Varicocele and infertility: why a prevention?

Trace and essential elements as vital components to improve the performance of the male reproductive system: Implications in cell signaling pathways

Successful male fertilization requires the main processes such as normal spermatogenesis, sperm capacitation, hyperactivation, and acrosome reaction. The progress of these processes depends on some endogenous and exogenous factors. So, the optimal level of ions and essential and rare elements such as selenium, zinc, copper, iron, manganese, calcium, and so on in various types of cells of the reproductive system could affect conception and male fertility rates. The function of trace elements in the male reproductive system could be exerted through some cellular and molecular processes, such as the management of active oxygen species, involvement in the action of membrane channels, regulation of enzyme activity, regulation of gene expression and hormone levels, and modulation of signaling cascades. In this review, we aim to summarize the available evidence on the role of trace elements in improving male reproductive performance. Also, special attention is paid to the cellular aspects and the involved molecular signaling cascades.

Role of Anti-Müllerian Hormone in Male Reproduction and Sperm Motility

Anti-Müllerian hormone (AMH) is secreted by Sertoli cells and is responsible for the regression of Müllerian ducts in the male fetus as part of the sexual differentiation process. Serum AMH concentrations are at their lowest levels in the first days after birth but increase after the first week, likely reflecting active Sertoli cell proliferation. AMH rises rapidly in concentration in boys during the first month, reaching a peak level at ∼6 months of age, and it remains high during childhood, then they will slowly decline during puberty, falling to low levels in adulthood. Serum AMH measurement is used by pediatric endocrinologist as a specific marker of immature Sertoli cell number and function during childhood. After puberty, AMH is released especially by the apical pole of the Sertoli cells toward the lumen of the seminiferous tubules, resulting in higher levels in the seminal plasma than in the serum. Recently, AMH has received increasing attention in research on male fertility-related disorders. This article reviews and summarizes the potential contribution of serum AMH measurement in different male fertility-related disorders.

Early male aging or poor clinical consideration for males in IVF centers? An original study

The Italian law 40/2004 allows the use of assisted reproduction techniques only if there are no other effective therapeutic approaches to overcome infertility. According to article 4 paragraph 1, the impossibility of removing the otherwise impeding causes to achieve a pregnancy must be ascertained before the couple undergoes assisted reproduction techniques. On this premises, we sought to evaluate the percentage of couples who underwent or were addressed to assisted reproduction techniques despite a known and potentially treatable male infertility factor in fertility centers in the city of Catania, Italy. To accomplish this, andrologists, urologists and endocrinologists were asked to report the number of couples already addressed to assisted reproduction techniques which they counseled in the trimester April-June 2018 having a under 35-year-old female partner and at least one among the following untreated conditions: (A) oligoasthenoteratozoospermia and FSH <8 mIU/ml, (B) third-degree varicocele (mono or bilateral form), and (C) leukocytospermia or urogenital infections. Of the 320 enrolled couples, 75 (23%) met the criterion A, 45 (14%) the criterion B, and 62 (19%) the criterion C. More than a half couples were addressed to assisted reproduction techniques despite a potentially treatable male infertility factor.

Sonography in male infertility: a look beyond the obvious

Infertility affects 15-20% of the reproductive age range population; the male factor accounts for up to 40-60% of these. With female factor infertility catching most of the limelight in research, diagnosis and treatment, the other half of the problem has not been duly addressed. Imaging has an important role to play in the evaluation of male infertility, especially to identify correctible (obstructive) causes. We review the scrotal, trans-rectal sonographic and Doppler findings in infertile men to aid in the accurate diagnosis and proper management of such patients.

Effect of selenium on testicular damage induced by varicocele in adult male Wistar rats

PROJECT

Varicocele is an abnormal tortuosity and distension of the veins of the pampiniform plexus in the spermatic cord. It is the most common surgically correctable cause of male infertility. Several studies have revealed the effects of increased oxidative stress on serum, semen, and testicular tissues in patients with varicocele or in animal models. The aim of this study was to investigate the effects of sodium selenite on testicular damage induced by experimental left varicocele in male Wistar rats.

PROCEDURE

In the present study, the effects of oral administration of sodium selenite (at doses of 0.05, 0.1, 0.2, and 0.4mg/kg bw) were assessed in normal and varicocelized rats.

RESULTS

The varicocelized control rats showed decrease in sperm quality parameters, decreased activity of testes CAT, GPX and SOD, increased levels of MDA, and damage in testicular architecture. Administration of sodium selenite significantly reduced these changes to nearly normal levels, but did not change these parameters in normal rats. Histopathological studies further confirmed the protective effects of sodium selenite on varicocele-induced testicular damage in rats. Administrations of sodium selenite did not change these parameters in normal rats.

CONCLUSIONS

Taken together, the results of this study suggest that sodium selenite treatment may have beneficial effect on the testes of varicocelized rats.

Laparoendoscopic single-site varicocelectomy compared with conventional laparoscopic surgery: a systematic review and meta-analysis

Purpose

To present a systematic review and meta-analysis comparing laparoendoscopics single-site varicocelectomy (LESS-V) versus conventional laparoscopic surgery (CTL-V).

Methods

A literature search was performed using The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded and Google Scholar. Literature reviewed included meta-analyses, and randomized and nonrandomized prospective studies. We utilized weight mean difference (WMD) to measure hospital stay, time to return normal activity, postoperative pain and improvement of semen parameters and odds ratio (OR) to postoperative complications and cosmetic satisfaction. We used the Cochrane Collaboration’s Review Manager 5.1 software for statistical analysis.

Results

We identified six publications which strictly met our eligibility criteria. Meta-analysis of extractable data showed that LESS-V was better than CTL-V in postoperative pain (WMD: −0.46; 95 % CI −0.75 to −0.17; p = 0.002), time to convalescence (WMD: −1.4 days; 95 % CI −2.55 to −0.25; p = 0.02) and cosmetic satisfaction (OR 6.86; 95 % CI 2.89–16.28; p < 0.00001). However, CTL-V was better than LESS-V in operative time (WMD 1.96 min, 95 % CI 0.96–2.96; p = 0.0001). There were no differences between LESS-V and CTL-V in hospital stay (WMD: −0.02 days, 95 % CI −0.39 to 0.35; p = 0.92) and postoperative complications (OR 1.13, 95 % CI 0.57–2.21; p = 0.73).

Conclusions

This meta-analysis comparing the efficacy of LESS-V and CTL-V showed that LESS-V was safe, with significantly reduced postoperative pain, shorter recovery time, and better cosmetic outcome.

Improvements in Scrotal Thermoregulation in Patients with Varicoceles Treated by Using Traditional Korean Medicine: Two Case Reports

A varicocele is a dilatation of the pampiniform venous plexus within the spermatic cord. The incidence of varicoceles is 15%, and it occurs in more than 40% of men in infertile couples. Traditional Korean medicine (TKM) has been used to treat male infertility in Korea. We present two cases of men with varicoceles diagnosed via physical examination and scrotal thermography. We treated these men for two months by using TKM techniques, which included acupuncture, pharmacopuncture, and herbal medicine. We used scrotal thermography to evaluate the varicoceles before and after TKM treatment. After TKM treatment, the scrotal thermoregulation of both patients improved. In Patient 1, the temperature difference between the left and the right pampiniform plexus (i.e., ΔTP) was 2.8°C before treatment. It decreased to 1.3°C after treatment. In addition, the temperature difference between the testicles (ΔTT) was 1.5°C before treatment; it decreased to 0.2°C after treatment. In Patient 2, the ΔTP was 1.5°C before treatment; it decreased to 0.2°C after treatment. This report is the first to show that TKM may be an option for treating patients with varicoceles, as determined by using a scrotal thermography evaluation.

Free radicals in adolescent varicocele testis

We examine the relationship between the structure and function of the testis and the oxidative and nitrosative stress, determined by an excessive production of free radicals and/or decreased availability of antioxidant defenses, which occur in the testis of adolescents affected by varicocele. Moreover, the effects of surgical treatment on oxidative stress were provided. We conducted a PubMed and Medline search between 1980 and 2014 using “adolescent,” “varicocele,” “free radicals,” “oxidative and nitrosative stress,” “testis,” and “seminiferous tubules” as keywords. Cross-references were checked in each of the studies, and relevant articles were retrieved. We conclude that increased concentration of free radicals, generated by conditions of hypoxia, hyperthermia, and hormonal dysfunction observed in adolescent affected by varicocele, can harm germ cells directly or indirectly by influencing nonspermatogenic cells and basal lamina. With regard to few available data in current literature, further clinical trials on the pre- and postoperative ROS and RNS levels together with morphological studies of the cellular component of the testis are fundamental for complete comprehension of the role played by free radicals in the pathogenesis of adolescent varicocele and could justify its pharmacological treatment with antioxidants.

Time-domain analysis of scrotal thermoregulatory impairment in varicocele

Varicocele is a common male disease defined as the pathological dilatation of the pampiniform plexus and scrotal veins with venous blood reflux. Varicocele usually impairs the scrotal thermoregulation via a hemodynamic alteration, thus inducing an increase in cutaneous temperature. The investigation of altered scrotal thermoregulation by means of thermal infrared imaging has been proved to be useful in the study of the functional thermal impairment. In this study, we use the Control System Theory to analyze the time-domain dynamics of the scrotal thermoregulation in response to a mild cold challenge. Four standard time-domain dynamic parameters of a prototype second order control system (Delay Time, Rise Time, closed poles locations, steady state error) and the static basal temperatures were directly estimated from thermal recovery curves. Thermal infrared imaging data from 31 healthy controls (HCS) and 95 varicocele patients were processed. True-positive predictions, by comparison with standard echo color Doppler findings, higher than 87% were achieved into the proper classification of the disease stage. The proposed approach could help to understand at which specific level the presence of the disease impacts the scrotal thermoregulation, which is also involved into normal spermatogenesis process.

Morphological and surgical overview of adolescent testis affected by varicocele

Varicocele is a common pathology of the testis frequently associated with infertility. For its management, a fine morphological study of the testis, both macroscopically and microscopically, and an accurate choice of surgical procedure are mandatory. The present review focuses its attention on the anatomic substrates of adolescent varicocele and its pathophysiologic modifications. The comprehensive assessment of all the reported alterations should be considered by the clinician before deciding the type of treatment and the timing.

Infrared digital thermography of scrotum in early selection of progressive varicocele

Varicocele is frequent but correctable cause of male infertility. Varicocelectomy is the most commonly performed operative procedure for varicocele. Majority of varicocele patients do not have fertility problem, therefore surgical correction is not recommended in all prevalent cases. On the other hand, varicocele is a progressive condition in some cases and individual with varicocele is at risk for developing impairment which can ultimately lead to semen deterioration and consequent infertility. Selection of patients with varicocele that will progress and cause infertility is beyond our current diagnostic capabilities. Diagnostic assessment of varicocele depends on physical examination and scrotal ultrasound/doppler. Infrared digital thermography of scrotum is a non-invasive and objective diagnostic method for early varicocele detection by means of temperature measurement on the scrotal skin surface. The criteria for diagnostic use of scrotal thermography were recently presented. We hypothesize that the infrared digital thermography of scrotum could be the cornerstone in detection of varicoceles that tend to progress with impairment of semen quality and will require surgical correction, among all prevalent varicocele cases.

Scrotal infrared digital thermography in assessment of varicocele--pilot study to assess diagnostic criteria

The aim of this study was to assess scrotal thermography in diagnostics of varicocele and suggest potential diagnostic criteria. Twelve patients with clinically diagnosed varicocele were examined with scrotal infrared digital thermography, physical examination and ultrasound/doppler. The main outcome measure was evaluation of thermography diagnostic criteria for varicocele. Mean temperature at left pampiniform plexus was ≥ 34 °C in 83%, and at right pampiniform plexus in all cases was ≤ 34 °C. In 92% of patients, temperature at the left testicle was ≥ 32 °C, whereas at the right testicle it was >32 °C in 50% patients. Temperatures between left and right pampiniform plexus and between left and right testicle were significantly different with P < 0.0001 and P < 0.006 respectively. In all patients, temperature difference between pampiniform plexuses was ≥ 0.6 °C. In 92% of patients, temperature at left pampiniform plexus was equal or higher to thigh temperature with the mean temperature difference of 1.1 ± 1.1 °C. Temperature at right pampiniform plexus was colder than the thigh in 92% of patients. This study suggests diagnostic criteria of five thermographic signs to easily diagnose varicocele. Scrotal thermography presents feasible, short and low cost diagnostic method for varicocele. Further study on a larger number of patients and healthy participants is needed to evaluate sensitivity and specificity of this method.

Laparoscopic vs open varicocelectomy in children and adolescents: review of the recent literature and meta-analysis

PURPOSE

Laparoscopic varicocelectomy has gained popularity in recent years. The aim of this study was to identify clinical evidence about the reliability of this technique in the recent literature.

METHODS

We performed a Medline search for articles published during the last 10 years, using the key words "varicocele," "treatment," and "adolescent." As limits, we used last 10 years, adolescent, clinical trials, randomized controlled trials, meta-analysis, and multicenter retrospective and prospective studies. The results were investigated in recurrence and hydrocele formation.

RESULTS

We pooled 37 studies, but 26 of these were excluded because they were neither relevant nor concerned an adolescent population. Meta-analysis showed that there was no statistical difference between laparoscopic surgery and open surgery in recurrence rate and postoperative hydrocele rate. In the laparoscopic group, the incidence of recurrence was higher in the patients undergoing artery ligation compared to patients undergoing artery and venous ligation. Furthermore, a lower rate of postoperative hydrocele was recorded in patients undergoing dye injections before laparoscopic ligation.

CONCLUSIONS

Meta-analysis and literature analysis showed that the results after laparoscopic varicocelectomy are comparable to other surgical procedures. The laparoscopic approach has the advantage to treat simultaneously bilateral varicocele.

Scrotal thermoregulatory model and assessment of the impairment of scrotal temperature control in varicocele

Varicocele is defined as the pathological dilatation of the pampiniform plexus and scrotal veins with venous blood reflux. Varicocele may impair scrotal thermoregulation and spermatogenesis, even when present in asymptomatic forms. In this study, we use the control system theory to model scrotal thermoregulation in response to a standardized cold challenge in order to study the functional thermal impairment secondary to varicocele. The proposed model is based on a homeostatic negative feedback loop, characterized by four distinct parameters, which describe how the control mechanisms are activated and maintained. Thermal infrared images series from 49 young patients suffering from left varicocele and 17 healthy controls were processed. With respect to healthy controls, left varicocele patients presented higher basal scrotal temperature and faster recovery of the left hemiscrotum. The model indicated that varicocele alters local heat exchange processes among cutaneous layers and inner structures. The estimated model parameters help in the assessment of the scrotal thermoregulatory impairment secondary to the disease.

Conventional progesterone receptors (PR) B and PRA are expressed in human spermatozoa and may be involved in the pathophysiology of varicocoele: a role for progesterone in metabolism

The physiological roles of intracellular progesterone (PRG) receptors (PRs) have been studied intensively in female mammals, while their functions in male are scarce. Conventional PRs were evidenced in our study by Western blotting, concomitantly in healthy spermatozoa and in oligoasthenoteratozoospermic samples without and with varicocoele. Transmission electron microscopy revealed the presence of the PRs on the membrane as well as in the nucleus, mitochondria and flagellum. A reduced expression of the PRs was observed only in varicocoele spermatozoa. Responses to PRG treatment on cholesterol efflux, tyrosine phosphorylation, src and Akt activities, acrosin activity and acrosome reaction in varicocoele spermatozoa were reduced or absent. To further investigate PRG significance in human male gamete, we focused its action on lipid and glucose metabolism. The evaluation of the triglycerides content, lipase and acyl-CoA dehydrogenase activities suggests that PRG through the PRs exerts a lipolytic effect on human spermatozoa. An increase in glucose-6-phosphate dehydrogenase activity was also obtained, evidencing a role for PRG on glucose metabolism. In 'varicocoele' spermatozoa, the PRG did not induce energy consumption. The action of PRs on sperm metabolism is a novel finding that renews the importance of PRG in male fertility. Our results showed that varicocoele may lead to male factor infertility by a mechanism involving a decreased PR expression in human spermatozoa that evidences a detrimental effect on spermatozoa at the molecular level, going beyond the abnormal sperm morphology described to date.

Imaging in male-factor obstructive infertility

The main purpose of imaging evaluation in male infertility is to identify and treat correctable causes of infertility, such as obstruction of the seminal tract. Various imaging modalities are available to evaluate men with obstructive infertility including scrotal ultrasonography, transrectal ultrasound (TRUS), vasography, magnetic resonance imaging, seminal vesicle aspiration, seminal tract washout, and seminal vesiculography. To date the most reliable and accurate diagnostic technique for obstructive infertility is unclear. In this review article, we report the role of these modalities in diagnosis of obstructive infertility. Scrotal sonography is the initial modality, and if patient results indicate non obstructive azoospermia as varicocele or testicular pathology they will be treated according to standard protocols for management of these pathologies. If the patient findings indicate proximal obstructive azoospermia, they can be managed by vasoepididymostomy. If the scrotal ultrasound is normal, TRUS is the second imaging modality. Accordingly, they are classified into patients with criteria of obstructive infertility without urogenital cysts where TRUS-guided aspiration and seminal vesiculography can be performed and transurethral resection of the ejaculatory ducts (TURED) will be the management of choice. In patients with urogenital cyst, TRUS-guided cyst aspiration and opacification are performed. If the cyst is communicating with the seminal tract, management will be transurethral incision of the cyst. If the cyst is not in communication, the obstruction may be relieved after cyst aspiration. If the obstruction is not relieved, TURED will be the management of choice. Sperm harvested during aspiration may be stored and used in assisted reproduction techniques. If the results of TRUS are inconclusive or doubtful, endorectal magnetic resonance imaging should be performed to serve as a “detailed map” for guiding corrective operative interventions.