Varicocele Research Articles

(O-08) IMPACT OF SUBINGUINAL MICROSURGICAL VARICOCELECTOMY ON MALE INFERTILITY: SEMINAL PARAMETERS, SERUM TESTOSTERONE, AND PREGNANCY RATE - RETROSPECTIVE COHORT AT A UNIVERSITY HOSPITAL IN RIO DE JANEIRO

Abstract Introduction and Objective Varicocele is the most common identifiable cause of male infertility, and varicocelectomy is the most frequently performed surgery for its treatment. This condition impacts infertility cases and sperm quality. Microsurgical varicocelectomy is considered the gold standard treatment for varicocele. This retrospective cohort aims to evaluate the effects of microsurgical varicocelectomy on seminal parameters, serum testosterone, and pregnancy rate in the context of male infertility in 39 patients who underwent the procedure at a university hospital in Rio de Janeiro. Methods This study is a retrospective cohort conducted between January 2016 and February 2023, involving 39 men who underwent subinguinal microsurgical varicocele repair in the context of marital infertility. Pre- and post-operative analyses of seminal parameters were based on the criteria of the World Health Organization from 2010. Post-operative semen analysis and serum testosterone levels were assessed 3 to 6 months after varicocelectomy. The pregnancy rate was observed through interviews until February 28, 2023. Results Subinguinal microsurgical varicocelectomy is associated with a significant increase in testosterone levels and an improvement in seminal parameters, all with statistical significance. Testosterone levels increased by an average of 84.2 (±14.7) ng/dl. The pregnancy rate also increased significantly, with 51.3% of couples achieving pregnancy as of the time of this study. Conclusion In this patient population, infertile men with clinical varicocele who underwent subinguinal microsurgical varicocelectomy showed a significant increase in testosterone levels, improvement in seminal parameters, and a significant reduction in the proportion of azoospermia. Furthermore, there was an increase in the occurrence of pregnancy in couples with marital infertility. Statistical Results Financing No conflict.

(207) Premature Ejaculation and Varicocele, are they Associated? Systematic Review

Abstract Introduction Premature ejaculation (PE) is one of the most common sexual disorders that negatively impacts couple’s satisfaction. Varicocele on the other hand is a highly prevalent condition affecting men population. A higher incidence of PE is observed among patients with varicocele, which incited several authors to evaluate the possible correlation between varicocele and PE. Others went beyond that to investigate whether varicocele repair can lead to an improvement in PE. Objective To systematically review the literature for all the studies exploring the relationship between PE and varicocele. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed, Google scholar and Scopus databases were used to look for articles published up to June 2023 using the appropriate keywords. Articles reporting an association between the presence of varicocele and PE and exploring changes in ejaculation latency time after varicocele correction were included. Data including study design, sample size, varicocele details, PE diagnostic method, outcome measured and tools used to measure it were collected. The Newcastle-Ottawa scale was used for assessing the quality of the included studies. Results A total of eight studies were identified, two of them were retrospective and six were prospective. Intravaginal ejaculation latency time (IELT) was used as a diagnostic tool for PE in 5 studies, Premature Ejaculation Diagnostic Tool (PEDT) in 1 study, Chinese Index of Sexual Function for Premature Ejaculation-5 (CIPE-5) scores in 1 study, and subjective assessment in 2 studies. Two studies looked for the prevalence of PE among patients with and without varicocele. Both studies showed a significantly higher frequency of PE among varicocele patients. Whereas six studies evaluated the improvement in ejaculatory function after varicocelectomy; five of them revealed a statistically significant improvement. Quality check: only one study was of strong quality while the remaining 7 studies were of fair quality. Conclusions Limited evidence suggests the presence of positive relation between varicocele and PE. The small number of studies and patients, lack of enough prospective clinical trials, short term follow up, heterogenous study design and absence or diversity in the diagnostic tools used prevent our ability to build strong evidence. For the purpose of supporting the relation and validate it, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(340) The Association Between Varicocele and Premature Ejaculation: Systematic Review

Abstract Introduction Premature ejaculation (PE) is one of the most common sexual disorders that negatively impacts couple’s satisfaction. Varicocele on the other hand is a highly prevalent condition affecting men population. A higher incidence of PE is observed among patients with varicocele, which incited several authors to evaluate the possible correlation between varicocele and PE. Others went beyond that to investigate whether varicocele repair can lead to an improvement in PE. Objective To systematically review the literature for all the studies exploring the relationship between PE and varicocele. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed, Google scholar and Scopus databases were used to look for articles published up to June 2023 using the appropriate keywords. Articles reporting an association between the presence of varicocele and PE and exploring changes in ejaculation latency time after varicocele correction were included. Data including study design, sample size, varicocele details, PE diagnostic method, outcome measured and tools used to measure it were collected. The Newcastle-Ottawa scale was used for assessing the quality of the included studies. Results A total of eight studies were identified, two of them were retrospective and six were prospective. Intravaginal ejaculation latency time (IELT) was used as a diagnostic tool for PE in 5 studies, Premature Ejaculation Diagnostic Tool (PEDT) in 1 study, Chinese Index of Sexual Function for Premature Ejaculation-5 (CIPE-5) scores in 1 study, and subjective assessment in 2 studies. Two studies looked for the prevalence of PE among patients with and without varicocele. Both studies showed a significantly higher frequency of PE among varicocele patients. Whereas six studies evaluated the improvement in ejaculatory function after varicocelectomy; five of them revealed a statistically significant improvement. Quality check: only one study was of strong quality while the remaining 7 studies were of fair quality. Conclusions Limited evidence suggests the presence of positive relation between varicocele and PE. The small number of studies and patients, lack of enough prospective clinical trials, short term follow up, heterogenous study design and absence or diversity in the diagnostic tools used prevent our ability to build strong evidence. For the purpose of supporting the relation and validate it, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

Fertility Rate and Sperm DNA Fragmentation Index following Varicocelectomy in Primary Infertile Men with Clinical Varicocele: A Prospective Longitudinal Study.

Varicocele is one of the most common treatable causes of male infertility, and its treatment may be beneficial for fertility. This study aimed to evaluate fertility rate and DNA fragmentation index (DFI) following varicocelectomy in primary infertile men with clinical varicocele. This prospective longitudinal study was conducted on primary infertility men, in a tertiary center from December 2018 to December 2019 with one-year follow-up. Data of the semen parameters, DFI (%), and fertility rate were gathered before, as well as 4 and 12 months after undergoing varicocelectomy. For data analysis, SPSS software and analytical test were used. Out of 76 patients who were analyzed, 22 (29%) became fertile and 54 (71%) remained infertile. Semen parameters and DFI (%) were improved significantly following varicocelectomy (P<0.001). Smoking history, occupational heated exposure, body mass index (BMI), and infertility duration were determined as predictors associated with fertility status (P<0.05). Although varicocele repair improved the DFI, the fertility rate was achieved in less than one-third of patients; it seems that the other parameters, such as the history of smoking, occupational heated exposure, overweight, and duration of infertility should be considered as predictors of fertility status, in primary infertile men who are a candidate for varicocelectomy.

A Nomogram for Predicting Infertility Risk in Patients With Varicocele Using Inflammatory Markers.

The purpose of this study was to develop a nomogram using hemogram inflammatory markers to predict the risk of infertility in patients with varicocele (VC). Patients with VC from March 2022 to June 2024 were retrospectively investigated. We divided the patients into two groups based on their fertility status. A total of 162 patients were enrolled: 81 in the infertile group and 81 in the fertile group. Statistical differences were observed between the two groups in lymphocyte, monocyte, erythrocyte, red cell distribution width (RDW), mean erythrocyte volume (MCV), mean platelet volume (MPV), platelet distribution width (PDW), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), MPV/platelet ratio (MPVPR), and systemic inflammation response index (SIRI) (p < .05). The 162 patients were divided into a modeling cohort and a validation cohort in a 7:3 ratio. A predictive nomogram was constructed based on independent influencing factors identified through univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis, calibration curve, and decision curve analysis were used to assess the model's performance. Multivariate logistic regression analysis indicated that erythrocyte count, PDW, NLR, and SIRI were independent influencing factors. The area under the curve for the nomogram predicting the risk of infertility in patients with VC was 0.869 in the validation cohort. The nomogram demonstrated good predictive performance. In this study, we developed an effective predictive nomogram for assessing the risk of infertility in VC patients using inflammatory markers. However, further external validation is crucial.

Effects of Varicocele Repair on Testicular Endocrine Function: A Systematic Review and Meta-Analysis.

The objective of this manuscript is to assess the effect of varicocele repair (VR) in patients with clinical varicoceles on serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and inhibin B serum levels. The study was performed in compliance with the Meta-Analysis and Systematic Reviews of Observational Studies (MOOSE) guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). All eligible studies were selected following the PICOS (Population, Intervention, Comparison/Comparator, Outcomes, Study design) model. The values of each outcome measured after VR were compared to the before parameters and, when available, to the values on patients with unrepaired varicocele, and to those of healthy controls with no varicocele. For total testosterone, the values were sub-analyzed based on the mean total testosterone levels before VR (<300 ng/dL or >300 ng/dL), the fertility status, the time of follow-up and the technique used for VR. From a total of 460 abstracts retrieved, 48 articles were included in our meta-analysis. Serum total testosterone levels were significantly higher after VR compared to both pre-treatment levels (mean difference [MD] 82.45 ng/dL, 95% confidence interval [CI]: 64.14-100.76; p<0.00001) and to the levels of patients with unrepaired varicocele (MD 91.64 ng/dL, 95% CI: 62.30-120.99; p<0.00001). They did not differ from the levels of healthy controls with no varicocele (MD -22.01 ng/dL, 95% CI: -68.59-24.58; p=0.35). The increase resulted to be independent from the mean total testosterone levels before VR, fertility status, time of follow-up and type of VR. After VR, a trend toward lower serum LH levels was found compared to before values (MD -0.37 IU/L, 95% CI: -0.74-0.01; p=0.06). When compared to the levels of patients with unrepaired VR, LH levels after VR were significantly lower (MD -0.96 IU/L, 95% CI: -1.56 to -0.35; p=0.002). LH levels were not significantly higher than healthy men without varicocele (MD 0.84 IU/L, 95% CI: -0.68-2.36; p=0.28). Patients with VR had significantly lower FSH levels compared to their pre-treatment values (MD -1.43 IU/L, 95% CI: -1.82 to -1.04; p<0.00001), and also to those of patients with non-repaired varicocele (MD -2.35 IU/L, 95% CI: -4.06 to -0.65; p=0.007). When compared to healthy controls with no varicocele, FSH levels were significantly higher (MD 2.71 IU/L, 95% CI: 1.12-4.31; p=0.0009). Lastly, after VR no significant change in inhibin B serum levels was seen compared to pre-treatment levels (MD 11.76 pg/mL, 95% CI: -3.83-27.35; p=0.14). The present meta-analysis is the largest to date to assess the impact of VR on Leydig cell and Sertoli cell function using a before-after analysis for uncontrolled studies, and using data from patients with unrepaired varicoceles or healthy patients without varicocele as controls. VR was found to increase and restore to normality serum levels of total testosterone and LH. This evidence could be of value in considering the treatment of varicocele in patients with low testosterone or those who show a progressive decline in testosterone levels.

Impact of Varicocele Repair on Assisted Reproductive Technique Outcomes in Infertile Men: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis, we investigated assisted reproductive technology (ART) success in infertile men with clinical varicocele and abnormal semen parameters who underwent varicocele repair (VR) before the ART procedure as compared to those who did not. A comprehensive search of the Scopus, PubMed, Embase, and Cochrane Library databases was conducted using a specific query string to identify studies examining the impact of VR on ART outcomes, including fertilization rate, clinical pregnancy, pregnancy loss, and live-birth rate, until October 2023. Outcomes were analyzed based on the type of ART. Studies on VR in infertile men with non-obstructive azoospermia and those who underwent ART only due to female factor infertility were excluded from the study. Out of 1,554 articles reviewed, only 9 met the inclusion criteria for the study. All the included articles were observational studies. The variability in study quality in the included literature resulted in a moderate overall risk of bias. Data analysis showed that for intrauterine insemination, there was no difference in the clinical pregnancy rate (odds ratio [OR] 1.01, 95% confidence interval [CI]: 0.42, 2.45; p=0.97). However, for intracytoplasmic sperm injection (ICSI), men with VR showed a significant improvement in fertilization rate (mean difference 10.9, 95% CI: 5.94, 15.89; p<0.01), clinical pregnancy rate (OR 1.38, 95% CI: 1.07, 1.78; p=0.01) and live-birth rate (OR 2.07, 95% CI: 1.45, 2.97; p<0.01), compared to men who did not undergo VR. The findings of this systematic review and meta-analysis suggest that VR has a positive impact on pregnancy and live birth rates after ICSI. However, biases like small sample sizes and heterogeneous populations highlight the need for larger, well-designed prospective studies to validate these findings.

Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis.

Varicoceles can be a source of elevated seminal oxidative stress (OS) and sperm DNA fragmentation (SDF). However, it remains unclear whether varicocele repair (VR) could reduce these parameters. This systematic review and meta-analysis (SRMA) aims to investigate the impact of VR on SDF and seminal malondialdehyde (MDA). A literature search was performed in Scopus, PubMed, Ovid, Embase, and Cochrane databases. This SRMA included randomized controlled trials and observational studies reporting the pre- and postoperative levels of SDF and seminal OS in infertile men with clinical varicocele that underwent VR. Subgroup analyses included techniques of VR and SDF testing. The effect size was expressed as standardized mean difference (SMD). Out of 1,632 abstracts assessed for eligibility, 29 studies with 1,491 infertile men were included. The analysis showed a significant reduction in SDF after VR, compared to preoperative values (SMD -1.125, 95% confidence interval [CI] -1.410, -0.840; p<0.0001) with high inter-study heterogeneity (I²=90.965%). Reduction in SDF was evident with microsurgical technique and non-microsurgical inguinal approaches (SMD -1.014, 95% CI -1.263, -0.765; p<0.0001, and SMD -1.495, 95% CI -2.116, -0.873; p<0.0001), respectively. Reduction in SDF was significant irrespective of testing was done by sperm chromatin dispersion (SMD -2.197, 95% CI -3.187, -1.207; p<0.0001), sperm chromatin structure assay (SMD -0.857, 95% CI -1.156, -0.559; p<0.0001) or TUNEL (SMD -1.599, 95% CI -2.478, -0.719; p<0.0001). A significant decrease in seminal MDA levels was observed following VR (SMD -2.450, 95% CI -3.903 to -0.997, p=0.001) with high inter-study heterogeneity (I²=93.7%). Using pre- and post-intervention data, this SRMA indicates a significant reduction in SDF and seminal MDA levels in infertile men with clinical varicocele treated with VR. These findings may have important implications for the future management of this selected group of infertile patients.

Role of varicocele repair in the era of assisted reproductive technologies: Lessons from 2000 cases of microsurgical varicocele repair.

In an era of advanced maternal age, there is less conclusive evidence regarding the treatment outcomes of varicocele repair for assisted reproductive technology (ART). Progress in basic research on varicocele is notable whereas there are many clinically relevant points to discuss. Based on our experience with more than 2000 cases of microsurgical varicocele repair, we focused on the effectiveness of varicocele repair, pathophysiology, surgical approaches, contributions to ART, sperm DNA fragmentation, and varicocele-associated azoospermia in this review with the aim of identifying clearer directions for basic and clinical research on varicocele. Microsurgical low ligation for varicocele repair is expected to remain the gold standard for surgical therapy. Based on the findings from a number of systematic reviews and meta-analyses, negative opinions regarding the efficacy of microsurgical varicocele repair in male infertility treatment have become virtually nonexistent. However, the majority of evidence regarding surgical indications and effectiveness pertains to improvements in semen parameters or non-ART pregnancy rates. Further understandings regarding to pathophysiology of varicocele will likely be gained through comprehensive genetic, transcriptomic, and epigenetic analyses using blood and testicular samples from humans and we hope to develop new diagnostic methods and pharmacotherapy.

From pathophysiology to practice: addressing oxidative stress and sperm DNA fragmentation in Varicocele-affected subfertile men.

Varicocele can reduce male fertility potential through various oxidative stress mechanisms. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress, damaging the sperm chromatin. Sperm DNA fragmentation, in the form of DNA strand breaks, is recognized as a consequence of the oxidative stress cascade and is commonly found in the ejaculates of men with varicocele and fertility issues. This paper reviews the current knowledge regarding the association between varicocele, oxidative stress, sperm DNA fragmentation, and male infertility, and examines the role of varicocele repair in alleviating oxidative-sperm DNA fragmentation in these patients. Additionally, we highlight areas for further research to address knowledge gaps relevant to clinical practice.

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations.

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA. A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process. Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit. This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Effect of varicocele surgery on sperm quality

Introduction: A varicocele is a vascular lesion characterised by dilatation and tortuosity of the veins of the pampiniform plexus and is found in approximately one-fifth of the adult male population. It is the most common cause of treatable infertility. Physical examination may or may not show a varicocele which is mostly diagnosed only when patients present with infertility or adolescents during a physical examination, like testicular hypotrophy, impairment in spermatogenesis mainly in the form of low or absent count, decreased sperm motility, and abnormal sperm morphology. Treatment for varicocele includes medical therapies, radiological embolization, and surgical techniques. Medical therapy, including antioxidants and anti-inflammatory agents, has been utilized with variable success. Radiological embolization of varicocele is a new technique in the treatment of varicocele, but it is associated with high recurrences and high cost. Varicoceles are surgically treated either by open or laparoscopic approaches the principal aim being occlusion of the dilated veins of the pampiniform plexus. A definitive conclusion of indication of medical treatment cannot be drawn at present because most published studies have inadequate design and lack controls. Various studies in the past have concluded significant changes in sperm parameters (total count, motility, morphology) post-varicocele repair. However, few other studies suggest no improvement in sperm parameters following surgical varicocele repair and studies that conclude recommendations against repair of varicocele. Thus, conflicting opinions have opened the scope to establish this fact by this study. Aim: To evaluate changes in sperm morphology, sperm count, and sperm motility in a patient with varicocele after varicocele surgery. Materials and methods: The study was conducted in the Department of Surgery, North Delhi Municipal Corporation Medical College &amp; Hindu Rao Hospital, Delhi, India from August 2019 to February 2021. The sample size was calculated to be 50 using Slovin’s formula with a confidence level of 95% with a margin error taken as 5% (p - value 0.05). Sperm morphology, sperm count, and sperm motility were the parameters studied before and after 3 months of surgery. Results: The majority of patients belonged to the age group of 18 to 25 years (42%) followed by 26 to 35 years (40%) (27.78 ± 6.547 years). Left-sided varicocele was more common (54%), followed by bilateral varicocele (42%). Varicocele grade II was most common (58%) followed by grade I (30%) and lastly grade III (12%). Total sperm count improved by 8.88 million per ml after varicocelectomy. Total sperm motility improved by 6.08% after the surgery. Total normal sperm forms improved by 6.44% after varicocele repair. Conclusion: Based on the findings it was concluded that Varicocelectomy results in significant improvement in total sperm count, total sperm motility, and total normal sperm morphology. The best improvement was seen in sperm count followed by total normal sperm forms and lastly total sperm motility.

Varicocelectomy outcomes among patients with azoospermia and severe oligasthenoteratozoospermia.

Varicocele is a reversible cause of male infertility. However, there are conflicting data available concerning the benefit of varicocele repair for patients with nonobstructive azoospermia (NOA) and severe oligoasthenoteratozoospermia (OAT). To address the benefit of varicocelectomy in patients with severe OAT and NOA with regard to their semen parameters and surgical sperm retrieval rate in those who underwent testicular sperm extraction (TESE) or testicular sperm aspiration (TESA). This retrospective cohort study was conducted on a sample of 13 patients diagnosed with NOA and severe OAT who underwent varicocelectomy for infertility treatment with no prespecified exclusion criteria. Thirteen patients were enrolled. Five patients were diagnosed with NOA; eight were diagnosed with severe OAT. For improvements in the semen parameters postoperatively, the semen concentration of all patients was significantly increased compared to the preoperative concentration (3.59 ± 10.0.8 vs. 0.25 ± 0.31, P = 0.02) and the remaining parameters were unchanged. Regarding sperm retrieval, three patients underwent TESE and two patients underwent TESA, in which all had positive results. Varicocele repair was found to improve the semen parameters in patients with NOA and severe OAT and produced a successful surgical sperm retrieval rate in all patients who underwent TESA or TESE.

Assessment of semen parameters after microsurgical varicocelectomy in men from infertile couples

Introduction. Varicocele is one of the frequently identified and corrected causes of male subfertility. However, varicocele correction results in improved sperm quality only in 60 – 70% of subfertile men. At the same time, it is not completely clear which semen parameters improve to a greater extent, and what is the proportion ofpatients with an improvement in parameters to normozoospermia.Objectives. To assess qualitative changes in semen after microsurgical varicocelectomy according to WHO 2021 Laboratory manual of semen analysis.Materials &amp; methods. This study analysed qualitative changes in sperm in infertile men after varicocelectomy. All patients had a clinical varicocele, for which microsurgical varicocelectomy was performed. The study included 100 subfertile men with varicocele and abnormal sperm parameters.Results. In the postoperative period (after 6 months), the main semen parameters increased significantly. Also, the proportion of patients with isolated asthenozoospermia decreased by 22% (p &lt; 0.05), the proportion of patients with oligoasthenozoospermia decreased by 14% (p &lt; 0.05). The proportion of patients with normospermia was 35% (p &lt; 0.0001). In patients with oligoasthenozoospermia significant improvement in sperm to normospermia was observed in 19% of cases.Conclusions. Varicocele repair leads to an improvement in the quality of the ejaculate in subfertile men with palpable varicocele and pathozoospermia, with the most significant improvement in sperm motility. However, only in a third of patients semen quality improved to normal levels. Additionally, varicocelectomy demonstrated high efficacy in patients with oligoasthenozoospermia.

Varicocelectomy in Male Subfertility Treatment: ‘‘Updated’’ Indications for Surgery

We analyzed the recent literature data on varicocelectomy in treatment men from infertile couples. There are still a lot of unresolved issues that require clarification. It is still unclear the exact pathogenesis of testicular malfunction in some men with varicocele. Recent European and American urological guidelines recommend varicocele repair in men from infertile couples with “abnormal” semen parameters. Although, according to the 6th ed. of WHO laboratory manual for the examination and processing of human semen it is not clear the cut-off values between normal and abnormal semen parameters. Also, still unclear why approximately third part of patients do not experience any improvement after varicocele repair. According to the recent data analysis, total progressively motile sperm count (TMSC) and sperm concentration can be the significant predictors of semen improvement and pregnancy after varicocele repair. However, it should be remarked that the mean quality of existed data from low to moderate. All mentioned issues indicate the necessity of further large-scale multicenter randomized clinical trials.

Seminal TEX101 May Predict Seminal Sperm Recovery after Varicocelectomy in Nonobstructive Azoospermic Patients with Varicocele

Background. Infertile men with nonobstructive azoospermia (NOA) associated with varicocele may benefit from varicocele repair with recovered sperms in semen. Currently, there is no clinically applied method to predict the success of seminal sperm recovery in this subset of azoospermic men. Objective. We aimed to evaluate the predictive role of the seminal testis expressed protein (TEX101) in sperm recovery in the semen of NOA men with palpable bilateral varicocele after microsurgical varicocelectomy. Patients and Methods. This prospective cross-sectional cohort study included 40 patients with NOA and bilateral varicocele. Seminal TEX101 levels were measured followed by subinguinal microsurgical varicocele repair. Two seminal analyses were carried out at 3- and 6-month follow-up periods to evaluate seminal sperm recovery. Results. After varicocele repair, sperms were recovered in the semen of 10/40 patients (25%) along the follow-up periods (seven patients after 3 months and additional three patients after 6 months). The preoperative median seminal TEX101 level was significantly higher in NOA men with seminal sperm recovery compared with NOA patients without seminal sperm recovery (13.5 vs. 9.8 ng/ml, p = 0.014 ). Besides, the serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) median levels were significantly higher in NOA men without seminal sperm recovery compared with NOA men with seminal sperm recovery ( p = 0.001 , p = 0.01 ). There were nonsignificant differences comparing the preoperative testicular volume or serum testosterone levels between the two investigated groups ( p = 0.072 , p = 0.272 ). A cutoff value of 9.9 ng/ml was demonstrated to have preoperative TEX101 prediction of seminal sperm recovery (sensitivity of 90% and specificity of 57%). Conclusion. Preoperative seminal TEX101 could be considered as a biomarker for sperm recovery for seminal sperm recovery in NOA cases associated with varicocele after its surgical repair. Further work at this point with larger number of cases should be carried out to verify its potential importance.

Effect of Microsurgical Varicocele Repair on Sperm Capacitation and Probability of Generating a Pregnancy as Measured by Pre and Postoperative Novel Testing With Cap-Score

To study whether varicocele repair would improve sperm capacitation and probability of generating a pregnancy. Data were collected prospectively from 40 consecutive adult men who presented with infertility confirmed by semen analysis (SA) and found to have a varicocele on exam or ultrasound who underwent unilateral or bilateral subinguinal microscopic varicocelectomy. We recorded pre and postoperative SA, Cap-Score, and probability of generating a pregnancy (PGP) with a 3-month follow-up. Values were compared using paired t test and Wilcox rank-sum test. Results showed a 17.4% relative increase in Cap-Score (23%-27% capacitation), 25% relative increase in PGP (24%-30%), as well as statistically significant improvements in sperm concentration, motility, and total sperm count postoperatively. This study confirms that microsurgical varicocelectomy significantly improves sperm capacitation ability and improves the expected probability of generating a pregnancy within 3 rounds of intrauterine insemination. The improvement in sperm capacitation ability may help explain how varicocele repair may improve the chance of pregnancy, regardless of standard semen parameter improvements.

Varicocele Surgery: Three Years Experience

Despite available treatments like varicocelectomy, a standard therapy remains controversial. Varicocele repair has shown promise in improving sperm parameters, but further research is needed, especially in nonobstructive azoospermia cases. Techniques such as microscopic testicular sperm extraction and intracytoplasmic sperm injection have shown some success in achieving pregnancies. Objective: To articulate our hands-on experience and understanding pertaining to varicocele. Methods: This study included patients who presented to our clinic due to varicocele and underwent surgical procedures between November 2020 and January 2023. Results: This research involved 26 varicocele patients, primarily age rage was 27.5 years old. The majority (85%) had varicocele on the left side, and 15% had bilateral varicocele. The mean vein diameter was 3.58mm and 2.6mm for the left side and bilateral cases respectively, with a general average of 3.45mm. Analysis of sperm count, motility, and morphology reflected an average of 32.6 million/ml, 23.2%, and 5.23%, respectively. An average of 4.45 veins was ligated during surgery, with a slight variance based on the side. One patient lost approximately 85% of the testicular blood supply due to a complication during surgery, leading to testicle hardening without atrophy. Two patients experienced recurrence (7.6% recurrence rate). Negative and positive correlations were found between the number of ligated veins and preoperative sperm count (p=0.043, r=-0.408), and vein diameter and preoperative sperm morphology (p=0.004, r=0.544), respectively. Conclusions: Despite the limitations, our study provides valuable insights into the relationship between varicocele severity and sperm parameters.

Zishen Yutai Pill improves sperm quality and reduces testicular inflammation in experimental varicocele rats

ObjectiveZishen Yutai Pill (ZYP), containing 15 Chinese traditional medicine, is a safe and well quality-controlled TCM preparation with promising effects in many fields of reproduction. The current study was designed to investigate the therapeutic effects of ZYP on sperm quality and testis in varicocele (VC) rats. Materials and methodsMale Wistar rats were randomly divided into four groups (n = 6), i.e., a sham group, a VC group, and VC groups treated with different dose of ZYP (1575 and 3150 mg/kg/d, respectively). The experimental VC model was established by partial ligation of left renal vein. Six weeks after model establishment, ZYP was orally administered once a day for the next 6 weeks. Parameters relating to testis and sperm quality were assessed. Hematoxylin–eosin staining was used to showed testicular tissue damage in experimental VC rats. Expressions of proteins relating to NLRP3 inflammasome pathways were determined using Western blot (WB). The mRNA expressions of relating genes were determined using quantitative real-time PCR (qRT-PCR) analysis. ResultsZYP could significantly improve sperm motility and decrease sperm DNA fragmentation index in VC rats (P < 0.05). Hematoxylin-eosin (HE) staining showed that ZYP could alleviate testicular tissue damage caused by experimental varicocele in rats. Compared to the VC model, expressions of NLRP3, ASC, and caspase-1 in rats treated with ZYP were significantly down-regulated, as validated by both qRT-PCR and WB analysis (P < 0.05). ConclusionsIn brief, ZYP could improve sperm DNA integrity by inhibiting the NLRP3 inflammasome pathway and alleviating the chronic inflammation of testicular tissue induced by experimental varicocele in rats.

(524) Adolescent Varicocelectomy: Long-term Follow-up of Clinical Outcomes and Patient Satisfaction

Abstract Introduction Worldwide 10–15% of male adolescents have a varicocele, which is the most common surgically correctable cause of male subfertility. In young adult men, varicocele can be associated with smaller testis volume and abnormal semen parameters. However, there is still controversy in whether surgical repair has better long-term outcomes than just active surveillance. Objective To evaluate satisfaction, symptoms improvement, hypogonadism, and paternity in patients who underwent varicocelectomy when they were adolescents. Methods We performed a retrospective chart review of adolescents undergoing varicocelectomy from 2011-2021. Inclusion criteria were having primary varicocele, having 12-21 years at time of surgery, having had the varicocelectomy &amp;gt;1-year ago, ≥1 postoperative visits, and having answered the questionnaire. Exclusion criteria were having a diagnosis of secondary varicocele (renal malignancy or venous abnormality) and incomplete records. Data about clinical, surgical, and postoperative outcomes were gathered. Patients were contacted by phone and were asked about orchialgia, paternity, varicocele recurrence, diagnosis and treatment for hypogonadism, and satisfaction after surgery. Descriptive analysis and paired t-test were used, statistical significance was assessed at p&amp;lt;0.05. Results From a total of 50 patients meeting the inclusion criteria, we were able to contact 23 patients. The mean age at varicocele diagnosis was 17.43±2.52 years. Varicocele was grade 3 in 16 (69.6%) patients and left-sided in 17 (73.9%) patients. Eight (34.8%) patients had a preoperative testicular ultrasound, that in 2(25%) patients showed testicular volume discrepancy &amp;gt;20%. At the physical exam, 6(26.1%) patients were found to have asymmetric testicles. Overall, 2(8.7%) patients had a previous varicocele repair and 7(30.4%) had a preoperative abnormal semen analysis. Mean age at surgery was 18.78±2.02 years. Microscopic varicocelectomy was performed in 22 (95.7%) patients, mainly in the left-side (78.3%). Pre- and postoperative FSH and T levels were done in 10 patients, without any significant difference after surgery (p=0.074 and p=0.069, respectively). Pre- and postoperative semen analysis were performed in 12 patients and showed a significant improvement in motility after varicocelectomy (p=0.022). Mean follow-up after surgery was 1.42±1.40 months. The questionnaire was performed in a mean of 3.43±2.55 months after varicocelectomy and the mean age of the responders was 22.3±3.11 years. Orchialgia persisted in 7 patients (30.4%), predominately in the left side (71.4%). None of the patients had been diagnosed with varicocele recurrence nor had required a surgical reintervention. Twenty-one (86.9%) patients were not actively trying to achieve a natural conception nor had been involved in a pregnancy after varicocelectomy. Two patients (8.7%), with a preoperative abnormal semen analysis, were able to conceive. None of the patients referred to have hypogonadism nor being under testosterone therapy. The majority of patients (86.9%) referred to be satisfied with the postoperative results. Conclusions Our results suggested that long-term outcomes of varicocelectomy in adolescents would show high patient satisfaction, low rate of recurrence, no association with hypogonadism, and a significant persistence of testicular pain. Although male fertility after varicocelectomy demonstrated promising results, a longer follow-up assessment should be done when patients are actively trying to conceive, to have a more representative sample size. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Acerus, Boston Scientific, Endo Pharmaceuticals and Coloplast