grade 1 (27%) or grade 2 (21%) varicocele. Pregnancy rates 2 years postoperatively were 40% for grade 1, 46% for grade 2 and 37% for grade 3 varicocele patients. The difference in pregnancy rates among the groups was not statistically significant.In conclusion, infertile men with a large varicocele have poorer preoperative semen quality but repair of the large varicocele in those men results in greater improvement than repair of a small or medium sized varicocele.

Varicoceles: Radiologic Diagnosis and Treatment

The association of clinically apparent varicoceles with male subfertility and infertility has been noted in the urology literature since the late nineteenth century, and surgical ligation of varicoceles has been considered appropriate therapy in an attempt to improve semen quality and increase fertility for the past 40 years. It has been established by several authors cited herein that varicocele size does not predict prognosis after ligation reliably. Because subclinical varicoceles may affect testicular function and histologic characteristics adversely and because age at time of therapy may affect probability of successful enhancement of fertility, the interest of radiologists and urologists has been directed toward diagnosis and treatment of both clinically obvious and clinically occult varicoceles, particularly in young adult men or adolescent boys. Testicular growth after varicocele ligation in adolescent boys also suggests a benefit from early intervention. Sonographic evidence of a varicocele must be correlated with analysis of semen for sperm density, motility, and morphology, as not all patients with varicoceles are infertile. Although surgical therapy is standard for varicocele occlusion, fairly extensive evidence exists to show that percutaneous transvenous occlusion of varicoceles is feasible, safe, and effective, particularly in the setting of varicocele recurrence after conventional surgical treatment.

Predictive Parameters of Successful Varicocele Repair

A total of 130 men presenting with oligospermia and clinically identifiable scrotal varicoceles was evaluated, treated surgically and followed for 1 year for pregnancy rate. The treatment outcome was compared to an age-matched cohort of 83 oligospermic men who had received empirical medical therapy with clomiphene citrate (25mg. per day) for the same 1-year interval. This study was done to contrast treatment modalities in infertility and not as a strict control. Only eugonadotropic patients in both groups were used for comparison.In the varicocele group the over-all pregnancy rate was 38.5 per cent. Four variables (a lack of testicular atrophy, sperm density greater than 50 million per ejaculate, sperm motility 60 per cent or more and serum follicle-stimulating hormone values less than 300ng. per ml.) proved to be accurate preoperative predictors of postoperative pregnancy success. Four other variables (varicocele size and laterality, sperm forward progression greater than 2 and normal sperm morphology 60 per cent or more) did not yield statistically significant rates of improvement in pregnancy postoperatively.The pregnancy rate of the eugonadotropic patients undergoing varicocele repair was 45.8 per cent. Despite statistical similarity in patient age, sperm density and mean gonadotropin levels the medically treated patients had a pregnancy rate of only 25.5 per cent, significantly lower than the surgically treated patients.In summary, patients with an identifiable varicocele had a greater chance of achieving a pregnancy following surgical correction than did those treated with empirical drug therapy. In addition, certain preoperative variables in the physical and laboratory analyses appeared to portend a greater surgical response.

Noninvasive imaging procedures in the diagnosis and therapy control of varicoceles. I: Sonography and thermography in the diagnosis of varicoceles

69 patients with clinically suspected varicoceles were examined thermographically and sonographically prior to testicular phlebography. The combination of sonography and thermography permitted precise differentiation into normal findings (7%), left-sided varicoceles (86%) and bilateral varicoceles (7%). Thermography was advantageous with an accuracy of 97.3%. Sonography had an accuracy of 90.5%. No clear correlation was found between varicocele size and degree of hyperthermia. The combination of sonography and thermography affords a high degree of accuracy in the diagnosis of varicoceles, including subclinical and infantile varicoceles.

Are conventional sperm morphology and motility assessments of predictive value in subfertile men?

Sperm morphology and motility are believed to be important prognostic factors for fertility. Results of a group of 67 men investigated for primary infertility who had mean sperm concentrations greater than 5 million per ml and who later produced pregnancies, were compared with those of 67 matched controls who remained infertile. All female partners were potentially fertile. The groups were matched for other known prognostic factors for fertility, namely, wife's age, the duration of infertility, sperm concentration and varicocele size. There were no significant differences between the two groups overall in the (mean +/- SEM)% of sperm with normal morphology (58.3 +/- 2.1; 58.5 +/- 2.2), or motility (40.6 +/- 1.8; 37.0 +/- 2.0). However, among oligospermic men from the two groups, sperm motility was significantly higher (P less than 0.05) in the subsequently fertile group (43.1 +/- 2.6%) than in the persistently infertile group (33.3 +/- 3.7). These results indicate that sperm morphology as currently assessed may not be important in predicting fertility in subfertile men with a mean sperm concentration over 5 million/ml and the % sperm motility may only be a relevant predictor in oligospermic men.

Factors related to semen improvement and fertility after varicocele operation

Factors related to semen improvements and fertility after high ligation of the left internal spermatic vein were investigated in 97 men from infertile couples. Changes in some semen characteristics after operation suggest a relationship between varicocele size and semen improvements and an inverse relationship between preoperative semen values and semen improvements. An inverse relationship seemed to exist between varicocele grades and deterioration of semen values. Fertility after operation was related to age and to semen improvements. Preoperative semen characteristics had no prognostic value for postoperative fertility.

Varicocelectomy and male fertility: comparison of semen quality and recurrence of varicocele following varicocelectomy by two techniques.

Two hundred thirty-eight infertile men aged between 20 and 50 years suffering from left varicocele underwent ligation of the internal spermatic vein. The patients were operated on using Ivanissevich technique IT (210 patients) or the Bernardi technique BT (28 patients). In the BT group recurrences were found in 7.1% as against 28% in the IT group. The low rate of recurrence found in the BT group might be due to the fact that the patients were under local anaesthesia and collaborated with the surgeon. Varicocelectomy was followed by significant improvement in sperm quality 3 to 9 months after operation. Improvement among the fertile men was more rapid than among the infertile men. Sperm concentration improved significantly in 50% of the cases. Sperm motility improved in 37% of the cases, while morphology improved only in 29% of the cases. Sperm vitality was identical in response to that of motility. Varioocelectomy did not cause any change in the seminal plasma constituents (volume, pH, fructose). Improvement in sperm quality was identical in the IT and BT groups, as was the impregnation rate. 94 couples reported pregnancies 39.5%), which occurred within 2 years after operation (12 +/- 1.5 months mean +/- SEM). No correlation was found between size of varicocele and improvement in sperm quality and fertilizing capacity.

Factors affecting fertility after varicocelectomy.

We performed high ligation of the internal spermatic vein in 27 cases of left varicocele with disturbance of spermatogenesis, and studied postoperative fertility. The results indicated that the cases were divided into three groups, namely group I in which pregnancy occurred after ligation: group II in which the sperm count increased but no pregnancy occurred, and group III in which there was no improvement in the sperm count. The age, size of varicocele, preoperative volume of bilateral testicle, bilateral testicular histologies, serum LH, serum FSH, peak responded value after LH-RH administration, plasma testosterone and response after HCG administration were evaluated. We detected that the volume of bilateral testicles, bilateral testicular histologies, serum FSH and the response after LH-RH administration served as good indicators for postoperative evaluation of fertility.

Leydig Cell Function in Oligospermicmen with Varicocele

AbstractWe report on the evaluation of Leydig cell function in 16 young men with sperm counts less than 10 million per ml. and with various degrees of unilateral or bilateral varicocele. An in vitro technique of incubation of testicular tissue with radiolabeled precursors was used for evaluation of Leydig cell androgen synthesis. A significant suppression of in vitro testosterone formation was observed in almost 90 per cent of the patients. Circulating testosterone and luteinizing hormone levels were within the normal range. However, when the patients were grouped according to the in vitro testosterone synthesis data a correlation between the circulating testosterone and gonadotropin levels was observed. Sperm motility was highest for patients with highest testosterone synthesis rates. No correlation among the ages of the patients, size of varicocele, degree of oligospermia or histologic appearance of the seminiferous epithelium could be demonstrated. An increased Leydig cell number was observed in testes with highest in vitro testosterone formation. Since testicular volume was lowest in this group this finding could represent a relative rather than an absolute increase in Leydig cell density. No improvement in sperm count or motility was observed after varicocelectomy and no pregnancies occurred. This study shows a disturbance of androgen biosynthesis in testes of men with varicocele and sperm counts less than 10 million per ml. Consequently, Leydig cell function should be evaluated carefully in all Oligospermic patients regardless of the presence of varicocele. Plasma testosterone levels are not sufficiently sensitive tests of testicular function. If Leydig cell dysfunction is diagnosed in men with varicocele medical treatment in addition to varicocelectomy should perhaps be considered.

Varicocele Size And Results of Varicocelectomy in Selected Subfertile Men with Varicocele

Varicocele Size And Results of Varicocelectomy in Selected Subfertile Men with Varicocele