Outcomes of magnification-assisted microsurgical subinguinal varicocele repair: A bicentric retrospective study.

Impact of varicocelectomy prior ICSI on clinical and neonatal outcomes: A multilevel analysis

Surgical repair can be offered to patients with scrotal pain of suspected varicocele origin. The estimated success rate of pain resolution is approximately 80%, although recent publications have been inconsistent. Predictive variables for successful outcomes remain contested. The current study aimed to evaluate the efficacy of microscopic repair in resolving varicocele pain and to identify variables that predict successful outcomes. During the study period, microscopic subinguinal varicocelectomy was performed in 59 patients with varicocele-related pain. Grade III left varicocele was present in 36 (61%) patients. The median width of the left varicocele, as measured by ultrasound, was 4.2 mm (IQR 4-5), with reflux identified in 39 (66%) patients. The most common type of pain-dull pain-was present in 39 (66%) patients. Exertional pain and sharp pain were reported by 11 (19%) and 9 (15%) patients, respectively. The median follow-up time was 24 months (IQR 13-35), while 46 (78%) patients were contacted by telephone more than 12 months after surgery. Fifty (85%) patients reported complete pain resolution, while partial resolution and persistent pain were reported by 4 (6%) and 5 (9%) patients, respectively. Two variables that increased the risk of pain persistence were repeat varicocele repair surgery and pain as a secondary or additional indication for surgery. Follow-up time of more than 12 months after surgery reduces the risk of pain persistence. A varicocelectomy is a good option for resolving painful varicocele in most patients, especially those whose only indication for surgery is pain. Repeat varicocele surgery appears to increase the risk of persistent pain. A longer follow-up period (more than 12 months after surgery) increases the chances of pain resolution.

Background: Varicocele is a common, correctable cause of male infertility, often associated with impaired spermatogenesis. Microsurgical subinguinal varicocelectomy is considered the gold standard for varicocele repair, with documented benefits on semen quality, particularly sperm count.Objective: The objective of this study was to evaluate the effect of microsurgical varicocelectomy on sperm count in infertile men diagnosed with clinical varicocele.Methodology: This prospective observational study was conducted at the Institute of Kidney Diseases, Hayatabad Medical Complex, Peshawar, Pakistan, over six months (October 1, 2024, to March 31, 2025). A total of 100 male patients aged between 20 to 45 years with clinical Grade I-III varicocele and abnormal semen parameters were enrolled. Patients underwent microsurgical subinguinal varicocelectomy after baseline semen analysis. A follow-up semen analysis was performed three months postoperatively. Pre- and postoperative sperm counts were compared using paired t-tests. Subgroup analysis was performed based on varicocele grade and laterality.Results: The mean preoperative sperm count was 12.5 ± 6.8 million/mL, which significantly increased to 20.2 ± 8.1 million/mL postoperatively (p < 0.001). Patients with Grade III varicocele showed the highest improvement (22.6 ± 9.1 million/mL, p = 0.003). No significant difference was observed based on laterality (p = 0.087).Conclusion: Microsurgical varicocelectomy significantly improves sperm count in men with clinical varicocele, particularly in higher-grade cases. It should be considered an effective first-line intervention in the management of varicocele-associated male infertility.

To compare the therapeutic efficacy and safety of local anesthesia and spinal anesthesia for the patients with varicocele (VC) who underwent microsurgical varicocelectomy (MV). We retrospectively analyzed the data of VC patients who underwent MV treatment at the Andrology Department of the Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine from May 2020 to March 2023. Cases with complete clinical data and follow-up evaluation were selected and divided into a control group (spinal anesthesia) and an observation group (local anesthesia) according to different anesthesia methods. The surgical time (including anesthesia time), visual analogue scale (VAS) score for pain, hospital stay, treatment cost, sperm concentration, forward motile sperm rate, and normal sperm morphology rate after three months of surgery, as well as postoperative complications and recurrence rate were compared between the two groups. A total of 107 eligible cases were included, with 56 cases in the control group and 51 cases in the observation group. There was no significant difference in the VAS score for pain during and after four hours of surgery, as well as postoperative complications, and recurrence rate between the two groups (P> 0.05). There was an significant increase in sperm concentration, forward motile sperm rate, and normal sperm morphology rate in both of two groups after three months of surgery (P<0.05). However, there was no significant difference between the two groups three months after surgery (P>0.05). The surgical time and hospital stay were shorter than those of the control group (P<0.05). And the treatment cost in observation group was lower than that of the control group (P<0.05). Both local anesthesia and lumbar anesthesia for MV treatment of VC have good efficacy and safety. However, patients treated with MV under local anesthesia for VC have obvious advantages in terms of operation time (including anesthesia time), hospital stay, and treatment cost, which is worthy of clinical promotion and application.

BackgroundVaricocele is the most common correctable form of male infertility. Varicoceles have been established to result in worsened semen parameters as well as elevate sperm DNA fragmentation (SDF). There is data indicating that varicocele repair improves semen parameters and SDF, however; there is a paucity of data assessing the correlation of varicocele clinical grade with the severity of SDF and the amount of improvement in SDF with varicocele repair based on grade. The purpose of this study was to assess the difference in baseline sperm DNA fragmentation indices (DFIs) in infertile men with varicoceles based on the clinical grade of the varicocele and the amount of improvement in DFI following varicocele repair.MethodsA retrospective chart review was performed in men who presented for a fertility evaluation and were diagnosed with a clinical varicocele and underwent varicocele repair with preoperative and 3-month postoperative semen analyses with DFI testing.ResultsThere was no significant difference in the level of SDF based on the grade of varicocele, and there was not a significant correlation between the grade of the varicocele and the amount of improvement in SDF from baseline to 3 months after varicocele repair.ConclusionsWhen counseling infertile men undergoing varicocele repair for elevated SDF, the grade of varicocele may not impact the amount of improvement expected in SDF following repair, suggesting that varicocele patients may be counseled similarly on expectations for response regardless of varicocele grade.

The pathological mechanism of venous reflux in varicocoele (VC) remains unclear. The theory of vascular remodeling may play an important role. This study aims to explore the potential pathological mechanism of VC and its association with abnormal vascular remodeling in VC patients. We collected specimens of spermatic veins from VC patients who received microsurgical varicocelectomies at the Department of Andrology, the Affiliated Hospital of Qingdao University, from January 2020 to January 2024. The spermatic veins of VC patients were divided into three subgroups based on diameter (<1mm, 1-3mm, and >3mm), with a control group consisting of spermatic veins from hydrocele patients. Differences in venous morphology and ultrastructure between these groups were examined using optical microscopy (OM) and transmission electron microscopy (TEM). The expression of alpha-smooth muscle actin (α-SMA) and osteopontin (OPN) was evaluated by immunohistochemical staining and Western blot analysis. Substantial hyperplasia and disordered arrangement of smooth muscle cells (SMCs) in the spermatic veins of VC patients were observed. Thickness and clumpy aggregation of collagen fibers were also noted under OM, with a significantly higher proportion observed. An increase in dense bodies and mitochondrial vacuolization in the VC group were revealed by TEM. Immunohistochemical staining showed that both α-SMA and OPN were enriched in SMCs. Western blot analysis showed that the expression of OPN was significantly greater in the 1-3mm and >3mm subgroups compared with the control group (p<0.05), while the expression of α-SMA did not show a significant decrease. The pathological changes in morphology and overexpression of OPN in SMCs indicates a possible spermatic vascular transition from the contractile to secretory phenotype. This abnormal vascular remodeling might be associated with the reflux in the spermatic veins of VC patients.

Abstract Study question Can an automated semen analyzer integrated with sperm DNA fragmentation test provide a reliable assessment of fertility potential for varicocele patients? Summary answer The artificial intelligent optic microscope (AIOM) semen analysis system can efficiently provide reliable semen quality reports, demonstrating an 80% concordance with reference method. What is known already Varicocele (VC) is the most common cause of reversible male infertility. Although impairments in basic semen parameters are frequently identified in VC patients, it provides limited insight into the interpretation of male fertility. Many research studies have consistently shown elevated sperm DNA fragmentation (SDF) in VC patients, suggesting that SDF testing could improve the assessment of their fertility potential. However, conventional SDF methods, such as the TUNEL assay, are hindered by operational complexity and a lack of standardized protocols, leading to a gap between understanding VC-associated SDF and its clinical application. Study design, size, duration A monocentric observational study was conducted at the Department of Urology, University of Foggia, Italy, from July 2023 to January 2025. This study recruited participants aged 18–55 years that were divided into two groups: those diagnosed with VC (n = 68) and normozoospermic individuals (n = 32) serving as controls. Participants/materials, setting, methods Semen samples were collected after 3–5 days of abstinence and allowed to fully liquefy before further analysis. First, basic semen analysis was conducted using the LensHooke® X12 PRO system (X12). Next, SDF was assessed using the LensHooke® R11 test (R11) with automated scoring via the X12, and TUNEL assay conjugated with flow cytometry was used as a reference method. Main results and the role of chance Basic semen analysis revealed that VC patients had significantly lower sperm concentration [22.7 (8.4-51.2) M/mL vs. 39.1 (30.5-49.1) M/mL, p = 0.0024], total sperm count [71.4 (34.5-210.6) M vs. 119.9 (78.0-180.9) M, p = 0.0183], motility [40.5 (24.0-67.0) % vs. 61.0 (55.0-64.0) %, p = 0.0001], and normal morphology [3.0 (2.0-4.0) % vs. 5.0 (4.0-5.0) %, p &amp;lt; 0.0001] compared to controls. The DNA Fragmentation Index (DFI) for R11 was significantly higher in VC than controls [11.3% (7.6-14.6) vs. 16.0% (8.6-24.2), p = 0.0066]. Reported values are median (Q1-Q3) and p-values derives from Mann-Whitney/Wilcoxon signed-rank test. The concordance between R11 and TUNEL showed 80% concordance, with a Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) value of 0.6. For the first time, we demonstrated a strong correlation between the novel SDF testing model (R11-X12) and the established reference method (TUNEL assay). It is implied that integrating the R11-X12 model into clinical practice could improve the assessment of fertility potential in VC patients. Limitations, reasons for caution The findings indicate that the R11-X12 model provides results comparable to the reference method. However, a well-designed study addressing inter-observer variability is essential to validate its clinical applicability for routine sperm DNA fragmentation assessments. Wider implications of the findings X12, designed for spermogram analysis and DFI assessment, features an automated scoring system that streamlines andrology workflows while reducing manual subjectivity. Furthermore, its reporting time is significantly shorter than traditional manual methods. These advantages underscore the R11-X12 PRO system’s suitability for diagnosing VC-related symptoms and conducting comprehensive fertility assessments. Trial registration number Yes

Objective： Varicocele (VC) induces male infertility by mediating changes in the testicular microenvironment, in which testicular hypoxia and high-pressure are important pathological conditions. This study aims to compare the mouse spermatogenesis (GC-2spd) cells and Sertoli (TM4) cells of mouse testis after hypoxic modeling and hypoxic and high-pressure combined modeling, and to explore the feasibility of establishing a hypoxic and high-pressure combined cell model. Methods： On the basis of cell hypoxia induced by CoCl2, the complex model of testicular cell hypoxia and high pressure was constructed by changing the osmotic pressure of GC-2 and TM4 cell medium with a high concentration of NaCl solution. After selecting the intervention concentration of CoCl2 by MTT test and detecting the expression level of HIF-1α for the determination of the optimal osmotic pressure conditions of the cell model, the cells were divided into normal group, hypoxia model group and composite model group. And the levels of OS, programmed cell death, inflammatory factors, and the expression levels of pyroptosis-related proteins were compared between the normal group and the groups with different modeling methods. Results： The optimal intervention concentration of CoCl2 in GC-2 and TM4 cells was 150 and 250μmol/L, respectively, and the expression of HIF-1α was the highest in both cells under osmotic pressure of 500 mOsmol/kg (P<0.05). Compared with the normal group, the SOD levels of GC-2 and TM4 cells decreased (all P<0.05), CAT level decreased (all P<0.05), and MDA level increased (all P<0.01), and the OS level of GC-2 and TM4 cells was more obvious than that of the hypoxia model group (all P<0.05). Compared with the normal group, apoptosis occurred in GC-2 and TM4 cells after composite modeling (all P<0.05). Compared with the normal group, the mRNA expressions of IL-1β, IL-18, TNF-α and COX-2 in GC-2 and TM4 cells significantly increased (P<0.01) and higher than those in hypoxia model group (P<0.05) and induced pyroptosis (P<0.01). The expression level of GSDMD increased (P<0.05). Conclusion： The cell model with hypoxia and high pressure combined modeling can not only induce oxidative stress and apoptosis of cells better than that with hypoxia alone, but also further cause inflammatory response damage and pyroptosis, which simulates the changes of testis microenvironment mediated by hypoxia and high pressure combined conditions in VC. This cell model can be used for studying the pathogenesis of VC-associated male infertility, evaluating drug efficacy, and exploring pharmacological mechanisms.

Correlation of 17-OH Progesterone Changes With Semen Parameters and Pregnancy Outcomes in Hypogonadal and Eugonadal Patients After Varicocelectomy.

This study aims to explore the correlation between plasma homocysteine (Hcy) levels and the clinical grading of varicocele (VC) when analyzing the potential pathogenesis of endothelial cells injury by Hcy. A total of 184 VC patients, aged 18–46 years, were included in this study. These patients visited The Second Hospital of Dalian Medical University (Dalian, China), between January 2022 and September 2024. Patients were divided into three groups based on clinical grading: Group A (59 cases, Grade I), Group B (28 cases, Grade II), and Group C (97 cases, Grade III). Additionally, 120 individuals with normal fertility test results during the same period were selected as the control group. Routine blood and biochemical indices were collected from the patients. Differences in clinical indices between groups were compared, and univariate and multivariate linear regression analyses were performed to identify factors associated with clinical grading. The results showed that the median Hcy levels in the control group and in patients with Grade I, II, and III VC were 9.56 (interquartile range [IQR]: 8.66, 14.02) µmol l−1, 11.28 (IQR: 9.71, 14.55) µmol l−1, 11.84 (IQR: 10.14, 15.60) µmol l−1, and 12.27 (IQR: 9.52, 15.40) µmol l−1, respectively. The differences between the four groups were statistically significant (χ2 = 12.41, P = 0.006). Multivariate regression analysis indicated that Hcy is a factor associated with the clinical grading of VC (t = 2.53, P = 0.013). Hcy is associated with the clinical grading and may have clinical value in assessing severity of VC.

Varicocele (VC) is a common cause of male infertility, yet there is a lack of molecular information for VC-associated male infertility. This study investigated alterations in the seminal plasma metabolomic and lipidomic profiles of infertile male VC patients. Twenty infertile males with VC and twenty-three age-matched healthy controls (HCs) were recruited from Peking Union Medical College Hospital (Beijing, China) between October 2019 and April 2021. Untargeted metabolite and lipid profiles from seminal plasma were analyzed using mass spectrometry. Four hundred and seventy-six metabolites and seventeen lipids were significantly different in infertile male VC patients compared to HCs. The top enriched pathways among these significantly different metabolites are protein digestion and absorption, aminoacyl-transfer RNA (tRNA) biosynthesis, and biosynthesis of amino acids. Different key lipid species, including triglyceride (TG), diacylglycerol (DG), ceramides (Cer), and phosphatidylserine (PS), varied between VC and HC groups. The distinct metabolites and lipids were moderately correlated. DL-3-phenyllactic acid is a potential diagnostic biomarker for VC-related male infertility (area under the curve [AUC] = 0.893), positively correlating with sperm count, concentration, and motility. Furthermore, DL-3-phenyllactic acid is the only metabolite shared by all four comparisons (VC vs HC, VC-induced oligoasthenospermia [OAS] vs VC-induced asthenospermia [AS], OAS vs HC, and AS vs HC). DL-3-phenyllactic acid significantly decreased in OAS than AS. Metabolite-targeting gene analysis revealed carbonic anhydrase 9 (CA9) might be the strongest candidate associated with the onset and severity of VC. The seminal plasma metabolite and lipid profiles of infertile males with VC differ significantly from those of HCs. DL-3-phenyllactic acid could be a promising biomarker.

To compare the clinical efficacy between microscopic varicocelectomy and laparoscopic varicocelectomy in the treatment of varicocele（VC）with male infertility. A total of 307 patients who were diagnosed with VC complicated with male infertility and admitted to the Affiliated Hospital of Qingdao University from October 2018 to October 2022 were recruited for retrospective analysis. The patients were divided into the microscopic group (180 cases) and laparoscopic group (127 cases) according to the surgery method. The pre- and postoperative clinical data of these two groups were analyzed, including the degree of dilatation and reflux time of internal spermatic vein，hemodynamic parameters of testicular capsular artery，proportion of progressive motility spermatozoa (PR), concentration of spermatozoa, proportion of normal morphology sperm，the pregnancy outcome of spouses and the incidence of complications related with surgery within 2 years postoperatively. All the surgeries for the 307 patients in this study were successful. There was no significant difference in operation time, hospitalization time and management expenses between the microscopic group and the laparoscopic group (P>0.05). Compared to the patients in laparoscopic group, the patients in the microscopic group received a better improvement in venous diameter, reflux time of spermatic veins and hemodynamic parameters of testicular capsular artery (P<0.05). Moreover, the semen analysis showed that the PR, spermatozoa concentration and proportion of normal morphology sperm in the microscopic group were also obviously increased than those in the laparoscopic group (P<0.05). During the 2-year follow-up period, the conception rate of spouses in the microscopic group was 67.2%, while only 47.2% in the laparoscopic group, in which the difference was statistically significant (P<0.05). Besides, the time-to-pregnancy ( TTP ) within 2 years postoperatively in the microscopic group was significantly shorter than that in the laparoscopic group（P<0.05). Meanwhile, the incidence of adverse pregnancy outcomes in the microscopic group was also significantly lower than that in the laparoscopic group (P<0.05). It is worth mentioned that the spontaneous conception rate of spouses with successful pregnancy in the microscopic group was also significantly higher than that in the laparoscopic group (P<0.05). Severe complication such as testicular atrophy, bleeding and infection did not appear in both of two groups. However, the incidences of testicular hydrocele and recurrence of VC postoperatively in the laparoscopic group were significantly higher than those in the microscopic group (P<0.05). Both microscopic varicocelectomy and laparoscopic varicocelectomy can be applied to the management of VC combined with male infertility. But microscopic varicocelectomy showed better clinical efficacy in improving the testicular hemodynamic parameters, semen quality, pregnancy outcome and postoperative complications, which is worthy of further clinical applications.

BackgroundIn infertile couples whose male partner has alterations in semen parameters frequently, a comprehensive andrological approach is lacking and approximately 30–50% are classified as idiopathic infertility. These couples are often directly addressed to assisted reproduction techniques (ARTs). However, several clinical conditions may benefit from medical treatment. By acting on etiology and/or risk factors, this aims at improving seminal parameters and restoring natural fertility.ObjectivesTo verify the impact of a comprehensive andrological assessment on the management of infertility (in particular, in couples with isolated male factor infertility) using as the primary outcome the natural pregnancy rate.Materials and methodsA multicenter retrospective study was conducted between 2015 and 2022 in 1014 couples with primary infertility seeking natural conception (including 266 couples with previous ART failure). Each couple underwent a multidisciplinary evaluation. This involved: a gynecologist and an andrologist both with expertise in infertility, a psychologist when requested, and a fertility awareness practitioner according to a unique diagnostic and therapeutic multidisciplinary protocol.ResultsAn isolated male factor was found in 23% of couples. In 45%, it was associated with female factors also. The comprehensive diagnostic approach reduced the proportion of idiopathic infertility to 8% of the couples. Targeted treatment, based on diagnostic categories, was associated with spontaneous pregnancy in 40.9% of the couples. In the 233 cases without female factors, normal semen parameters were observed only in 13% of patients. Male genital tract inflammation was observed in 48.8% of the patients, genital tract infection in 43.1%, and hypospermatogenesis in 16.7%. Patients with infections were treated with antibiotics and probiotics. If further inflammation was documented, this was followed by low‐dose corticosteroids and antioxidants. Follicle stimulating hormone (FSH) treatment was used in patients with hypospermatogenesis, and varicocele repair surgery was performed in four patients.Discussion and conclusionsOur data underline the efficacy of a comprehensive approach to the diagnostic process of male factor infertility, both in reducing the percentage of idiopathic infertility and in restoring natural fertility based on a targeted treatment.

Not all varicocele (VC) patients experience improvements in semen quality after undergoing varicocelectomy. This study aims to investigate whether phosphoglycerate kinase 2 (PGK2) protein in seminal plasma could serve as a predictive biomarker for the enhancement of sperm motility post-varicocelectomy. Sixty patients diagnosed with VC-associated asthenospermia and who underwent varicocelectomy at the Third Affiliated Hospital of Southern Medical University were included in this study. Semen samples from 33 healthy donors were also collected. Hematological and semen analysis parameters were assessed at baseline and at the 6-month postoperative follow-up. The concentration of PGK2 in seminal plasma was determined using enzyme-linked immunosorbent assay (ELISA). Additionally, eleven machine learning algorithms were employed to develop a model to evaluate the effectiveness of varicocelectomy based on PGK2 concentration, hematological parameters, and semen quality indicators. The levels of PGK2 in seminal plasma were significantly lower in VC patients compared to healthy donors (P<0.001). Increased levels of PGK2 were observed in the VC subjects after the varicocelectomy (P<0.001). PGK2 concentration was found to be a significant indicator [area under curve (AUC) =0.735, 95% confidence interval (CI): 0.601-0.860] and an independent predictor (P=0.003, P=0.049) of the success of varicocelectomy. The linear discriminant analysis (LDA) model demonstrated strong classification ability for assessing varicocelectomy outcomes in both the training (AUC =1.000, 95% CI: 1.000-1.000) and testing (AUC =0.804, 95% CI: 0.619-0.963) groups. PGK2 in seminal plasma shows promise as a potential biomarker for predicting improved sperm motility following varicocelectomy, thus aiding in clinical decision-making regarding therapeutic approaches.

To observe the effect of Guilu Taohong Formula on semen quality in varicocele (VC) models of rats, and to explore its possible mechanism. Forty-eight male SD rats were randomly divided into four groups (sham group, model group, Guilu Taohong Formula group and L-carnitine group). After the establishment of models, the rats were treated with intragastric administration for eight consecutive weeks. The general condition of the rats was observed. After the gavage, the testicular and epididymal indices were calculated. Semen quality was assessed using an automatic semen analyzer. Apoptosis of testicular cells was assessed by TUNEL staining. And the expression levels of B-cell lymphocytoma-2 (Bcl-2), Bcl-2-associated X protein (Bax) and cysteine aspartate protease-3 (caspase-3) in testicular tissue were detected by Western blot. Compared with the sham group, testicular index, epididymal index, sperm concentration, the percentage of progressive motility of sperm (PR%) and the expression level of Bcl-2 decreased in model group(P<0.01). An increased apoptosis rate of spermatogenic cells and the expression levels of Bax and caspase-3 proteins were observed in model group as well(P<0.01). Compared with the model group, the testicular index, epididymal index, sperm concentration, PR% and the expression level of Bcl-2 in Guilu Taohong Formula group increased significantly (P<0.05, P<0.01). A decreased apoptosis rate of spermatogenic cells and the expression levels of Bax and caspase-3 proteins were detected in Guilu Taohong Formula group as well(P<0.01). Similarly, the L-carnitine group showed increased testicular index, epididymal index, sperm concentration, PR% and the expression level of Bcl-2 protein (P<0.05, P<0.01), where showed decreased apoptosis rate of spermatogenic cells and the expression levels of Bax and caspase-3 proteins compared with model group (P<0.01, P<0.05). Guilu Taohong Formula improves semen quality in VC model rats and reduces the apoptosis rate of spermatogenic cells in testicular tissue, which may be related to the promotion of Bcl-2 protein expression and the inhibition of Bax and caspase-3 protein expression levels.

Background: Non-obstructive azoospermia (NOA) is a form of male infertility, often associated with conditions influencing spermatogenesis, such as varicoceles. While varicocele repair is a standard intervention, the role of micronutrient supplementation in improving semen parameters and enhancing fertility outcomes in men with NOA and varicocele is promising. Case Summary: The patient is a 30-year-old white Lebanese Caucasian male presenting with a previous diagnosis of NOA, with low testosterone levels and elevated follicle-stimulating hormone and luteinizing hormone levels. Clinical examination, hormonal assessment, scrotal ultrasound, and semen analysis revealed non-obstructive azoospermia associated with bilateral varicoceles. After ongoing bilateral varicocelectomy, the patient was prescribed Cyclofert MaleTM, a combination of L-carnitine L-tartrate, N-acetyl-cysteine, coenzymeq10, Zinc, folic acid, selenium, vitamin C, vitamin E, and Lycopene, at a dose of two tablets per day, for six months. At follow-up, semen analysis revealed improved sperm concentration; and successful in vitro fertilization (IVF) with blastocyst transfer was achieved. Conclusion: This case reveals the potential role of micronutrient supplementation in improving semen parameters and IVF outcomes. Cyclofert MaleTM offers a promising adjunctive and non-invasive treatment option for men with NOA and infertility

BackgroundHemodynamic alterations in the spermatic vein are implicated in infertility among patients with varicocele (VC). Contrast-enhanced ultrasound (CEUS), a powerful tool for hemodynamic analysis, remains unexplored for VC. This study aimed to demonstrate the feasibility of using CEUS to evaluate spermatic vein hemodynamics in patients with VC and establish a clear correlation between specific hemodynamic patterns and impaired semen parameters. This study included 165 patients with left-sided VC and 50 healthy volunteers. All participants underwent CEUS of the spermatic veins, along with maximum venous diameter and testicular volume measurements and serum sex hormone levels and routine semen analyses. The sperm DNA fragmentation index was measured in 146 patients with VC and 37 healthy controls.ResultsThe analyses revealed four distinct blood flow patterns of the spermatic vein: steady flow, intermittent stasis, intermittent reflux, and filling defect. In healthy spermatic veins, the predominant blood flow patterns included steady flow and intermittent stasis. Spermatic veins with VC exhibited a significant increase in the intermittent reflux and filling defect patterns, with the proportion rising as the clinical grade increased. The four patterns were further grouped into the “steady flow & intermittent stasis” and “intermittent reflux & filling defect” patterns for logistic regression analyses; the intermittent reflux & filling defect pattern was revealed as an independent risk factor for impaired sperm concentration, total sperm counts, progressive motility, morphology, and DNA fragmentation index.ConclusionsThis study validated the feasibility of CEUS for assessing the hemodynamics of the spermatic vein and established the intermittent reflux & filling defect pattern as an independent predictor of impaired semen parameters.

Varicocele has a detrimental effect on testicular growth and spermatogenesis, hence the importance of its management. This management remains controversial among Tunisian urologists; diagnostic and therapeutic choices tend to vary from one urologist to another. The aim of this survey is to evaluate the practices of Tunisian urologists regarding varicocele management compared to the latest international guidelines. A cross-sectional study was conducted among Tunisian urologists, members of the Tunisian Association of Urology, using a computerized questionnaire available online. The response rate was 51.6%. Approximately 80% of Tunisian urologists reported that they diagnose and manage patients with varicocele at least once a week. Half of the Tunisian urologists use a grading system for classification. Over 75% of Tunisian urologists believe that scrotal ultrasound and semen analysis should be systematically requested. Half of them consider treatment starting from Dubin and Amelar grade 2, while the other half treat from Dubin and Amelar grade 3. The majority agreed that the results of varicocele repair are controversial, with 10% never performing bilateral varicocele repair. The vast majority planned surgical treatment (95%), with sub-inguinal approach and magnification used in only 16% of cases; 25% never froze sperm before varicocele repair. Recent recommendations had clear messages to promote in terms of diagnosis, therapeutic indications, and modalities. This work highlights the existence of gaps between recommendations on certain aspects of varicocele management, suggesting a review of continuous medical education modalities regarding this pathology in particular.

The role of varicocele repair (VR) in infertile men with non-obstructive azoospermia (NOA) and varicocele is controversial in the current guidelines, despite available studies. This study aims to assess the impact of VR on testicular sperm retrieval, sperm recovery from the ejaculate, and clinical pregnancy rates in infertile men with NOA and clinical varicocele through a systematic review and meta-analysis (SRMA) of controlled studies. A systematic literature search was conducted using the Scopus and PubMed databases up to November 2023. Among the 1,847 articles retrieved, five observational controlled studies comparing reproductive outcomes between infertile men with NOA and clinical varicocele who underwent VR, and a control group that received no treatment, met the inclusion criteria for this SRMA. The selected studies included 269 men with NOA who underwent VR before the testicular sperm extraction (TESE) procedure and 364 men who did not undergo VR. The pooled estimate demonstrated a significantly higher odds ratio (OR) of 2.17 (95% confidence interval [95% CI]: 1.17-4.01, p=0.01) for surgical sperm retrieval in the VR group. VR significantly increased the likelihood of sperm appearance in the ejaculate, with an OR of 7.8 (95% CI: 3.59-16.94, p<0.001). Besides, VR provided a significantly greater clinical pregnancy rate with intracytoplasmic sperm injection (ICSI) compared to non-operated men (OR: 2.18, 95% CI: 1.03-4.60; p=0.04). This is the first SRMA, consisting of only controlled studies, to demonstrate that VR performed prior to TESE in men with NOA significantly improves sperm production as reflected in the spontaneous appearance of sperm in the semen and higher odds of surgical sperm retrieval and clinical pregnancy compared with non-operated men. Thus, these findings highlight the potentially beneficial impact of VR in men with NOA and clinical varicocele.