Varicocelectomy In Infertile Men Research Articles

Spontaneous pregnancies post-microsurgical varicocelectomy in infertile men with severe oligozoospermia: a preliminary vietnamese report.

This study evaluated whether microsurgical varico-celectomy performed in infertile men with severe oligozoospermia (SO) resulted in improved semen parameters or increased rates of spontaneous pregnancy (SP) and performed a cost-effectiveness analysis comparing intrauterine insemination (IUI), in vitro fertilization (IVF), and varicocelectomy. This study included 25 patients with SO who underwent microsurgical varicocelectomy between September 2019 and May 2022, which resulted in post-surgical SP in all cases. Men with azoospermia, abnormal karyotype, or Y-chromosome microdeletion were excluded from the study. Serum luteinizing, follicle-stimulating, and testosterone hormones were measured preoperatively. Semen was analyzed every 3 months postoperation. The incidence of SP was recorded at each visit. Cost-effectiveness for assisted reproductive technologies was calculated based on reported costs. Several parameters were evaluated as potential predictors of the response to microsurgical varicocelectomy using univariate and multivariate analyses. After a mean postoperative observation period of 7 months, 25 couples with SP after microsurgical varicocelectomy were recruited. The mean sperm concentration increased from 3 million/mL (interquartile range [IQR]: 2-5 million/mL) to 12 million/mL (IQR: 5-17 million/mL; p<0.05), and mean sperm motility improved from 4% (IQR: 3%-6%) to 7.6% (p<0.05). Total motile sperm count (TMSC) increased to 3.08 million (IQR: 1.02-5.83 million) from a preoperative value of 0.34 million (IQR: 0.16-0.83 million). A cost-effectiveness analysis comparing IVF with varicocelectomy indicates that varicocelectomy may represent a better first-line option for infertile men with very low preoperative TMSC. However, further research remains necessary to confirm this result. Varicocelectomy should be discussed as a treatment option for men with SO and may improve sperm quality and fertility potential, resulting in SP.

Nomogram for Predicting Semen Parameters Improvement after Microscopic Varicocelectomy in Infertile Men with Abnormal Semen Parameters.

Information on the prediction of improved semen parameters following varicocelectomy is scarce and mostly contradictory. Therefore, we developed and validated a nomogram to predict whether abnormal semen parameters in infertile men could improve following microscopic varicocelectomy (MSV). From January 2018 to December 2021, 460 consecutive patients who underwent MSV were included. Of them, 336 patients as a development cohort at the Xiang Hua institution. As a validation cohort, Hu Nan Center (124 patients) was used. Clinicopathologic patient information was recorded. The likelihood ratio test using Akaike's information criteria was employed as the stopping rule, and multivariate logistic regression was utilized to create a prediction model with regression coefficients. The effectiveness of this prediction model was evaluated based on its ability of discrimination, calibration, and clinical utility. The initial total progressively motile sperm count (TPMSC) and vein diameter were predictors of this model. The model demonstrated strong discrimination for the validation cohort, with an area under the receiver operating characteristic (AUROC) of 0.925 (p &lt; 0.001), and strong calibration (unreliability test, p = 0.522). The decision curve study proved the model's clinical applicability. According to our research, the improvement of semen parameters in infertile men following MSV was significantly predicted by greater vein diameter and higher initial TPMSC. This nomogram aids in individualized decision-making on the varicocele preoperative treatment plan and may help to enhance the therapeutic result.

Nomogram for predicting spontaneous pregnancy after microscopic varicocelectomy in infertile men with normal hormone

IntroductionThe current challenge for the treatment of varicocele is identifying patients who could benefit the most from surgery. We aimed to develop and validate a nomogram for predicting spontaneous pregnancy following microscopic varicocelectomy in infertile men, based on a large cohort.MethodsTwo hundred eighty-two consecutive patients who underwent microscopic varicocelectomy from January 2018 to December 2020 were enrolled as participants in the study. Xiang Hua center (206 patients) as a development cohort. Hu Nan center (76 patients) as a validation cohort. Patient clinicopathologic data were recorded. Multivariate logistic regression was used to build a predictive model with regression coefficients. Then, backward stepwise selection was applied, and the likelihood ratio test with Akaike’s information criterion was used as the stopping rule. The performance of this predictive model was assessed for discrimination, calibration, and clinical usefulness.ResultsPredictors of this model included the age of female partners, diameter of veins, initial and increased total progressively motile sperm count. The model demonstrated good discrimination with an AUROC of 0.925 (p < 0.001) and calibration (Unreliability test, p = 0.522) in the validation cohort. Furthermore, the model was clinically useful, according to decision curve analysis.ConclusionsOur findings indicated that younger female partners, larger diameter of veins, higher initial and increased total progressively motile sperm count were significant predictors of spontaneous pregnancy in infertile men, post microscopic varicocelectomy. This nomogram may assist in individual decision-making on the treatment strategy of varicocele preoperatively and improve the treatment outcome.

P-043 Does BMI affect the outcome of microsurgical varicocelectomy in Infertile men?

Abstract Study question Does Body Mass Index (BMI) affect the semen parameter outcome after microsurgical varicocelectomy in infertile men? Summary answer BMI significantly affects the quality of semen parameters of infertile men with varicocele. However, it does not influence the outcome of varicocele repair. What is known already Varicocele is the most common correctable cause for male infertility. It has been proven that varicocele affects different semen parameters which can be corrected by varicocelectomy, thus restoring male fertility potential. Obesity is another well-known risk factor for male infertility. Both varicocele and obesity can affect semen parameters through similar pathophysiological mechanisms including hyperthermia and increased seminal oxidative stress. Although, varicocele was found to be negatively correlated with BMI, the effect of BMI on varicocele management was not investigated. Study design, size, duration This retrospective study of 1170 patients presenting with male factor infertility to a tertiary medical center over a period of 8 years. The inclusion criteria were patients who underwent microsurgical varicocelectomy for infertility. Patients with a genetic abnormality, history of chemotherapy or radiotherapy or leukocytospermia were excluded. Participants/materials, setting, methods 813 patients were recruited and grouped according to BMI international score into Group A (n = 251patients, BMI &amp;lt; 25kg/m2), Group B (n = 289patients, BMI 25-29.9kg/m2), Group C (n = 183patients, BMI 30-34.9kg/m2 ) and Group D (n = 90patients, BMI&amp;gt;34.9kg/m2) Semen analysis, sperm DNA fragmentation(SDF), hormonal profile were collected pre-and 3 months post-operatively. Chi-squared test, Spearman correlations and Mann-Whitney test were used for statistical analysis of the study data. p-value &amp;lt;0.05 was considered significant. Main results and the role of chance The patients’ mean age was 35.87±8.17 years. High-grade varicocele (II and III) was significantly more prevalent in the lower BMI groups (group A and B, p &amp;lt; 0.001). BMI showed significant negative correlation with sperm concentration (r=-196, p &amp;lt; 0.0001), total motility (r=-117, p = 0.001) and progressive motility (r=-107, p = 0.002). The basal pre-operative investigations showed significant difference between the obesity groups as regards sperm concentration (p &amp;lt; 0.001), total motility (p = 0.003) and progressive motility (p = 0.037). The more obese groups (Groups C and D) showed the poorest semen parameters. Postoperatively, all groups showed significant improvement in sperm concentration (A:p=0.03, B:0.01, C:&amp;lt;0.001, D:0.01). Total and progressive motility were only significant in Groups A (p = 0.06, &amp;lt;0.0001 respectively), B (p &amp;lt; 0.0001, 0.03 respectively) and C (p &amp;lt; 0.0001, &amp;lt;0.0001 repectively) while in Group D, total motility was improved clinically but did reach statistical significance (p = 0.07) and progressive motility didn’t show improvement. Morphology was significantly improved in only Group B (p = 0.02). There was no significant difference between the 4 groups as regards the median improvement of semen parameters postoperatively except for morphology which improved significantly more in the less obese patients (p = 0.002). Limitations, reasons for caution The main limitation is the retrospective design of the study. Wider implications of the findings In infertile patients with varicocele, obesity is an additional factor that leads to worse semen parameters, thus weight reduction may help in these cases. Clinicians should not be discouraged to go for varicocelectomy in obese patients based on the improvement in semen parameters post-varicocelectomy in all obesity groups. Trial registration number Not applicable

P–004 Effect of varicocelectomy on sperm DNA fragmentation rates in infertile men with clinical varicocele: a systematic review and meta-analysis

Abstract Study question Does varicocelectomy improve sperm DNA quality in men with infertility and clinically detected varicoceles? Summary answer Varicocelectomy reduces sperm DNA fragmentation (SDF) rates in infertile men with clinical varicocele. What is known already Varicocele has been linked to male infertility through various non-mutually exclusive mechanisms, including an increase in reactive oxygen species (ROS) production that may lead to sperm DNA damage. Damage to sperm DNA may result in longer time-to-pregnancy, unexplained infertility, recurrent pregnancy loss, and failed intrauterine insemination or in vitro fertilization/intracytoplasmic sperm injection. Therefore, interventions aimed at decreasing SDF rates, including varicocele repair, have been explored to improve fertility and pregnancy outcomes potentially, either by natural conception or using medically assisted reproduction. Study design, size, duration Systematic review and meta-analysis Participants/materials, setting, methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our systematic search included PubMed/Medline, EMBASE, Scielo, and Google Scholar to identify all relevant studies written in English and published from inception until October 2020. Inclusion criteria were studies comparing SDF rates before and after varicocelectomy in infertile men with clinical varicocele. Articles were included if the following SDF assays were utilized: SCSA, TUNEL, SCD test, or alkaline Comet. Main results and the role of chance Thirteen studies fulfilled the inclusion criteria and were selected for the analysis. The estimated weighted mean difference of SDF rates after varicocelectomy was –6.58% (13 studies, 95% CI –8.33%, –4.84%; I2=90% p &amp;lt; 0.0001). Subgroup analysis revealed a significant decrease in SDF rates using SCSA (eight studies, WMD –6.80%, 95% CI –9.31%, –4.28%; I2=89%, p &amp;lt; 0.0001), and TUNEL (three studies, WMD –4.86%, 95% CI –7.38%, –2.34%; I2=89%, p &amp;lt; 0.0001). The test for subgroup difference revealed that pooled results were conservative using the above SDF assays. Comet and SCD tests were used in only one study each; thus, a meta-analysis was not applicable. The studies were further categorized by the surgical technique (microsurgical versus non-microsurgical). This subgroup analysis showed a significant decrease in SDF rates using microsurgical technique (10 studies, WMD –6.70%, 95% CI –9.04%, –4.37%; I2=91%, p &amp;lt; 0.0001). After varicocelectomy, SDF rates were also decreased when non-microsurgical approaches were used, albeit the effect was not statistically significant (2 studies, WMD –6.84%, 95% CI –10.05%, 1.38%; I2=86%) (Figure 3). The heterogeneity was not materially affected by performing analyses by the above subgroups, suggesting that the SDF assay and surgical technique do not explain the inconsistency in the treatment effect across primary studies. Limitations, reasons for caution There were no randomized controlled trials comparing varicocelectomy to placebo for alleviating SDF levels. Heterogeneity was high, which may be explained by the low number of included studies. Pregnancy data are not available in most studies, thus the impact of reduced SDF after varicocelectomy on pregnancy rates unclear. Wider implications of the findings: Our study indicates a positive association between varicocelectomy and reduced postoperative SDF rates in men with clinical varicocele and infertility, independentetly of the assays used to measure SDF. These findings may help counsel and manage infertile men with varicocele and high SDF levels. Trial registration number Not applicable

Effect of varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele: a systematic review and meta-analysis

To evaluate the effect of varicocelectomy on sperm deoxyribonucleic acid fragmentation (SDF) rates in infertile men with clinical varicocele. Systematic review and meta-analysis. Not applicable. Infertile men with clinical varicocele subjected to varicocelectomy. Systematic search using PubMed/Medline, EMBASE, Cochrane's central database, Scielo, and Google Scholar to identify relevant studies published from inception until January 2021. We included studies comparing SDF rates before and after varicocelectomy in infertile men with clinical varicocele. The primary outcome was the difference between the SDF rates before and after varicocelectomy. A meta-analysis of weighted data using random-effects models was performed. Results were reported as weighted mean differences (WMD) with 95% confidence intervals (CIs). Subgroup analyses were performed on the basis of the SDF assay, varicocelectomy technique, preoperative SDF levels, varicocele grade, follow-up time, and study design. Nineteen studies involving 1,070 patients provided SDF data. Varicocelectomy was associated with reduced postoperative SDF rates (WMD -7.23%; 95% CI: -8.86 to -5.59; I2 = 91%). The treatment effect size was moderate (Cohen's d = 0.68; 95% CI: 0.77 to 0.60). The pooled results were consistent for studies using sperm chromatin structure assay, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling, sperm chromatin dispersion test, and microsurgical varicocele repair. Subgroup analyses showed that the treatment effect was more pronounced in men with elevated vs. normal preoperative SDF levels, but the impact of varicocele grade remained equivocal. Meta-regression analysis demonstrated that SDF decreased after varicocelectomy as a function of preoperative SDF levels (coefficient: 0.23; 95% CI: 0.07 to 0.39). We concluded that pooled results from studies including infertile men with clinical varicocele indicated that varicocelectomy reduced the SDF rates. The treatment effect was greater in men with elevated (vs. normal) preoperative SDF levels. Further research is required to determine the full clinical implications of SDF reduction for these men.

Bilateral is superior to unilateral varicocelectomy in infertile men with bilateral varicocele: Systematic review and meta-analysis.

To investigate whether bilateral surgery can bring more benefits to infertile patients with bilateral varicocele than unilateral surgery. A search of PubMed, Web of Science, EMBASE and the Cochrane Library on 13 January 2019 was conducted to identify studies published in English that used varicocelectomy. The protocol of the present meta-analysis was pre-published on PROSPERO (registration number CRD42019093894). Primary outcomes were spontaneous pregnancy rates. A total of eleven articles were finally enrolled in, with a total of 1,743 patients. Spontaneous pregnancy rate was higher in patient with bilateral varicocelectomy than unilateral varicocelectomy with an odds ratio (OR) of 1.89 (95% CI 1.52-2.35; I2 =0%; p<.00001). The results indicated bilateral is superior than unilateral varicocelectomy concerning sperm concentration (SMD: 2.88×106 /ml; 95% CI: 1.06, 4.70; I2 =93%), sperm motility (SMD: 5.08; 95% CI: 2.65, 7.50; I2 =0%), progression of sperm motility (SMD: 6.48; 95% CI: 5.16, 7.81; I2 =0%) and sperm morphology (SMD: 2.38%; 95% CI: 0.72, 4.03; I2 =94%) between bilateral and unilateral varicocelectomy. Bilateral varicocelectomy may be superior to unilateral in regard to spontaneous pregnancy rate and sperm motility for infertile male with bilateral varicocele (both left clinical and right subclinical varicocele and bilateral clinical varicocele).

Outcome of varicocelectomy on different degrees of total motile sperm count: A systematic review and meta-analysis

ABSTRACTIt is crucial to identify the subfertile men with varicocele who will benefit the most from varicocelectomy, and the factors which help in predicting the response to varicocelectomy. We aimed to evaluate the impact of varicocelectomy on total motile sperm count (TMSC) and spontaneous pregnancy (SP) rates. A comprehensive literature search was performed using Medline/PubMed and Google Scholar up to December 26, 2018, with no restriction on language and year of publication. Published articles reporting different degrees of TMSC before and after varicocelectomy in infertile men with varicocele (palpable and/or clinical) were extracted. In addition, SP rates as a function of TMSC after varicocelectomy were reviewed. Potential biases were analyzed to rule out skewing factors. Mean TMSC was graded as: <2 million – profound, 2–5 million – severe, 5–10 million – moderate, and >10 million – mild. Data were analyzed using Stata11. Among the total 96 articles identified through electronic and manual searches of references, nine articles fulfilling the inclusion criteria were included. All degrees of TMSC resulted in a significant postoperative improvement, with only small differences, among the profound [10.20 million (95% confidence interval [CI]: 9.11–11.30, p < 0.0001)], severe [15.77 million (95% CI: 10.65–20.89, p < 0.0001)], and moderate groups [19.18 million (95% CI: 10.40–27.96, p < 0.0001)]. However, the mild group demonstrated a highly significant improvement [49.68 million (95% CI: 38.74–60.62, p < 0.0001)]. After varicocelectomy, the SP rate was highest in the TMSC >20 million group (55.4%), followed by TMSC 5–20 million group (45.4%), and TMSC <5 million group (26.3%). In comparison, the TMSC <1.5 million group demonstrated the lowest SP rate (16.0%). Moderate evidence suggests that varicocelectomy results in a significantly improved TMSC. The improvement in TMSC and SP rates is higher in patients who present a mild or moderate decreased TMSC.Abbreviations: TMSC: total motile sperm count; SP: spontaneous pregnancy; ART: assisted reproductive technology; IVF: in-vitro fertilization; IUI: intrauterine insemination; WMD: weighted mean difference; CI: confidence interval

The role of artery-preserving varicocelectomy in subfertile men with severe oligozoospermia: arandomized controlled study.

There is wide agreement nowadays that a clinical varicocoele should be ligated to treat male factor infertility. However, the significance of testicular artery preservation in patients with severe oligozoospermia has not been addressed before. To assess the outcome of varicocelectomy in infertile men with severe oligozoospermia and clinical varicocoeles and to compare internal spermatic artery preservation vs. artery ligation. This prospective randomized study included 302 infertile patients with severe oligozoospermia and clinical (grade II/III) varicocoeles. Patients were randomized into two groups: group A (150 patients) underwent artery-preserving varicocelectomy (APV) and group B (152 patients) underwent artery-ligating varicocelectomy (ALV). The primary outcome was to assess the changes in sperm density and motility at 3 and 6months postoperatively in both groups. The secondary outcome was to compare the natural pregnancy rate at 1-year of follow-up. Univariate and multivariate analyses were performed to determine factors affecting pregnancy rate. In both groups, there was a statistically significant improvement in sperm density and motility at 3 and 6months postoperatively. In group A, there was a greater improvement in sperm density (p<0.001) and motility (p<0.001) compared to group B. At 1-year follow-up, overall 35.1% achieved a natural pregnancy. Group A achieved a significantly higher natural pregnancy rate (40% vs. 30%, p value=0.03) compared to group B. Smaller testicular volume and ALV were the independent predictors of lower pregnancy rate ((HR=3.2, 95% CI 1.2-8.3, p=0.01) and (HR=3.2, 95% CI 1.4-7.1, p=0.003), respectively). In men with severe oligozoospermia and a clinical varicocoele, APV results in improved outcomes as compared to ALV with respect to semen parameters and natural pregnancy rates. Therefore, all attempts should be made to preserve internal spermatic arteries (ISA) during varicocelectomy in men with severe oligozoospermia.

Varicocelectomy May Improve Results for Sperm Retrieval and Pregnancy Rate in Non-Obstructive Azoospermic Men.

BackgroundAssessing the net-results of microsurgical varicocelectomy in infertile men with non-obstructive azoosper- mic (NOA) and clinical varicocele in five years at Royan Institute.Materials and MethodsThis is a descriptive retrospective cohort study. A backward-looking review of patients treated for NOA and varicocele from march 2011 to march 2016 was performed. In addition, MDTESE results of 57 patients with NOA and clinical varicocele, with 537 NOA patients without varicocele were compared.ResultsOf 57 patients who underwent varicocelectomy, eight patients (14%) had sperm on sperm analysis post-opera- tively. One of the eight patients was single, and one of them had spontaneous pregnancy (1/7) 14%, and one had a child by microinjection (1/7) 14%. Out of these 8 patients, 6 had hypospermatogenesis pathology. Of 38 patients who under- went MDTESE, 14 patients (36%) had sperm on their testis tissues, but one of them had no egg fertilization. Therefore, the fertilization rate was (92%). Of the remaining 13 patients, 3 had live child birth (3/13) 23%. Sperm retrieval rate (SRR) in NOA men without clinical varicocele was lower from those who had varicocele and NOA (22 vs. 36%). Also live birth rate in NOA men with varicocelectomy was higher than NOA men without varicocele (23 vs. 11%).ConclusionMicrosurgical varicocelectomy in NOA men may have positive effects on post-operative sperm in ejacu- late and natural or assisted pregnancies, but it seems that the effect is more significant on MDTESE results and follow- ing successful microinjection. Meanwhile, SRR and live birth rate was higher in our patients compare to NOA men without clinical varicocele.

The application of laparoscopic Doppler ultrasound during laparoscopic varicocelectomy in infertile men

The aim of this study is to evaluate the benefits of laparoscopic Doppler ultrasound (LDU) application during laparoscopic varicocelectomy (LV), and to compare the surgical outcomes and complications between LDU-assisted LV (LDU-LV) and conventional LV for infertile patients with varicoceles; 147 infertile patients were randomly divided into two groups. Operative and postoperative parameters, semen parameters, and the pregnancy rate were compared. There were no differences in baseline demographics. The operative time was significantly longer in LDU-LV group than LV group. The incidence of postoperative hydrocele was 1.4% (1/72) in LDU-LV group versus 10.7% (8/75) in LV group, which showed a significant difference (P < 0.05). However, other surgical outcomes, such as postoperative hospital stay, postoperative recurrence, and testicular atrophy, were similar between the two groups. Sperm concentration and sperm motility were significantly increased in both groups at 3, 6, and 12 months after surgery (P < 0.01), and they were higher in LDU-LV than LV group in 12 months after surgery (34.21 ± 6.36 vs 29.99 ± 6.04 for concentration, P < 0.05; 40.72 ± 8.12 vs 37.31 ± 6.12 for motility, P < 0.05). Sperm morphology was comparable between the two groups. The pregnancy rate showed no significant difference (44.4% of the LDU-LV vs 37.3% of the LV, P > 0.05). In conclusion, compared with LV, LDU-LV could safely and effectively ligate all spermatic veins and preserve spermatic arteries without leading to high varicocele recurrence and postoperative hydrocele. Given the benefits that sperm counts as well as sperm motility favoring LDU-LV, we recommend that LDU should be routinely used as an effective tool to improve outcomes and safety of laparoscopic varicocelectomy.

The effect of adjuvant vitamin C after varicocele surgery on sperm quality and quantity in infertile men: a double blind placebo controlled clinical trial.

Varicocele is one of the most common causes of male infertility and spontaneous pregnancy rate after varicocelectomy is only about 30%. The most important seminal antioxidant is vitamin C but recent studies about the effects of vitamin C on spermatogenesis are controversial; therefore, we decided to evaluate its role after varicocelectomy. In a double blind randomized controlled clinical trial, 115 men with infertility and clinical varicocele with abnormal semen analyses were recruited. After surgery, the intervention group received vitamin C (250 mg bid) and the control group received placebo for three months. Mean sperm count, motility, and morphology index of two semen analyses (before and after surgery) were compared between the two groups. Univariate general linear model and stepwise linear regression were used in analysis. The mean age (±SD) of participants was 27.6±5.3 years. Vitamin C group had statistically significant better normal motility (20.8 vs. 12.6, P=0.041) and morphology (23.2 vs. 10.5, P<0.001) than placebo group. Considering the values prior to surgery as covariate, vitamin C was not effective on sperm count (P=0.091); but it improved sperm motility (P=0.016) and morphology (P<0.001) even after excluding the confounding effect of age (P=0.044 and P=0.001, respectively). Vitamin C was also an independent factor in predicting motility and normal morphology after surgery. Ascorbic acid can play a role as adjuvant treatment after varicocelectomy in infertile men.

The influence of antisperm antibodies, intratesticular haemodynamics and the surgical approach to varicocelectomy on seminal variables

ObjectiveTo evaluate the effect of antisperm antibodies (ASAs), hormonal levels, intratesticular haemodynamics and the surgical approach on the outcomes of varicocelectomy in infertile men, as assessed by seminal variables. Patients and methodsIn a prospective case-series study, 82 infertile men with varicocele (35 left and 47 bilateral) were evaluated. The preoperative assessment included a physical examination, semen analysis, assessment of ASAs in seminal plasma, hormonal levels (follicle-stimulating hormone (FSH), luteinising hormone and testosterone), and scrotal colour Doppler ultrasonography (CDUS) to measure the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and pulsatility index. Patients were scheduled for varicocelectomy, with high ligation (Palomo) used in 40 patients (18, 45%, with left and 22, 55%, with bilateral varicocele), or an inguinal approach (Ivanissivich) with loupe magnification used in 42 (17, 40%, with left and 25, 60%, with bilateral varicocele). The men were reassessed at ⩾3months after surgery and according to the improvement in seminal variables (expressed as a ⩾50% increase in total motile sperm count, TMSC), patients were further categorised into ‘improved’ or ‘unimproved’. Binary logistic regression analysis was used to investigate the predictors of improvement. ResultsBefore surgery the ASAs were positive in 17 men (21%). There was no significant difference between the right and left sides in intratesticular haemodynamics. The TMSC was improved in 52 (63%) patients who had a significant improvement in the haemodynamic variables. Intratesticular haemodynamics, serum FSH and testosterone levels differed significantly between the improved and unimproved patients. Positivity for ASAs, the surgical approach and laterality of the varicocele were not significantly different, although the ASA-positive cases were characterised by a significant decrease in motility. Logistic regression analysis showed that the EDV, PSV, FSH, testosterone level and bilateral testicular volume (BTV) were significant predictors of improvement. ConclusionPositivity for ASAs is not a predictor of the outcome after varicocelectomy but affects only the motile fraction in positive cases, despite the improvement in other seminal variables and testicular haemodynamics, and regardless of the surgical approach. The EDV, PSV, FSH, testosterone and BTV were significant predictors of a successful outcome.

Clinical Outcome of Microsurgical Varicocelectomy in Infertile Men With Severe Oligozoospermia

To evaluate the outcome of microsurgical varicocelectomy in infertile men with severe oligozoospermia and to identify the predictive parameters associated with the efficacy of microsurgical varicocelectomy in this cohort of patients. This study included 102 consecutive severe oligozoospermic patients who underwent microsurgical varicocelectomy between 2000 and 2013. The significance of several parameters as predictors of response to microsurgical varicocelectomy was evaluated using univariate and multivariate analyses. Responders were defined as those who fulfilled the following criteria: (1) sperm motility rate improved after surgery and (2) sperm concentration increased from <1 × 10(6)/mL to ≥ 5 × 10(6)/mL or from 1-5 × 10(6)/mL to ≥ 10 × 10(6)/mL. After the mean postoperative observation period of 8.2 months, the mean sperm concentration increased from 2.4 to 11.6 million/mL (P <.001), and the mean sperm motility improved from 32.8% to 42.2% (P = .0024). There were no significant differences in the levels of hormonal parameters between the preoperative and postoperative measurements. Of the 102 patients, 42 (41.1%) were determined to be responders, and the wives of 17 (16.7%) conceived naturally. Univariate analysis identified preoperative sperm concentration (≥ 2.0 vs <2.0 million/mL) and laterality of varicocele (bilateral vs unilateral) as significant predictors of response to varicocelectomy. Only preoperative sperm concentration appeared to be independently related to the efficacy of varicocelectomy in men with severe oligozoospermia on multivariate analysis. Varicocelectomy may improve the sperm quality and fertility potential in men with severe oligozoospermia, particularly for those with relatively high sperm concentration.

Subinguinal Varicocelectomy With Loupes Only, Sans Surgical Microscope

Dear Editor, I would like to comment Abdelrahman and Eassa on their important paper on the assessment of loupe-assisted subinguinal varicocelectomy in infertile men (1). Methodology was complete, including a group of patients and another of controls, of adequate sample size, defined with valid inclusion and exclusion criteria, and followed-up at 3 and 6 months with measures of seminal count/morphology and relevant hormones. As for surgical anatomy and technique, the authors correctly approached internal spermatic veins after opening the internal spermatic fascia. They correctly mention a ‘compartment of the vas’ internal to the internal spermatic fascia. Many experts, however, erroneously state that the vas sits outside the internal spermatic fascia (2). The vas indeed lies internal to the internal spermatic fascia (i.e. in the spermatic cord’s internal compartment) but is further ensheathed by a membranous layer continuing from the respective layer of the abdominopelvic extraperitoneal tissue. The internal spermatic vessels, nerves and lymphatics all within the internal compartment are similarly packed by another membranous sheath (3). The authors preserved the veins of the vas, “except when abnormally engorged veins were evident”. My preference is not to ligate these, but instead cremasteric veins plus their anastomoses with the external pudendal vein. The cremasteric veins are found between the internal and external spermatic fasciae, i.e. in the cord’s external compartment. Intact veins of the vas serve for venous flow after ligation of the internal spermatic and cremasteric veins. Gubernacular veins were not ligated; consequently the testis was not delivered. I concur: if sacrificed, testicular venous return relies only on the small deferential veins (3). With loupes only (sans surgical microscope), 0% recurrence and 0% hydrocele were achieved; admirable rates, totally comparable with those of subinguinal varicocelectomy under microscope -better than rates of others using loupes [2.9% hydrocele, 2.9% reccurence (4)]. Complication rates of subinguinal varicocelectomy without loupes— 15% hydrocele, 10% recurrence seem higher than others’ 7.3% hydrocele, 2.63% recurrence (5), which, however, merge inguinal and subinguinal procedures. In statistical analysis, the authors unfortunately disregarded their paired and time-series design, and performed multiple, pair-wise comparisons, increasing probability of type I error. Instead, analysis should start with testing for normal distribution; if so, a 2-way-ANOVA for repeated measurements would reveal an overall difference; then post-hoc analysis should follow to detect differences between duos of data. In case of non-normal distribution, Friedman test should be applied for the time-series triplets of each group, and Mann-Whitney U-tests for duos of data at each time point (6). In conclusion, the paper strongly supports loupe-assisted subinguinal varicocelectomy in infertile adults. It can be ameliorated in surgical anatomy regarding compartments of the spermatic cord, and has pitfalls in statistical analysis. Nevertheless, the paper has great virtues: excellent surgical results and justified semen and hormonal findings. What I liked most was the honest declaration ‘so it [this technique] should be used, especially in developing countries where the microsurgery equipment is not available every where”. I hope the authors obtain this equipment. I look forward to reading their next paper on microsurgical subinguinal varicocelectomy.

Obesity negatively influences the outcome of microscopic varicocelectomy in infertile men

OBJECTIVE: Compared to men with normal weight, obesity is associated with a higher incidence and grade of varicocele together with lower serum testosterone, diminished semen parameters, and infertility. We sought to determine if obesity influences the outcome of varicocele repair. DESIGN: A retrospective review of infertile men undergoing microscopic varicocelectomy from 2005-2009. MATERIALS AND METHODS: Inclusion criteria included infertility, presence of a clinical varicocele, and postoperative follow-up more than 4 months. Men were excluded if they had a prior varicocele repair, genetic abnormalities, azoospermia, or an obstructive cause of infertility. Obesity was defined as body mass index (BMI)>30. Multiple variables were analyzed with respect to preoperative and postoperative sperm density, motility, and morphology. Univariate and multivariate analysis was used to analyze variables associated with greater than 50% improvement in sperm density. RESULTS: 245 (71 obese) men were included with mean age of 34.4 years and follow-up of 12.5 months. After varicocelectomy, sperm density, motility, and normal morphology significantly improved (p<0.05). Preoperatively, obesity was associated with low testosterone (p<0.01) and increased seminal reactive oxygen species (ROS) (p=0.03). BMI correlated with increased operative time (r=0.4, p<0.01) and operative complications (p=0.04). Compared to obese men, non-obese men displayed a greater improvement in sperm density (11.6x106/mL vs 5.3x106/mL, p<0.01) and normal morphology (5.6% vs -5.4%, p<0.01), but not motility (3.4% vs 0.1%, p=0.09). On multivariate analysis, only initial sperm density and obesity was negatively associated with a 50% improvement in sperm density (p<0.05). CONCLUSION: As previously reported, obesity is associated with low testosterone and increased ROS. After microscopic varicocelectomy, the seminal parameters of obese men show less improvement then non-obese men suggesting that BMI can influence varicocelectomy success.

Microsurgical and nonmagnified subinguinal varicocelectomy for infertile men: a comparative study

To compare semen parameters, pregnancy, recurrence, and complication rates after microsurgical and nonmagnified subinguinal varicocelectomy for infertile men. Prospective, randomized study. Ghodran General Hospital, Kingdom of Saudi Arabia. One hundred sixty-two infertile male patients with varicocele. Eighty-two patients were treated by microsurgical subinguinal varicocelectomy (MSSIV) (group I), whereas 80 patients were treated by conventional, nonmagnified subinguinal varicocelectomy (NMSIV) (group II). The patients were postoperatively evaluated by physical examination and semen analysis after 4 and 12 months. Pregnancy rate was monitored during the follow-up period. Postoperatively, mean sperm count and motility improved significantly in both groups: 42.7% and 67.1% of the MSSIV group and 23.7% and 33.8% of the NMSIV group showed ≥50% improvement in sperm count and motility after 1 year. Patients having bilateral varicocele showed significantly better improvement of sperm count than those with unilateral varicocele after both MSSIV and NMSIV. The pregnancy rate at the end of the follow-up period reached 37.8% in the MSSIV group and 21.2% in the NMSIV group. The recurrence rate was zero in the MSSIV group and 11.3% in the NMSIV group. The rate of hydrocele formation was 1.2% in the MSSIV group and 8.7% in the NMSIV group. Microsurgical subinguinal varicocelectomy has a better improving effect on sperm count and motility, higher spontaneous pregnancy rates, and lower postoperative recurrence and hydrocele formation than conventional subinguinal varicocelectomy in infertile men.

UP-2.058: Recovery of Spermatogenesis After Microsurgical Subinguinal Varicocelectomy in Infertile Men

There are conflicting opinions on favorable influence of surgical treatment varicocele on recovery of spermatogenesis for patients with clinical varicocele and infertility (Evers and Collins, 2001, 2003; Ficcara et al., 2006; Richardson et al., 2007; Marmar et al., 2007). The objective: to evaluate the effect of microsurgical subinguinal varicocelectomy on recovery of spermatogenesis in infertile men.

Efficacy of Bilateral and Left Varicocelectomy in Infertile Men With Left Clinical and Right Subclinical Varicoceles: A Comparative Study

To determine whether it is necessary to perform bilateral varicocelectomy (BV) in infertile men with left clinical and right subclinical varicoceles by comparing the outcomes of BV with those of left varicocelectomy (LV) in these patients. A total of 104 infertile men with left clinical and right subclinical varicoceles were randomly divided into 2 groups: BV (n = 51) and LV (n = 53). Both BV and LV were performed using a retroperitoneal approach with ligation of the dilated internal spermatic veins. The sperm concentration, sperm motility, normal morphology, serum testosterone level, bilateral testicular volume, and spontaneous pregnancy rate were measured pre- and postoperatively. Statistical analysis was performed using analysis of variance and the chi(2) test, with significance determined by P < .05. The patients in the 2 groups had comparable preoperative age, partner age, sperm concentration, sperm motility, normal morphology, left varicocele grade, serum testosterone level, and bilateral testicular volume (P > .05). Both BV and LV resulted in significant increases in sperm concentration, sperm motility, and normal morphology (P < .05). No significant changes in serum testosterone level or bilateral testicular volume were observed after varicocelectomy in the 2 groups (P > .05). No significant differences were found in the postoperative sperm concentration, sperm motility, normal morphology, bilateral testicular volume, serum testosterone level, and spontaneous pregnancy rate between the 2 groups (P > .05). These findings suggest that no benefit is realized with BV compared with LV in infertile men with left clinical and right subclinical varicoceles.

Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis

To determine the efficacy of varicocelectomy as a treatment for male factor infertility by improving the chance of spontaneous pregnancy. Meta-analysis. Cleveland Clinic's Glickman Urological Institute. Infertile men with abnormal results on semen analyses and a palpable varicocele. Surgical varicocelectomy. Spontaneous pregnancy outcome. The odds of spontaneous pregnancy after surgical varicocelectomy, compared with no or medical treatment for palpable varicocele, were 2.87 (95% confidence interval [CI], 1.33-6.20) with use of a random-effects model or 2.63 (95% CI, 1.60-4.33) with use of a fixed-effects model. The number needed to treat was 5.7 (95% CI, 4.4-9.5). Surgical varicocelectomy in infertile men with palpable lesions and at least one abnormal semen parameter improves the odds of spontaneous pregnancy in their female partners. Five studies were included (two randomized, three observational). All were scored for bias. Our study suggests that varicocelectomy in selected patients does indeed have beneficial effects on fertility status.